Loading...
HomeMy WebLinkAbout0023 JAMES OTIS ROAD - Health 23 James Otis Road, Centerville =rt s i r .���1 J�4ECYClFpco UPC 12543 N O�R •�{'°SST COH`+J��a HASTINGS, MN r No. . II �` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for � gpogar 6pgtem Congtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade tY Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.c ,_; (J4M eS d 44.5 1;?Cf Owner's Name,Addresssi and Tel No. vPurl In1 Assessor's Map/parcel Installer's Name,Addres85 Ma&b.Street Designer's Name,A dress and Tel.No. W. Yarmouth, MA 02673 IYIej r t/eh� . 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) 33 O gpd Design flow provided 33/. S gpd Plan Date r Number of sheets / Revision Date 'V I A Title Cf 11C -J-C4_ a 4 Size of Septic Tank {,rjJet e rit, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) t!— / ,as-t 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 EnvironmentalIdend not to place the system in operation until a Certificate of Compliance has been issued by this Board of H lh. Signed l Date 81 '6 Application Approved by _ Date -27 06 Application Disapproved by: Date for the following reasons Permit No. ))*- 1 Date Issued 27 d f 3 R 41 No.. Fee I!� THE COMMONWEALTH OF MASSACHUSETTS ' Epteredincomputer: .z �` ...� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,' MASSACHUSETTS, '`[pprication for �Digpo!6al *p6tem Congtructton Permit Application for a Permit to Construct O Repair O Upgrade Abandon O ❑Complete System ❑Individual Components Location Address or Lot No.c) jA(_)1 PSS - 1 Owner'/s Name, dres j and Tel.No. Assessor's Map/parcel /7 f — /(0 3 Installer's Name,Address,and Tel.No. Designer's Name, dress and Tel.No. !Y4eVer �hc� . Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers O Cafeteria( ) Other Fixtures 2 Design Flow(min,required) .33 O gpd Design flow provided 33/ S gpd Plan Date Number of sheets Revision Date N 1 A f _ �. ' Title Size of Septic Tank efl i-1/,, 9 /D d O} Type of S.A.S. Description of Soil ,-)/,4 r-7 Nature of Repairs or Alterations(Answer when applicable) P A s1 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. p Signed 1\ (C Date _ C) CJ - is// Application Approved byJt2 Date Application Disapproved by: Date for the following reasons Permit No. hlX 9- !1 f Date Issued 3 2 7 r)(„ --------------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ` Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( , )by at z) JA KAtS i S (2 U� �r.K 041! has been constructed in accordance / 04 with the provisions of Title 5 and the for Disposal System Construction Permit No. �w�' 11 dated 3/') -7 Installer Designer #bedrooms Approved design flow gpd The issuance of this ermit ha not be construed as a guarantee that the system WGI functiQh design d. Date "I Z Inspector 1 f • /1 No. 66 Fee /U 6 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=igpo.5a1 *p!5tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( �� Abandon ( ) System located at ©)? V,Q i21 PS and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Con traction must be completed within three years of the date of this permit. Date '�) 2 In Approved b7 • Town ®f Barnstable- Regulatory Services I 1 t *. Thomas F.Geiler,Director anz�iV��sLs,a Public Health Division kFpa Thomas McKean,Director 200 fain Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Aoizi L, 11, Wob Designer: Installer: A & CA C0 __ Address: . #Pol _box Address: 350 Main Street _ W. Yarmo ith no n Ivy ms37 On�0/(5 C'AnC6 was issued a permit to install a (date) (installer) septic system at �. �AMLeS based on a design drawn by (address) �- S, dated c ' e3 U'0,6 (designer) Icertify 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. t 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 fello-:;l. VyA OF DARREN sta r s Signature) Q . 1140 SgNITAR%PN J"� (Designers Signature) (Affix Designers tamp Here) PLEASE RETURN TO BARNS ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF C2ARLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEI'VEID BY THE.BARNSTABLE PUBLIC HEA111A DDiTISI0N. THANK YOU. Q:Health'S`eptic/Designer Certification Form 4 Cap r 22 TOWN OF BARNSTABLE i LOCATION�v �AMES t t 5 ' SEWAGE# 'VILLAGE '[l�V tC ASSESSOR'S MAP&LOT I� INSTALLER'S NAME&PHONE NO. 194 (9 C�►�Co SEPTIC TANK CAPACITY CX tS71N5, /6bz05,4 1 ry LEACHING FACILITY:(ty e),gfl V r 10� 3 D:5O 5 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: .3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility l l' 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 � �O 114 rrin F-LJ 63;zhls TOWN-OF BARNSTABLE :GCATION - S t_/ i i S R-6 — SEWAGE # VILLAGE Cy` ASSESSOR'S MAP & LOT 16 3 INSTALLER'S NAME&PHONE NO. t SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) ,! NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 �7on site or within 200 feet of leaching facility) Felt Edge of Wetland and Leaching Facility(If any wetlands exist 'within 300 feet of leaching facility) FY!et Furnished by1N� 1 .. _' ,# .. ,yf __ _ i�K�. ` V � � � � � � ib , „�:, .•s::.,,. �a� i ";•; .. .. �. 0 .:, ,. ... �.,I' . ,�� .