HomeMy WebLinkAbout0090 WILTON DRIVE - Health 90 WILTON DRIVE, CENTERVILLE
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12534
No.
HASTINGS,MN
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Town of Barnstable
do Regulatory Services
s
iQ � B «; Thomas F. Geiler,Director
9Vpr ae Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:. 508-862-4644. Fax:. 508-790-6304
October 4, 2006
Ms. Joyce W..Bird-Jezyk - -
90 Wilton Drive.
Centerville,.MA.02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5.
The septic.system owned by you located at 90 Wilton Drive, Centerville, MA was.last
inspected August 28th.by, Raymond Dumas,a certified-septic inspector for the State.of
Massachusetts:
The inspection of-your septic system showed that your system"Failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:.
Single cesspools automatically fail in the Town of Barnstable.
You have.2 years.from the date of the system failure to bring the system into compliance. .
If there are any questions about this reminder,.please feel free to.contact the Barnstable
Health Department..
BARNSTAB,L/E" HEAL DEPARTMENT
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
6 '
� c_I
��• Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for 30igoar 6potem Construction Vermtt
Application for a Permit to Construct( ) Repair(„Y Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. �` r- ®� Owner's Name,Address,and Tel.No.
�e. Z Y
Assessor's Map/Parcel �o VL
Installer's Name,A ress,and Tel N. Designer's Name,Address and Tel.No.
�Lo� •-r��..tzC.. �7 1 �(ti.e 5�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder (Nx?
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures rrll
Design Flow(min.required) 3 V gpd Design flow provided 3y gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ` �'�6 ��, Type of S.A.S. �A H f G r W 11
Description of Soil 54= p VfN4 A^� C
Nature of Repairs or Alterations(Answer when applicable)
V
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued bX this Board of Health.
S' ned Date
Application Approved b 1 %'iDate
Application Disapproved by: Date
for the following reasons
Permit No. 7
�� Date Issued
Fe lee)
THE,COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpplication for �Oiqonl �paem Con5truction Permit
Application for a Permit to Construct O Repair Upgrade O Abandon Complete System ❑Individual Components
jLocation Address or Lot No. C1 f- Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
A Installer' Name,cress,and Tel.Ng Designer's Name,Address and Tel.No.
C, "1 3 Maas
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(min.required)_3 30 gpd Design flow provided gpd
Plan Date kQ lq 1w. Number of sheets Revision Date
Title
Size of Septic Tank (,S Type of S.A.S. LA IAT r Qp -t, Pc k k-c-rjm r,% W/.u-
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
11 /LS7/tt R
Application Approved by i( Date
Application Disapproved by: Date
for the following reasons
Permit No. a00-7 7-00 57-- 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 scok�
,.at lic, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. --40c7 dated I
,,fnstaller Designer r"C'kle.
I
#bedrooms Approved design do b gpd
I' w
s permit shall be con trued as a guarantee that esi
The issuance of this the system wi,,�,ntio as si ne
Date Inspector
------------------------ -- - ----------------
No. �QQ-7 Fee C)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Miqoal *p6tem Construction permit
Permission is hereby granted to Construct ( ) Repair (1/") Upgrade Abandon
System located at 50 t>> V�j I,- Z r c. \j 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: Constructip mu be completed within three years of the date f this pe J,iz
Date 9/7 Approved bQy
Town of Barnstable
�pSHE T
�'ti� Regulatory Services
Thomas F. Geiler, Director
* BnxxsraBI E,
MASS.: �0� Public Health Division
lFD1Ap'�a Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 112-2_/6'7 Sewage Permit# 6J Assessor's Map\Parcel Zo8
Designer: ,$-IZ-R/f64—) HNA-tS PE Installer: —SL o"
f-4 & 5"A-V—e-i.q,
Address: 92 3 A.,urE 64 Address:
lw,4 6z4.7�-
M
On I� I �� � -\r(,,�v� was issued a permit to install a
(date) (installer)
septic system at Qa k.)/L?-o X-) ale-4 v E based on a design drawn by
(address)
dated I Z y o G
(designer)
V/ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
.ate+ Y
A &a �t'S
(Installer's Signature) , S5461NO
;
/ ZZ 6 ,
(Designer's Signature) (Affix D sign is Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Revised.doc
TOWN OF BARNSTABLE
LOCATION 10 (011 , 0PJ ✓►2.• SEWAGE #
VIUAGE C1J.►1�C 2y I (�-L. ASSESSOR'S MAP& LOT a 0�3 O
INSTALLER'S NAME&PHONE NO.
