HomeMy WebLinkAbout0077 THREE PONDS DRIVE - Health 77 THREE PONDS DR., CENTERVILLE
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No.mmmw OR OSTV
HASTINGS.MN
No. D00 3 Fee ®L J
THE COMMONWEALTH OF MASSACHUSETTS ._ Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migozaf *pztem QContrurtion permit
Application for a Permit to Construct( . )Repair( )Upgrade( 'Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 1-] Th('tc O()OS 7e- Owner's Name,Address and Tel.No.
Centecytll f1/�f! WILLIAM LENMy 502-1iZb-2069
AssMr's MMap/arc ,p ,� CE- kTFP_J 1 LlF
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
RD beer G 1 LFo y - St-R ExL/k\1 AT 10 KI D Ary 10 MA5O N -OBc. EN V 1 e0NM;41T*L
14 TEAB�(Z UV 'FaZESIDALEL EAST 5ANDWICH 509-933- 2-117
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow gallons.
Plan 'Date 12- 1&10 !' Number of sheets I Revision Date
Title 5 I TT-- PrN Q 5 EV&]h ff _?L R N
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been isstied by this B and o Heal I �_
Si ned Date 91d
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. 5 3 g' 1 Fee
a THE COMMONWEALTH'OF MASSACHUSF-TT Entered in computer:
..,. Yes
PUBLIC HEATH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
RppliCAtion for �h5po l bpgtem (Con!5truction Vermit
Application for a Permit to Construct( )Repair( )Upgrade( -)'Abandon( ) O Complete System O Individual Components
Location Address or Lot No. 1-7 eo fl o`> De Owner's Name,Address and Tel.No.
i
Ce.nin\-n le, MA V/ILLiA\A CChti \1 509 - Ll20 2.0
As ssor's Map arc I C C W Z E 2 V i L L'E
►`�I A 1� N _P A RCE L 12.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
_kU ILF1) GI f-XC/A\Ji\I i6NI DAvi0 MA1501\I - Oi3C 1N \1I NML�_iiftL,
`-I tEA6EV4\1) CNi, tv2C5-1 f- LE N51 5ANDL�iCH 5(19 33 - 21-17
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3� gallons per day. Calculated daily flow gallons.
Plan Date 12 I(o fU "S Number of sheets 1 Revision Date i
Title _ 5ITr A N 0 5FVQAEl >v LF)KI
Size of Septic Tank Type of S.A.S.
Description of Soil: x
Nature of Repairs or Alterations(Answer when applicable)
Date.last inspected:
w 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. �.
SfVE2_!�
%' Date 1 i 9 �✓
Application Approved - Date
Application Disapproved for the following reasons '
Permit No. Z Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate Of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(✓ )
Abandoned( )by bi a EXC6\JniI,,D n - T"'()ber 1 (3 ,I ri.\r
at -1 7 -F N RED ICU tJ-i�)5 C)P- C C N-1 C !Z\)I L L:F has been constructed in accor Aance
with the pro�.y isions of Title 5 and the for Disposal System Construction Permit No _ dated
r
Installer 1 1 Designer Q13C_ V i�� �c t G ( E S i i1 S
The issuance of this permit sh ll not a cos ued as a guarantee that the systtem will f ti designed.
Date Inspector
No. l.J�.�J 5 63� _� - ---- - -- —--• • - - --- - ----- ____�Fee_--�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migp0zar 6p$tem (Con!5tructiun Verrmtt
Permission is hereby granted to Construct( )Repair( )Upgrade K)Abandon( )
System located at I' ICE C IBC%i�d l�S T�E1 �� LCN7f�V 1 1 l�
i
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: Constructio7,��n
mucompleted within three years of the dale of this pe it.
Al
Date:_. l 1 - Approved�b
Vi1/1Vr VV mv. �- --------"
5/ZS��l
Notice: This Form-Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
1 hereby ce'rfi that the engineered Ian signed b me
Z, � -- - — Y fY S P 8x► Y
dated 1b,3r;-i0ncming the property located at
meets all of the
following criteria:
• This failed system is connected to a residential dwelling only..There are no commercial or
business uses associated with the dwelling. i
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applkaut may use historical data to conclude this fact or may conduct
preliminary tests at the site without a health agent present.
• 'There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
I;runptor method when applicable]
Please complete the following:
A) Top of Ground Surface EIevatioui(using GIS information)
B) G.W.Elevation ` +adjustment for high G.W. "--
DIl~FERENCE BETWEEN A and B `1
DATE.. 12. 116 165
SIGN
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms
\ maximum. No additional bedrooms are authorized itt the future without engineered septic system
PLUS.
qr haahh folder.peraokmp
Town of Aarnstable
Regidatory Semites
Thomas F.Geller,Director
Public Health Division
' Thomas McKean,Director
Zoo main Street,Hyannis,MA-02601
Fax: 5o8-79M304
Office: 508-862-4644
. Installer&Desioer Certification Foritn
Date:
Designer: _� 1 �•
Address:
Address:
on.1 �ao-fls
(date) er
septic system at _� _ - V61= jqsed on a design drawn by
s
M dated
(designer)
referenced above was installed substantially according to
I certify that the septic system approved changes sach as lateral relocation of the
the design,which may include minor
distribution box and/or septic tank.