� ',�:. - f i Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, Dm p-u� 04e,, i -4- ,hereby certify that the engineered plan signed by me dated 02-'^Zg•��,concerning the property located at 2�) �'�A4E5 OT1 S (�O&D meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • 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 Frimptor method when applicable] Please complete the following: c A) Top of Ground Surface Elevation(using GIS information) SS 1 NO w B) G.W. Elevation J l• +adjustment for high G.W. DIFFERENCE BETWEEN A and B SIGNED : DATE: UZ •2�'0 6 NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc P� 4 sa CENSUS TRACT # 1a9 o man P:lrraae, & Tarr E 859t` PAGE 40�, 9 30d 17-24 L r. ASSFS. PLANRTGAGE I N S P E C T 1 0 N PLAN of L A N 0 L 0 C A T F 0 AS 23 ,LAMES OTIS ROAD CENTERVILLE, MASSACHUSFTTS SCALE; 1"• 40' MAY 27, 1997 LCT a0c, � t aa' edya 06- 34' Ua •rl T" 16 DFt � pdOcH 150,00 � c�3 Y f bb M' UToR f I JAME:J VTI J ROAD 1 CF_RTIFY TO DUNNING, IURMAN, KIRRANE, & TERRY, MORTGAGE CORP OF THE EAST III iND ITS TITLE INSURANCE COMPANY, THAI 1HERE ARE NO VISIBLE. FNCROACHMFNTS OR ASEMENTS LXCEFT AS SHOWN AND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE UPERVISION, HE LOCATION OF DWELLING AS SHOWN HEREON IS N COMPLIANCE WITH THE 1 OCA! APPLICABLE UNING BY-LAWS WITH RESPECT TO HORIZONTAL tis IMENSIONAL REQUIREMENTS. , �< Nciai Y Ff:PmRA HE DWELLING SHOWN HERE OULS NOT FAII WITHIN SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON °'j;«E��°•f MAP OF COMMUN I 1 Y #250001-00MC DATED 1/19/85 BY THE F. I .A. � 4 Kenneth R. Ferreira s Engineering,Inc. rO.Ekw 19m3 '"`•�^"" Nf.�rBedfoM..MAUZ741-1903 _ SM 1)92-11U2U a tax:b08 992 3374 6ti`pAl 90115! (1) flls declarations eada above are on tke basis of or knoaltdid. inforsotian, and belie{ as the result of a mortgage plat plan lap* smr.rr i,„pbction made to the normal standard of oars of ra0)stored "and ♦vrveyort prsetitlog io t"assachusetts. (2) Detlarations are mode to the above named vlient only as of this date. (31 This plea vas oot made for recording vurpa■s4, for use in preparing dead dsseriptioot or for too strattlaea. (e) yerMestioea of ppopsrtr lino disensiens, bsilding Offsets, fences. or lot cunfiyofdtiun ear iL—be at¢*e98Dene4 colt by 44 satarate instrument ivrVty. Commonwealth of Massachusetts RECEIV�I Executive Office of Environmental Affairs Department of APR ? 8 1997 Environmental Protection m HEALTI-�-T. •OWN OiF L n, - William F.Weld ^- Governor Trudy Coxe " Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION. ._ Property Address:a 3 J R Mv-!5 GTt" '(Z.. 0, G,�.-P-ve''vt`(ekddress of Owner: Date of Inspection SC -7___ (If different) SC-c� Name of Inspector: t�ocsl�rl Company Name, Address and Telephone Num6 l1er: t Q'C 0t QC O I�jv3X!r rC YCSt. (`t 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: i/ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signal uie�"-�-__- Date: LI _ ]_�'7 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 sen: tv !ne system owner and copies sent to the buyer, ii applicable and the approving au;l-,on,}. INSPECTION SUMMARY: .--- --Check A, B, C,`or D:... .. __. .._.._.. A) SY EM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If"not determined", explain why not) The septic lank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if.the existing septic tank is replaced with a conforming septic tank as approved by the Board of.Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 sae= Printed on Reart ed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address Owner . t Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level-observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven':distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distributrdh box is levelled or replaced The system required pumping more than four tirnes.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 .y.. i C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the en 11 vironment. ,.. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTI.ONJNG IN A MANNER WHICH Wlll PROTECT. THt PUBLIC HIAITH AND SAFETY AND THE E.NViRONMENI: _ 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON iE'J: the c,Stem nas a seoiic lane: anu SOU au>orpuun .sNmen+ dnu a v%iliuu ivv 'itc; to a iu a c „616 S NN i G: irl Car, a surface.water supply. _ [ The systen, ha- i septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well _ The system ha> a septic tang, and soi! absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for col'iform 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:._.___...__. _.__. ..._..._.... D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board,of.Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/•55) 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A --- CERTIFICATION (continued) Property Address: Owner: e-TA t V Date of Inspection: t-4 -cl 7 DJ SYSTEM FAILS (continued): 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. ILI Any portion of a cesspool or privy is within 100 feetof a surface water supply or tributary to a surface water supply. "-" 1 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 qualigt,-anaij,5is. 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater tlarge System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is "ithin 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 suppiy 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. 1. 