SirP71C TANK CAPACITY
LEACHING FACILrrY: (type) ,Z +roe�r � �w�C_(size)
NO.OF BEDROOMS S
BUILDER OR OWNER dN
PERMTTDATE: 5 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and } 14 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) IJ `A Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) N i Feet
Furnished by
CAC)
d � QZ
kz -
TOWN OF BARNSTABLE •
LOCATION 'FU e!/�i oQ. ,c,e SEWAGE#
VILLAGE d—V,W%e ASSESSOR'S MAP&PARCEL a20 9 —USU
r'
INSTALLERS NAME&PHONE NO.
!;SEPTIC TANK CAPACITY
c LEACHING FACILITY:(type) 02 C9:s5 892Z S (size)
NO.OF BEDROOMS 3
0WNER +•c�,t,e �� ,�Z
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
i
I "gc�
t o'
i9 '
q TOWN OF B�ARNSTABLE
LOCAL?,ON ti 0 cc� � `' SEWAGE# JQd 7 — 005
VILL. GE Cp� fV1 ��, ASSESSOR'S MAP&PARCEL
1-J�INSTALLERS NAME&PHONE NO. UV
SEPTIC TANK CAPACITY Q Q coe,
LEACHING FACILITY:(type) H DQ VAT eGA (size) f® }( )( /o'd
NO.OF BEDROOMS 3 ' �S Ly
OWNER
` PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility �� Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
L
ithin 300 feet of leaching facility) /"► Feet
RNISHED BY Q(kr/ ,
13 ko I-ePk;c- 3 QoX �S
l �
P°
yy
L'rG.
TOWN OF BARNSTABLE
LOCATION '76P A✓1.4 Imp 30e SEWAGE #CCv7
VILLAGE ASSESSOR'S MAP & LOT S
)NSTALLER'S NAME fa PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY .4
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS ,PRIVATE WELL OR PUBL�IC WATER
BUILDER OR OWNER "�rs Z /r- —j—'a /C£
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r
a
14
35' "
O
d'
TOWN OF BARNSTABLE
LOCATION 7� k✓ I 3� SEWAGE # � (l,
cFwT'
VILLAGE ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY 4
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 'J—£Z
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
d#
0
c�
M
4�
°h
9
1`No. C� Fee + i/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for �Bigoal *pztem Construction Permit
Application for a Permit to Construct( )Repair(v(upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Gf® W`��-CQ� �\ Q Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
GPI 4X~d .
'Zoe- 03-0 �i0 c��•t^C'ov� vti. �.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
P', QC C- -7-7-Z- � o�
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ac P_ 2w s2s t�tvA�� v,.�oQw.�e
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 is 's �fHealth.
Signed Date Q'�.'S'�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
No: � Fee �
-'THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes✓ '
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS q
fppricatton for Migogal *pgtem Con!5truction Permit
Application for a Permit to Construct( )Repair((Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 90W Owner's Name,Address and Tel.No.
Assessor's Map/Parcel C . �`^'� �k J Le.. J F C.
�O`-Z S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Q C�c. oc,
t k S-TctQe 7 w kw_\ wA
Type of Building: F
.-Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria(
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
_ M P . Plan Date Number of sheets Revision Date
Title
"'t Size of Septic Tank Type of S.A.S. {
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) c� \
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 iss b s, o d f Health.
Signed Date
.Application Approved by IteM.L. _ Date 9' - Z
Application Disapproved for the following reaso s
Permit No. 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 �t�2,C Cc
at St h . D"\c--Q a , JZ C o,r=aA �\ a has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer ,v
The issuance of this pe t shall,not,be construed as a guarantee that the V_s iri will funct;on as designed'I
Date �-' s �� Inspector ?,�� •_. r� a
1 r
r
---------------------------------------
No. / S— / Fee _'—
_. THE CL'iLiiveONWEALTH"OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mizpozal 6potem Conotruction Permit
Permission is hereby granted to Construct( )Repair( 1, pgrade( )Abandon( )
System located at
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:Construction must be completed within three years of the date of this permit.