I ceZ, cert[fy that
that the septic system referenced above was installed with major changes (i.e.
•
nt
greater than 10' lateral relocation of&e SAS or any vertical relocation Of any" or
of the septic system)bat in accordance with State&Local ReP131i -PL"
certified as built by designer to follow. 6*i A�7
er's S )
M1
3
'4#
i
r �p
- Hele)(Affix Desig�8
s J 1
PLEASE RETURN TO BARNSTABLE PUBLIC HLAL'13I DsON. �—
OI+ COAZPLIANCE WII.L ND'r lB� ItiS� �� B C�LTH�tIVISIEfN.
gUIhT CARh ARE REC:�BY T� MIMI
TgANI�YOU
(2;He9ltbd8 0a/DeWPff Certification Form
_r 7 f I_x ..
SECTION 1 • • I ?
SENDER: COMPLETE
■ Complete items 1,'2,and 3.Also complete' ,A Signa !
a
item 4 if Restricted:Delivery is desired-4 ❑Agent I
X ' �` ❑Addressee
Is: Pnnt your name and address o the reverse . F,
so that we can return the card rod'• B;Received'gyt(�'rinte �la eA of live '
■ Attach this card to the back of the mailpiece, p
or 6n the fmdf if space'permks.•w
D. Is deliv a from item.1? ❑Yes; !
1. Article Addressed to: if YES,enter de ive' ad ss w� " No j
¢ Mr William Leahy ;,,+ I•D1V!p
77 Three Pond Drive - !
3.,Service Type !
Centerville,MA 02632 o Certified Mail o Express Mail ! x
O Registered ' '0 Retum Receipt for Merchandise I '
Insured Mail ❑C.O;D. }
4. Restricted Delivery?(Extra Fee) ❑Yes' i F
2.Artid*Number # ( t 4 1 ti #3I[f#' # #t # Rf. # de
frransfer firm service lab,
to2ss5 o2-nn-isao
PS Form 3811,February 2004 Domestic Return Receipt
V
"Jy n UNITED STATES POSTAL SERVI t+.61a 21h+.
�P-�yo�x.tage&+-emP id
p , UJPS
PIMA �e'mi t�N.as� G-10
f{` • Sender: Please r jt _ `_"�`p yopgV 'e,address; nlP 4 in th s' ox�
PUBLIC HEALTH DIVISION
i .
TOWN OF BARN STABLE SABLE
. 200 MAIN STREET
HYANNIS, MASSACHUSETTS 02601
�i`�'� .
tt�rrrrilds-flulIbaYr4t.111Ir.r�� 1ia.��rrsrr✓1i. �rrr �iy�►�r
COMMONWEALTH OF MASSACHUSETTS
w a
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSFORM ASSESSMENTS
PART A
CERTIFICATION
Property Address: / / //jree �H c/
eo
Owner's Name:
Owner's Address:
Date of Inspection: // 7 S r
Name of Inspector:{please print)
Company Name. wi 1
Mailing Address: D p
a`y
Telephone Number: Sog
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 m
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.i s The system:
Passes
Conditionally Passes
_.weds Further Evaluation by the Local Approving Authority
Fails
Q
Inspector's Signature: GV72
Date:- //
The system inspector shall submit a copy of this inspection report to the Approving Authori Bard
DEP)within 30 days of completing this inspection.If the system is a shared system or has i desi` flow 1I 0 � k
tY� of IIth a9h
gpd or greater,the inspector and the system owner shall submit the report to the appropriate reginal office`bf th ' w
DEP. The original should be sent to the system owner and copies sent to the buyer,if applical and the rovtn' .
authority.
co
Notes and Comments
r'r
q
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
conditions of use. e or different
Title 5 Inspection Form 6/15/2000
page 1
Page g 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: / /
Owner:
L-� '� 2r✓/ ��
Date of Inspection: G�
Inspection Summary: Check A,B,C,D or E/ALWAyS complete all of Section D
A. Sys em Passes:
I have not found any Information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B.
System Conditionally Passes:
ifs One or more system components as described in the"Conditional Pass"
section need to be p repaired.The system,,upon completion of the replacement or repair,as approved by the Board of Hea laced wor
ill
th,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined" lease
explain. P
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurall
unsound,exhibits substantial infiltration or exfiltration or tank failure is immin y
existing tank is replaced with a complying pproved y ent System will pass inspection if the
the Board of Health.
*A metal septic tank will pass inspection if it its structurally sound,not peaking and if a Certificate of Co
indicating that the tank is less than 20 years old is available. mpliance
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will ass to broken or
approval of Board of Health): P inspection if(with
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 P P year due to broken or obstructed i e s .The s stem will
Pass inspection if(with approval of the Board of Health): Y
broken pipe(s)are replaced
obstruction is removed
ND explain:
T; lu C incnnr*inn 4n ci,)nnn 2
_ Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION TION FORM
PART A ORM
CERTIFICATION(continued)
Property Address: �� � r, �va /j
c' a,Ve-
Owner: d 6 ��
Date of Inspection:
! g �s—
C.. .Further Evaluation is Required by the Board of Health:
'! Conditions exist which require further evaluation
is failing to protect public health,safety or the environment the Board of Health in order to deter
mine if the system
1 System will pass unless Board of Health determines in accordance with 310 C
system is not functioningin a manner which will protect public health safe
P MR 15.303(1)(b)that the
p 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
system is functioning in a manner that protects the public health,safety andenvironment:
ier,if y)determines that the
The system has a septic tank and soil absorption system SAS
surface water supply or tributary to a surface water supply. ( )and the SAS is within 100 feet of a
_ The system has a septic tank and SAS and the SAS is within a Zone 1 0
_ The system has a septic r f a public water supply.
P 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
private water supply Wen**.Method used to determine distance 100 feet but 50 feet or more from a
This system passes if the well water analysis,performed at a DEP certified laboratory,bacteria and volatile organic compounds indicates that the well is free from pollution
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 from for coliform
failure criteria are triggered.A- of the from that facility and
PY analysis must be attached to this formpm'provided that no other
3• Other:
Tctio c rncnnnrinn �,.�.,�ii v')nnn
3 '
Page 4 of 1 I
- OFFICIAL IN
SPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: / /Ioee 417N c/ 1
Owner: 2 - /
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
• Yes o
_ backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
i
Dscharge or ponding of effluent to the surface of the ground or surface waters due to.an overloaded or
logged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
spool
_ uid depth in cesspool is less than 6"below invert or available volume is less than%:day flow
_ -,,e'required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number
ref times pumped gg P P ( )
_ _✓jny portion of the SAS,cesspool or privy is below high ground water elevation.
_ Any portion of cesspool or privy is within 100 f
er supply. eet of a surface water supply or tributary to a surface
wat
any portion of a cesspool or privy is within a Zone 1 of a public well.
wry 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.]
,��(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
(/ described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:'
(The following criteria apply to large systems in addition to the criteria above)
Xno
stem is within 400 feet of a surface drinking water supply
stem is within 200 feet of a tributary to a surface drinking water supply
stem 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.
TiNn G fnc»onfinn Rn�m pit ciinnn 4
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: V / �I"e2 C f a
Owner: I-ec� 61)d- 67,,,L-
Date of Inspection: / p
Check if the following have been done.You must indicate"yes"or"no''as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
c//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?
V Have large volumes of water been introduced to the system recently
y 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)
Was the facility or dwelling inspected for signs age of sew back up .n
Was the site inspected for signs of break out?
TWere all system components,excludingthe SAS located ocated 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?
�7 _ Was the facility owner(and occupants if different from owner)provided with information on the
maintenance of subsurface sewage disposal systems? proper
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 C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
Titles G fncnArtinn Fnr.n 4/1 5
I
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS
TEM INSPEC
TION FORM
PART C
SYSTEM INFORMATION
Property Address:All
J Y►f&Owner• rv► lB/ot-6 3�
Date of Inspectio 7
RESIDENTIAL LO V CONDITIONS
Number of bedrooms(design): _Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR�,5.203(for example: 110 gpd x#of bedrooms): d
Number of current residents:'
Does residence have a garbage grinder(yes or no): /mod
Is laundry on a separate sewage system(yel or no): [if yes separate inspection required)
Laundry system inspected(ye or no):/i'
Seasonal use:(yes or no): b
Water meter readings, if available(last 2 years usage(gpd)):
Sump Pip(yes or no):Lv�
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on
(sea 10
ts
CMR 15.203):- d
Basis of design flow eats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
Pumping Records
GENERAL INFORMATION
•
Source of information: /fi0 4
Was system pumped as part of the inspection(yes or no):— G
If yes,volume pumped;
Reason for pumping: _gallons--How was quantity pumped determined?