Date: 9, — 2�/� Approved by
_ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF ��„„�� a
DEPARTMENT OF ENVIRONMENTAL PROTECT, OCT
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 k ACT 8 1998
WILLIAM F.WELD Y XE
Governor tary
ARGEO PAUL CELLUCCI S B UHS
Lt. Governor b1 m*nissioner
.. (, SUBSURFACE SEWAGE DISPOSAL SYSTE INSPECTION FORM
a PART A
o M _ o So . CERTIFICATION
Property Address: V IIJp TG4, b2' cqtN;kkgA l`^' Address of Owner: Laoci�- _DVNN'L
Date of Inspection: C(�l9 a (If different) 3c)d 'si 20' )
Name of Inspector: _\
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: ,'
Mailing Address:
Telephone Number: 'S CA.-"11—
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
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails q u C1
Inspector's Signature: 9Y
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 lregional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any.
failure criteria not evaluated are indicattdd below.
COMMENTS: 1 e G]�_ C-
�y.>
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, 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.
(revised 04/:5/97) Page 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
eJn�'�
CERTIFICATION (continued) .
p.ey�7.15 �f''
Property Address: VAC
Owner: `
Date of Inspection:
�B] SYSTE ONNDITIONALLY PASSES (continued)
*♦
Sew`agebackup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
k duto broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
� I � 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
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERML tES THAT THE SYSTEM IS NOT FLTCTION V G IN A
MANNER WF5CH 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"ILL FAIL UNLESS THE BOARD OF HEALTH (AND PLBLIC WATER SUPPLIER, IF APPROPRIATE)
DETER LINES THAT THE SYSTEM IS FUNCTIONING IN A b1ANNER 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
' I
(revised 04/25/97) Page 2 of 10
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either "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 from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
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 II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: WNWe.
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 of water have not been introduced into the system recently or as pan 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, naterial 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:
1 The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
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)]
d
(revised 04/25/97) Page 4 of 10
/ 1
e
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:90
Owner: 'f ri N<
Date of Inspection:
D FLOW CONDITIONS
RESIDENTIAL:
Design flow: UA-�d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents: 0
Garbage grinder (yes or no):�
Laundry connected to system'(yes or no):— ,
Seasonal use (yes or no):_t3
Water meter readings, if available (last two (2) year usage (gpd): .
Sump Pump (yes or no): N•
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present-. (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readines• if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFOR, ATION
PUNIPEIG RECORDS and source of dd'nformation:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
_ 2L_ 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: 30 tAOA
Sewage odors detected when arriving at the site: (yes or no) �
(revised 04/25197) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER: a
(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)
,Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(e lain)
If tank is metal. list ape _ Is age confirmed by Certificate of Compliance _(Y s/No)
Dimensions:
Sludge depth:
Distanct from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
Comments:
(recommendation for pumping. condition of inlet and outlet tees or ffles. depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
GREASE TRAP:
locate on site Ian)
( P
Depth below grade:
Material of construction: _concrete _metal _IrglassPolyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee o 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.)
(revised 04125/97) Page 6 of 10
I
r
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspections ,
TIGHT OR HOLDING TANK: (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.)
)ISTRIBUTION BOX:_
(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 I ge in[o or out of box, etc.)
PUMP CHAMBER:_
(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 appurtena/es, etc.)
(revised 00/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �Q Wl�lvN
Owner: 'bUrj Vj<-'-
Date of Inspection: I
SOI
L ABS
ORPTION SYSTEM (SAS):
uired: but may be approximated by non intrusive methods)
(locate on site plan, if possible: excavationnot re q
If not determined to be present, explain:
Type:
leaching pits, number:_
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.)
CESSPOOLS:.
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: R
Depth of solids layer:¢i �� 1,
Depth of scum layer: 1 u A' L-0
Dimensions of cesspool:" 1 - -96tt►X 7 'U" �." S�IRX'I
Materials of construction:s_t3Wcv 'C- f
,, or-K-_
Indication of groundwater: 1->
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of h�draulic failure, I vel of ponding cgnditi of etation, etc.
a ^SI NA
PRIVY:
(locate on site plan)
Materials of
construction:
Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 or to
' w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �Q GSt��1W
Owner:
Date of Inspection:
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)
t
�Z' 1` l
(revised 04/25197) P2gc 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
q rtrt SYSTEM INFORMATION (continued)
Property Address:
Owner: . b V n/vi-�
Date of Inspection: c
t
Depth to Groundwater tN Feet
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)
t( (� We w
(revised 04/25/97) P2ge 10 or 10
lime Town of Barnstable P# l
Department of Regulatory Services
' Public
• t�MAS&�A.r$ Health Division Date
200 Main Street,Hyannis MA 02601
EO MA't
Date Scheduled L,l ® PJ Time�_
Fee Pd,
Soil Suitability Assessment for Sewage Disposal
Performed By:
Witnessed.By
LOCATION& GENERAL INFORMATIO
[NEW
tion Address L k Vq �(- Owner's Name
Address C/D w i 1-u/� D c-
sor's Map/Parcel: �-� /v-6,5r /7C�
` Engineer's Name
CONSTRUCTION REPAIRS �.