Tn' SYSTEM
eptic tank,distribution box,soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_,Shared system(yes or no)(if yes, attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_ Other(describe):
Approximate age of all components,da e ' taIle if known)and source of information-
Were
Were sewage odors detected when arriving at the site(yes or no):Aa
Title Incnonrinn >:nr.n A/1 Siinnn 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
o.4 eVf
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: 3i /
Materials of construction:_cast iron �or40 PVC_other(explain):
Distance from private water supply well suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: - locat
_( e on site plan)
Depth below grade: �
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: �X
Sludge depth:
Distance from top of slu ge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or bale:__�
Distance from bottom of scum to bottoms Qf outlet tee o bale. /
How were dimensions determined: /"fl le g c v/<�
Comm ents(on pumping recommendations,inlet and ouch tee or baffle condition,structural integrity,liquid levels
elated to outlet invert,a idence of le ge,etc.):
4-, v7e �' @�✓
G H lv �� � � � � S✓o o� � — /l�o
GREASE TRAP:/ 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.):
Titles G �nCnPIHInn Rn�rn 4/1 v,)Ann 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: 0163�
Date of Inspection: /
TIGHT or HOLDING 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: allons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: if�present( must be opened)(locate on site plan)
Depth of liquid level above outlet invert: L
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into grout of box,etc.):
PUMP CHAMBER: locate on site plan)
Pumps in workingorder es or no(Y ).
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title C fncnnrfinn Rnrm�i�ci�nnn 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: / T Alegi Q„�f
Owner: '� �(/� •e� ,4 ��C 3
Date of]Inspection-
SOIL pr'
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
leaching pits,number:1 x
leaching chambers,number:
leaching galleries,number: i
leaching trenches,number, length:
leaching fields, number,dimensions: t-
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ondin
etc.): /14 / P g,damp soil,condition of vegetation,
e ...............j!......... ...... oi e C�
CESSPOOLS: /(/ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert.-
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction.
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level ofponding,condition of vegetation, etc.):
T tlo C fnenor►inn Fnrm lip cnnnn 9
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Page 10 of 11
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: e4
Date of Inspecti
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. L cate all wells within 100 feet.Locate where public water supply enters the building,
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�SYSTEM INFORMATION(continued)
Property Address: J ► �n°e I p_C'
/ H �1•� 3�
Owner: 42.44
Date of Inspection: . / 7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 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 de cri how you established the high ground water e evadi n:
� o G/e1�-A.j to&I mwC�-v
el e
Ov`/ .� • o
Title G Incnontinn P—m lii aiInnn 11
TOWN OF BARNSTABLE
LOCATION `l`7 —rkrct onoAS Qr i yc- SEWAGE #c2DoS G 3$
VILLAGE Ccn-4cru;11 r- ASSESSOR'S MAP & LOT ) 3 oZ
INSTALLER'S NAME&PHONE NO. a!2cr-1 Gi I-Fby 5*08 - q?7 - OGS3
SEPTIC TANK CAPACITY ZOOO
LEACHING FACILITY: (type) oo a/ X 2.
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: /a- ao - g-gym COMPLIANCE DATE:
Separation Distance Between They
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
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Az- -31 '
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12,
TROY WILLIAMS ?
SEPTIC INSPECTIONS
� OT
Certified by MA.Department of Environmental Protection rQ,^ 61 (508) 385-1300
�F
19 Hummel Drive
r1_1s 9$
South Dennis,MA 02660 R` «/
COMMONWEALTH OF MASSACHUSETTS .., ,� � �✓�
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Cno py
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIAM F.WELD TRUDY CORE
Govemor
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
• CERTIFICATION
Property Address: 7 7 h re e Pd,ct s or. ,
��S /�$ Address of Owner:
/0 .
Date of Inspection: (If different �C^ki CA, �`r C._e_
Name of Inspector: Troy Williams 126, 13cx- 8 t 3
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: _Troy .Williams Septic Inspections
Mailing Address: _19 Hummel DrivP� South Dennis , MA 02660
Telephone Number: _ (5,0 8) 3 8 5-13 0 0 02 6 68
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection: The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
,Passes r
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature. Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES: /V//9
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.
Indic2te yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(r—t..d 04/25/97) P.q. 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
77 Three Ponds Drive,Centerville,MA
Property Address: Dana Rice
Owner: October 15, 1998
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued) V/,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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N//9
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN,A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 77 Three Ponds Drive,Centerville,MA
Owner: Dana Rice
Date of Inspection: October 15, 1998
DI SYSTEM FAILS: NIA
You must indicate ei;,.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet front a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS: N//9
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(—i""d 04/25/97) _. ."
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
77 Three Ponds Drive, Centerville,MA
Property Address: Dana Rice
Owner: October 15, 1998
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
Pumping information was provided by the owner, occupant, or 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 f Pe g es o water have not been introduced into the system recently or
/ as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
✓ _ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material•of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
% The size and location of the Soil Absorption System on the site has been determined based on:
✓- _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
J _ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(r—i..d 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 77 Three Ponds Drive, Centerville,MA
Owner: Dana Rice
Date of Inspection: October 15, 1998
RESIDENTIAL: FLOW CONDITIONS
Design flow: ?3 3 U_g.p_d./bedroom for S.A.S.
Number of bedrooms: .3
Number of current residents: 6
Garbage grinder (yes or no): ^)o
Laundry connected to system (yes or no): ` '--.5
Seasonal use (yes or no): n/0
Water meter readings, if available (last two (2)year usage (gpd): ' 32-wo0 y y I/o h 5 7 = c/S,00 6
Sump Pump (yes or no): A/p
Last date of occupancy: ✓a c,4.N )- 1, g
COMMERCI WINDUSTRIAL: R119
Type of establishment:
Design flow:_ Qallons/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)
Water meter readings, if.available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
av✓l., ,� .� r7 C.t/�i o ,7.c✓ h ✓`
"'�7
VSIPm p��m�d a� �a,� Vf„„peRion. (yes or no)�/v
If yes, volume pumped: gallons
Reason for pumping:
TYPE QF 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) A[D
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Three Ponds Drive,Centerville,MA
Owner: , Dana Rice
Date of Inspection: October 15, 1998
BUILDING SEWER: / ///I
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _ 40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
)
i
Depth below grade:
Material of construction. concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: S�X 9 6,
Sludge depth:_ y„
Distance from top of sludge to bottom of outlet tee or baffle: o? �00�
Scum thickness:ll-, h
Distance from top of scum to top of outlet tee or baffle: G
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: f2r o ,
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.) PUc-'i"�t ,✓ ;y, l L u J, C p 4 -/
-14.1 ov 4-It4-
t✓o� h c r.�.�✓. NO S � Sh f a� �t /� y o✓ Ste✓
-�yvc ho �� v. K
h may/ra /
(� S ✓1 b / N L t f� C� lJ✓Y a.0 h 6 l 4-
GREASE TRAP:—Ez/�
(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:
(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.)
(r. isod 04/25/91)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Three Ponds Drive,Centerville,MA
Owner: Dana Rice
Date of Inspection:October 15, 1998.
TIGHT OR HOLDING TANK:A//I (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:z
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,.etc.) 0—L?.X W.o.f
hJ, ,ti WO✓k ✓� e GP-
PUMP CHAMBER: N14
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77'ice Ponds Drive,Centerville,MA
Owner: Dana Rice
Date of Inspection:October 15, 1998/
SOIL ABSORPTION SYSTEM (SAS): I/
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: /
leaching pits, number: bt.,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of)vegetation, etc.)
1,G w
� �✓ / �. W i Ci-- In• w'i-t Y �U� � �S{'"
4a
v�o a �ar� 4�C o u4,u w
CESSPOOLS: —/� S�s-f . or//; fSa s osc
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: /V//Y
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
ir.vi..d 04/2s/97i
P.q. 6 or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Three Ponds Drive,Centerville,MA
Owner: Dam Rice .
Date of Inspection: October 15, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
27
z7�
D-3�x
5y /000 y41(oti
(revisal 04/25/91) -
' ➢.o. • of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Three Ponds Drive,Centerville,MA
Owner: Dana Rice
Date of Inspection: October 15, 1998
Depth to Groundwater- Feet adjusted high groundwatcr Iced
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
vY l t1 cA, I f 4- rt Lo �1l vt o c, P S
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,2c`C q of �, v �.h J, I S ✓r o Lwtt l� s •j: �,
(rrvlaad 04/15/97) "", Pace 10 of 10
'OCAT10-N SEWAGE PERMIT NO.
A,* z�z L,
., ILLAGE
I N S T A L�LiER'S NAME i ADDRESS
2 C >
B U I L D E R OR O ANER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
I
i zg e
{
90......�Z/....... �. _ .� Fxs....- ............:.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE � LTH
��`rv�✓'' .................OF.... ttt�/t,_r,?... � ..................
,pplira#ion for Elispoii al Works Tonstrnrtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-- .f�. ..; 8 ra? .._ i'� ---------- -----•-----••-- •-------- •••--••-----------••-•----.......-•---....
Location Address
� or t No. -
aA ..........................................
e e Owner -Address
aw ......q. k-°�)'( .......................................•- ---...•........------.................... ----------....---------........-----•------
'Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms....:T�ne_,P,.........................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T e of Building No. of persons............................ Showers
YP g ----------•----------------- P ( ) — Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person§e day. Total dam`flow........3_- 0......-. ..............gallons.
9 Septic Tank—Liquid ca acit . DDogallons Length.......... _' Width.............. Diameter_.__......_._._. Depth � ..._..Disposal Trench—No........... Width....... . ....... Total Length _...___.___ Total leachingarea:__ �� s ft.
Seepage Pit No....... ........... iameter._=�._. Depth below inlet_.__.._____._._. Total leaching area. -.sq. ft.
Z Other Distribution box ( Dosing tank
Percolation Test Result Performed by..........0.ba�V.......D?; q-1.SLS.............. Date....��`:� �-
Test Pit No. I._ .......minutes per inch Depth of Test Pit...../4 j....... Depth to ground water........................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ..---------•.................•-•••••••••-----•-........•••-•••-------•••••----•----...•-•••.._...............................................................