. Telephone#
Land Use 2 E'S+ Dix r r A4t Slopes(%) 7 /G
Surface Stones A-1v
Distances from: Open Water Body ft Possible Wet Area
ft Drinking Water Well 8
Drainage Way___ft Property Line /_ r _ft Other
ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
41
Y
Parent material(geologic) IU Tsv A'S N Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 0 A�
Weeping from Pit Race_ .jIA
Estimated Seasonal High Groundwater !4
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: k�>a b*, x�-r-
Depth Observed standing in obs.hole: In. Depth to soil mottles:
Depth to weeping from side of obs.hole: in.
Index Well# Reading Date: Index Well level in. Groundwater Adjustment ,
AdJ,factor- Adj,drou idwwater level,� 9
PERCOLATION`PEST bate /2 / vt'Time o:
Observation t
Hole# Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ Time(9"-6")
End Pre-soak /O G-7
Rate Min./Inch Z^
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
r,
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in:) (USDA) . (Munsell) Mottling (Structure,Stones;Boulders.
ConsistencL% ravel
30 14 L. S . 'yA Y
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistengy.%
26)
/2v
f C,Mv&-�L-
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Cnitec Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders..
Consistency, Gravel)
Flood Insurance Rate Man:
Above 500 year flood boundary No— 'Yes ..
Within 500 year boundary No ✓ Yes
Within 100 year flood boundary No ✓ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? .ieCS
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on �� 4` (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,ex a and experience described in 3 10 CUR 15.017.
Signature Date 2�4/
Q;\sEP mPERCFORM.DOC
n.
ACCESS COVERS MUST BE WITHIN
MIN/Mum" INVERT EL EVA T I ONS : DES 1,GN ' CR I TER / A : GENERAL , NO
6 OF FINISH GRAD TES
MAXIMUM COVER
INVERT AT BUILDING 100, 73 DESIGN FLOW:
102.73 IRS ' I VTET ON
F T 2.* TO
BE LEVEL-7 INVERT AT BUILDING #2: /00.4 3 BEDROOMS AT 1/0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
MIN 2* OF PEASTONE
INVERT IN SEPTIC TANK: 96,25 BEDROOM EOUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONL Y.
4 D IAW PIPE
1 112' DIA. INVERT OUT SEPTIC TANK: 96.0
-57 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
1. 100.73. 196.0 10* DOUBLE-WASHED STONE INVERT. IN DIST. BOX: 93, SET. -SEE`,SITE-PLAN.IFH-20 -'BOX:, -93.4
2. 100.4 GAS 57 93.33 INVERT OUT DIST.
BAFFLE-1 SEPTIC TANK REOUIRED:
5 4 HIGH CAPACITY INFILTRATOR INVERT IN LEACH CHAMBER: _ 93-33' 330,G.P.D. X 200x -; 660 GAL.
OUTLET j. ALL CONSTRUCTION METHODS AND MATERIALS AND
TONE AROUND CHAMBERS W13.5*1 S BOTTOM OF LEACH CHAMBER: 92.5
D-BOX,, *� 11 1 1 SEPTIC TANK PROVIDED: 1500 GAL. MIN. 'MAINTENANCE OF. THE SEPTICISYSTEM SHALL
1500 GAL /0'r x 38'1 x IO'd i
ADJUSTED GROUND WATER: NIA TITLE 5 AND LOCAL
CONFORM TO MASS. D.t.P.�
SEPTIC TANK 6' CRUSHED STONE OR
OBSERVED GROUND WATER: NIA SOIL ABSORPTION SYSTEM REOUIRED: BOARD OF HEALTH REGULATIONS.
COMPACTED BASE
' 'DESIGN PERC RATE ( 5 MIN/INCH
BOTTOM OF TEST HOLE *1: 86.0
SOIL . TEXTURAL ,CLASS, 1 4. ALL SEPTIC SYSTEM 'COMPONENTS LOCATED UNDER
PROFILE : NOT TO SCALE
AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
EFFLUENT LOADING RATE - 0.74 6PDISF
THAN 3' IN DEPTH SHALL BE-CAPABLE OF WITH-330 GPD 0.74'GPDISF - 446 S.F. REQUIRED
STANDING H-20 WHEEL LOADS.