O Description of Soil........0-A.°_...-- 1-•------....:L _..1.Z .I 1;�t_!��._+-..Gram.v
x
V ..-•------••--------•---------------------••-------- ---------------•--••--•-••-------------------------------------------------------------•------------•---------------•--•--•------•------•----••--
W -•-
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•------......--•------------.........-•----------------........-------------•-------------------------------------••-------------------------------------...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT�.;;;. 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.
Sign -----•----------------------------•----......_.....--•--•-----•-----••-- ................................
Date
Application Approved By----- rl�• � ba: r ...........
Date
Application Disapproved for the following reasons: =----•----------------------------------•----------------•------------------•-••--•-------
.......-•-••-•.......................•••-••-•---....•-•--••--•-•---------•-••••--._......----••-••-----...-•--------•---••--------------------------------------••------- -------
Date
Permit No......................................................... Issued_....1
Date
No.._..� " �..... F$.. ' f .
THE COMMONWEALTH OF. MASSACHUSETTS ?;
Ij
BOARDWF... H T r
•
Appliration' , for,:Disposal orks...Zoaistrnrf ian rrntit
Application is hereby made for"a"Permit to Construct ( . ) or'Repair"( )=an In Sewage Disposal
System at: ?
............... -
Location-Address Lot
....................
. 11_.d .f. acur, u7sr. °Nl . .#. �.fQcrlrl�c.:_
Owner Address
is
Address
d' Type of Building Size Lot________________ _._...Sq. feet e
U .Ex Expansion Attic
.-� Dwelling No. of Bedrooms........ ________ ________________ p ( ) Garbage'>Grinder
Other—Type of Building ___`. No. of persons..........___________________ Showers
a YP g P ( ) Cafeteria
Other fixtures • ...............
................................ -- --------- --- )
W Design Flow.=___ ___._ __''.gallons'per-person per day. Total daily flow.......... _ ::.gallons.
R; Septic Tank-Liquid capacity. t � allonsngxli _�!�l_s!Width.., '• ._ Diameter._._.; __.___ Depth *�--
x
Disposal Trench No :.Total.Length�0 Total leaching are fie_ .....sq.ft.
Seepage Pit.No _:_;/f. meters ,Depth"bv. ____ ta�.lh�ng ar aq. ft.
Dia
Z -Other.Distribution box ( " Dosmg tank )
Percolation Test Res Performed'by _.. �.p- ._. , :` if, .-- -. Date..
Test Pit No 1 __ minutes per inch Depth of Test Pit /�_'_.____ Depth to ground water f
f=, Test Pit No 2_._ '. -minutes per inch-'—Depth-.of-Test:-Pit ,._________. Depth to ground.water '_._"_____________
O Description of Sotl- ? °- ��.t ..:.- .� 5 +,1' ° �. / _ se; �r +;
x
k
W
x ............... =-•-- -= ------ •-----------------------------
_..._
U Nature of Repairs or Alterations ..;Answer when applicable___.__:___ .................-_____._::____ _____:__: "__._______-___-...
.................................
"Agreement: !
The undersigneld :agrees to install+the aforedescribed 'Individual Sewage Disposal System in accordance with•'
the provisions of TITLE: 5 of the State Sanitary Code.—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance,has been issued by the board of health. J
......:.............•----+---•-•-•---•--•----....-•----.....--•---........--- ••-------- .....---......_....
Da
Application Approved BY...............................................-•----... ---------- J.
----- •-- •-- --•-•-----
------
• Date
Application Disapproved for the following reasons:................................................................................................................
...........................•--••-----___---•--------------------------------------------------------------
Date
PermitNo....................................................... Issued.------••---------------•-•----...-
Date
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD F HEA
OF........................::...........................................................
(Irdifirtttp of TontpliFanrr
Y...,pThat the dividual Sewage Disposal System constructed ( ) or Repaired ( )
A/1
� � tl"o
,
....................................................................
at............................................ -- -----------
has been installed in accordance with the provision The State Sanitary Qd s s ribed in the
application.for"Disposal Works Construction Permit .___. f� �� ��dated ------•--
T'HE ISSUANCE OF THIS CERTIFICATE SHALL NOT;BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. Inspector...................................................................................
s.
THE COMMONWEALTH--OF MASSACHUSETTS
BOA OF H
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as shown on the-+application for Disposal Works Construc t ..... Dated_________________..........................................
-----------------------------------------------` Board of 7th
DATE..............................................................:_------•--
FORM 1,25,5 HOBS & WARREN• INC.. PUBLISHERS
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LEGEND CERTIFIED PLOT. PI:ANtxRa .