PROVIDED: 4 ,HIGH CAPACITY INFILTRATOR
CHAMBERS W13.5*1 STONE AROUND.' A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR
460 S.F. 0.74 - 340 6PD APPROVED EOUAL.
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SOIL TEST PI T DA TAS PRECAST CONCRETE AND VATERITIGHT. D-BOX, SHALL
BE WA TER TESTED TO CHECK FOR L E VEL WHEN THERE
m INDICATES v INDICATES
PERCOLATION OBSERVED IS MORE THAN ONE OUTLET.
TEST GROUNDWATER
*DIG-SAFE'.
7. BEFORE CONSTRUCTION CALL
C91DH FND CRIDN FND ti TP P*11530 TP *2 1-888-DIG-SAFE AND THE LOCAL WATER DEPT.
HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR FOR L OCA T I ON, OF UNDERGROUND UTILITIES. ,
0' 97.0 0' 96.0
LOAMY IOYR
FILL A 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE t
/8.. ...................................I....... - 95.5 12*. ...............SAND- - ............J/-4 95.0 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
11.33*30 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
LOAMY IOYR LOAMY IOYR
101 SOOT A - B CO
SAND 314 SAND 416
CKA ROOIA 30-- ---------.................................. - 94.5 20* ........................................ - 94.3
STO LOAMY IOYR - C I kED-COARSE IOYR - 9. EXISTING CESSPOOLS TO BE PUMPED DRY AND
N SAND 416 SAND AND 518 BACKFILLED.
fA-OAK DRO00 44 - 93.3 60' GRAVEL
\ ��ll I Ii I RED-COARSE IOYR
A, L 0 T 6 C I
SAND AND 518
/0. 200± S.Fj'. 60'- GRAVEL
ING
LIV cc) t
te�AA;* 0
000
DECK
cE,sspO6t\.
D I"ING
ROOM NO WATER NO WATER
C1404 I32 86.0 120- 66.0
KIT
CESSPOOL A 'A
4 NIGH CAPAclry DATE.- DECEMBER I, 2006
IAAc1lLTR4T6R CN&BERS--
I d TEST BY: STEPHEN HAAS
210 Ar-CORMiR BRICK W14 OUA011 - . I I
1" .11 pA WITNESSED BY: DONALD DESMARAIS
STEP. EL-102.26 t ")A
PERC RATE: 2 MIN/INCH
0 T:
.qOO eALLON VAR I A NCES REOUIRED :
SEPTX TANO�'
ti 6 4 §bP 2 TITLE 5. MAXIMUM FEASIBLE COMPLIANCE
O'l K
CAOAGE
SECTION 15.211; (1) MINIMUM SETBACK DISTANCES
TPOI
iyl-�Z� I
IS REOUIRED BETWEEN THE SAS AND A SLAB. 6' IS PROVIDED.
0 MILL-pa-r-
_YAPOff-JtARR I ER A 4' VARIANCE IS REOUESTED.7
91,95*50
039
68
CB/OH FND 5 ,L=- P T 5 \Y` S TE D E S / /V
-P 0 W L- TOM OR VE- . "AP -:::10 8 . PARCEL �5 0
RA RIVS 7A RL E" cE-1v7-E-R v L- L- E- ) "A
ROUTE 28
T LEGEND
0 C7 E- 1--j zs- z K
L N CB CONCRETE BOUND
Ocus LONG
W-1
PO WATER L INE
-4 .2")0 0 45
10 '�HYDRANT 5CALE .20 '
6- GAS;�j NE
EAGLE SUFRVEY I N G I N
OHW OVER HEAD WIRES
L LIGHT POST 923 Rc> u t e 6A,
-E- UNDERGROUND ELECTRIC LINE N 0 Yarrr)outhper,t MA . .02675,
-T- ( 508 )UNDERGROUND TELEPHONE L INE //tit 3 6 2-8 1 3 2
-CTV- UNDERGROUND CABLEVISION LINE 508 4-32-5333
40.4 SPOT ELEVATION
-40-- EXISTING 4 CONTOUR
PROPOSED CONTOUR
LOCUS MAP 0 /0 20 40
JOB NO: 06 /274 FIELD:CFWIEEK CALC: SAHICFWTCHECK: CFW DRN: $A
99!2.5
C EXISTING
CESSPOOLS TO BE PUMP
BA CKF I L L ED