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'INt3�'CONTOUR 7 - - p - - LoT 7-H2��pnNU�s ,D u�'e
FI�IISHED!- SPOT, ELEVATION -6`�
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CLIENT __.- _ I CERTIFY THAT THE PROPoie`w
EI 1S .AE� REGISTERED1 JOB NO. .7g I;07 BUILDING SHOWN ON THIS, �P,L' Af'4
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CVI'L., i LAND CONFORMS TO THE ZONING , LAWS`
$URVEYOR_S DR. BY ' �. OF BARNSTABLE , MASS
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I-EA CHI IV o 5, DIMEIV510AI A -5 =77
SCALE 01MRV51o" a- 6 FT.
NUMBER OF BEDROOMS 3 D114ENSION C 4" FT.,41/A/.
CiARe„4GE DISPOSAL UNIT SOIL 1-0&
ro rA z. esr/mA7-Ez) F=i_o w 3 3 0 a.4 I..IoA Y S 0 14 7-e 5 T ICI SOIL 7_257ST# SOIL 7E572 0/404CHIN OF
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TOTAL jzAcH1w& AREA 2-1112 SQ. F77 PElcCoZ_A7-1oJVRA7',Eo2 — tljN.11,VCY .
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& 6T14p,*S,POT ELEVATION Oxe CERTIFIED PLOT , Pl_Ati
C �XIS.TdNa�- 'O4NTOUR = - p - - Lo T !� TNrc� PoNUs Dr�t�',E.,
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�ApOR.6ED�NBOARD OF HEALTH .9 All h :d -1 A '
DATE,-t;""` j.. AGENT SCALE DATE
QPEDGE "ENG,INEER/NG CO. ING�
Po POVI GPI hr••
Y CLIENT . __ . I CERTIFY THAT THE PROF!OIb,
: EG,I$TE.RE (REGISTERED JOB NO. .79 /07 BUILDING SHOWN ON THIS sf?L.AP
LAND CONFORMS TO THE ZONING LAMS
IENOINEERS SURVEYOR OF BARNSTABLE , MASS
DR. BY ' 4
3 NC MQPN ST 712 MAIN ST. CH BY R.p _
r�{� 50:.`.Y�1RMQ T.y, MASC. HYANNIS, MA 'S
SHEET_1_ OF Z-_ DATE EG. LAND SURrVE' YOR '
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INVERT AT 01114DiM6 -76 P =r C SEE TABULATION
INLET SEPTIC TANK 7 5,57 IC7- FT. 91AM. �.i
Szp-rlc 7-AlvH 753 Fr TABLE
E
BOX 7 SO _-7 GROUND WA rE,,R'
0024-rDISM480M1,0 -7
�N BOX 4.') FT, _THC rl ON 0.=
IIV,Z.-='r LEACH IdVa .4>.i 7- -745 FT. SEWAG6E. 01SROSA4
SYSTEM LEACH11V6- =/7' 7 A- 8 t-/I-AT/ON
SCALE : ;14 A S
DESIGN CRITERIA e; 6 FT.
,V"Af 491ER OF BEDROOMS 3
r, 4- F-r.AIIAI
GAR9AoGC015PO_lR,4Z. elvir SOIL /-0& S011- 7'A657'
To7-A4 P-j_ojv 33 o GAL.IpAy soll- 7-esT 4kl SOIL. 7-4-s-7#2
NUMBER OF4-4CMIN6 0/r_5 r4e-1 -V A=-L A-I/_LL L PATE Or SOIL TEST IS 17 E
$/0-E LCACHIIVCP PER jP1'r S41, lm;r• I jREsuj_-r.5 w/rAl-ESS.-D BY 1(3uArl K'-r
710,1V RATE At/
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ro7AI. 4,ff4cHllvG AREA SQ. Fr "A IM
FWleC0l_A'r101V RATE 0Z _ miA1.11,vcy .
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TES'�AT*
AIISESSORS MAP: 1
.._ _
TEST HOLE LOGS 4-
PARCEL
I
� �,��-- �—� ,��� �C„ st?I L EVALUATOR :
NOTES:
FLOOD ZONE: '� ��
WiTHE33: WO AWULftLk,�
REFERENCE: � tLTI+ "E al t
GATE: !
. L 1) The installation shall comply with Title V and Town of Barnstable Board of
4 ,gwevl w PERCOLiT I ON RA t E el1
r
Health Regulations.
�► 2) The installer shall verify the location of utilities, sewer inverts and septic
TH-I TH-2 components prior to installation and setting base elevations.
`` 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.
r i%ttel,r rluo
4) This plan is not to be utilized for property line determination nor any other
M
purpose other than the proposed s stem installation.
PkApt
Pe'6 . "Of k� t 5) ' yAll septic components must meet Title V specifications.
64f �' I� b) Parking shall not be constructed over H10 septic components.
LOCATION MAP �. : , '� `� Z15V 7) The property is bounded by property corners and property lines.
( 8) The property•owner shall review design considerations to approve of total
mm � b design flow and number of bedrooms to be considered for design. Receipt of
G,1
61 b payment for the plan and installation based on the plan shall be deemed-
11;��� Z, approval of the design flow by the owner.
9 The existing leach its shall be pumped and filled with material .
•• ) g P � ) P Pper Title V
ji,Q1 I t abandonment procedures. Those within the proposed SAS shall be removed
t„ LtWD. Gt3� along with contaminated soil.and replaced with clean washed sand per Title V
specs.
10)System components to be 10 feet from water line.
SEPT 1 SYSTEM D E S I G N 11) If a garbage grinder exists it is,to be removed and is the responsibility of the
owner to ensure such.
FLOW E',ST l TE
BEDROOMS AT 110 GAL/DAY/BEDROOM GAL/DAY
t .? - SEPT I# TANK
OY-30CA /DAY x 2 DAYS - GAL
/ S 4 USE 11 0 GALLON SEPTIC TANK �1 S111�.1
��t �h __ .Pt / ,mac ► ^t;� SO I 6= fItIT I S'YSTEM
3� 6 CK)
ii AV
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�t I
V°�l— ... SIDE AREA:
_
N ;OTT'OM AREA.: 2-Ail I of x Al . .
3YPm
SEPTIC SYSTEM SECTION C7
7/100
t"
a:YGAL
SEPTIC TANK L ,
`1w
SITE AND SEWAGE PLAN
LOCATION: # 7 7 � awI�1.5► �L
PREPARED FOR itu' wt
a SCALE: o
- r ,
DAV I D R . MASON Xe> DATE:/23D
Q DRC ENVIRONME TAL DEstGNS
EAST SANDWICH. MA
DATE HEALTH AGENT- (508) 833-2 1 77
_ _ I
ASSESSORS MAP: ^ f�17 TEST HOLE LOGS
PARCEL: � 7 - , .
,n NOTES:
1 - FLOOD ZONE:_ �oT ra�PC,lG SOIL EVALUATOR ( R�JI� � G/T�
ate° REFERENCE: G2.T l�/ ,Ea' f�.o! ` '
WITNESS: ,p
DATE: t
1/ 1) The installation shall comply with Title V and Town of Barnstable Board of
PERCOLATION RA 7 E .,, loll 1
4,,,,g, �r Health Regulations.
Dr
''�at Z' 2) The installer shall verify the location of utilities, sewer inverts and septic
La T14-1 TH-2 components prior to installation and setting base elevations.
`` �►�� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot."
4) This plan is not to be utilized for property line determination nor any other
stomp ao L°p� '� purpose other than the proposed system installation.
Me /D � r td Q5 a ZS 5 Ali 2�1 ) septic components must meet Title V specifications.
4AEJ jy L01ru� 6) Parking shall not be constructed over H10 septic components.
LOCAT 1 ON MAP � •^ 40 to 'r $ ,y�J The property is bounded by property corners and property lines.
(� 8) The property-owner shall review design considerations to approve of total
N1w, 5*40 S design flow and number of bedrooms to be considered for design. Receipt of
G I Gt payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
.. ` 9) The existing leach pit(s) shall be pumped and filled with material per Title V
abandonment procedures. Those within the proposed SAS shall be removed
along with contaminated soil and replaced with clean washed sand per Title V
� (t�lD tu�►-f1�.2 6�o C?QWD. G�4�.2. g eP
specs.
10)System components to be 10 feet from water line.
SEPT I C SYSTEM DES I G N ` 11) If a garbage grinder exists it is.to be removed and is the responsibility of the
owner to ensure such.
FLOW ESIJMATE
,{ BEDROOMS AT 110 GAL/DAY/BEDROOM GAL/DAY
� O SEPTIC TANK
/•- /< �- 1 GAJDAY x 2 DAYS _ GAL
/ / �• ��`Q,� � USE 1XI) GALLON SEPTIC TANK, DL-Itl? lkl
10 / �� cJ SOIL AB$ORPT I ON SYSTEM h
500 OJO.. ,>
XV
Al
N W A SIDE AREA.
BOTTOM AREA:' 2- !
r
SEPT I C SYSTEM SECTION
•
Or F&Wt -
I /
iR
584
0.00
GAL "7I, ti C50;Es164
V 1 ✓ � � +,
SEPTIC TAN
-13
2 ;
C/A L
i
-
Z 2� D� Ct Fi ��l
SITE AND - SEWAGE PLAN
V__
Z LOCATION : 7 7 "19�
3
I PREPARED FOR : h,/140-9 411
� -41
SCALE: � = D
-- DAY I D B . MASON gS DATE:/ / + 4
G 5 DBC ENVIRONMENTAL DESIGNS
� EAST SANDWICH . MA
DATE HEALTH AGENT
(508) 833-2177