1 (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B' CHECKLIST Property A dress: c_7 .J 0 m zs G +,,S Ce-,Z Owner: ,I c-_1i Date of Inspection: 7 Check if the following have been done: l/Pumping information was requested of the owner, occupant, and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. H_1(I As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for sigifs'of sewage back-up. -/The system does not receive non-sanitary or industrial waste flow ,.,/,The site was inspected for signs of breakout. r/All system components, excluding the Soil Absorption System, have been located on the site. _/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or /tees,'material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or app ximated by nun-intrusive methods. . 7f�c facili;, o.,;.i ;; o:cuNa'a:, if d fferc^.' from, ovmer' were provided \vith information on the proper maintenance of Sub- Surface,Disposal System. hf, I, �I I j (revised 8/15/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A Y\%E5 oT\S R9, C'N � Owner: �:ti��r✓ Date of Inspection: -l-,D17 t7 FLOW CONDITIONS RESIDENTIAL: -.. Design flow:�: gallons . Number of bedrooms: 3 —" Number of current residents: a Garbage grinder (yes or no): Laundry connected to system tyes or no):—Y— Seasonal use (yes or no): Water meter readings, if available: ��A- last date of occupancy: ' e'er ..;<\ COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:__gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_' Non-sanitary waste discharged to the Title 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: System pumped as pan of inspection: kyes oho)_ If yes, volume pompoo. gallons •'' _._ Reason for pumping: TYPE qk5YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow.cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and 'source of information: II Y✓S Sewage odors detected when arriving at the site: (yes or no) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: h-Yh OT Owner:VL-I t e-rv'i L Date of Inspection: H 7-1.7 SEPTIC TANK: (locate on site plan) _- Depth below grade: - , — --Material of construction: -- concrete metal —FRP —other(explain) --- v Dimensions: Sludge depth: & Distance from top o;sludge to bottom of outlet tee or baffle: Scum thickness:Q t Distance from top of scum to top of outlet tee or baffle: ICE A Distance from bottom of scum to bottom of outlet tee or baffle: I`V Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid Level in re tion to outlet invert, structural integrity, evidence of leakage, etc.) T' =a GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete.—metal _FRP—other(explain) - - Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: D;Ctance from hottrnm r,, c(j,m v, hr�nor.7,of N.Opi tee o, hallie- 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.l (revised e/:5/95) 6 I ,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 'M-eS Owner: Gy r ram. Date of Inspection: I-a-7-47 TIGHT OR HOLDING TANK:/ (locate on site plan). Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons --- Design flow: gallons/dad Alarm level: 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: N gao44u L, Comments: mote ri ievei anu distributes,, i> eu4o , e, Licnce of su:iu: evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) A ' Comments:, _(npte condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) f • s. SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address`: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (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: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locale 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 groundwatc:. 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.) Wa 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 8/15/95) 8 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property�,A�ddressc,�3 SYAvvNeS C-Tts �, e� Owner: ,k t-Q_ Date of Inspection: �J•'7-sj 7 SKETCH-OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' e� 0 I, DEPTH TO GROUNDWATER No wwrc�,-- Depth to groundwater: feet method of determination or approximation: u in i lzevised 6/15/95) 9 ,� l L o � w- THE COMMONWEALTH OF MASSACHUSETTS BOARD�.A H ��l1�+f�?�............O F.... Appliration for Uiipn,ial Workii Tomitrnrtinn Prrmit Application is hereby made for a Permit to Construct (!._} or Repair ( ) an Individual Sewage Disposal system .. �. ........... •----- ... ------•-- - ----------- oc ion:Address or ............•.................. .......•...••. ............... ................. Owner Address W —.................................... .................•.& ..� .............................................................. Installer Address UType of Building 3 Size Lot..� ,,_.c ►...Sq. feet �.� Dwelling—No. of Bedrooms............................................Expansion Attic (�'a Garbage Grinder ( A Other—Type of Building No. of persons............................ Showers a . g --------•----•----------•-•- P ( ) — Cafeteria ( ) dOther fixtures ..---••-•--•••• ••••--••-••----••-•.....•-•.........................•••••••••••••••-•-•-••••-••-........•-•-•••••-•-............-•-•--••-•••---_..... W Design Flow.........�F_.Zzz .....................gallons per person per day. Total daily flow.......... _.d..................gallons. WSeptic Tank—Liquid capacityl&4-K2.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....(_.Q ?.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per. inch Depth of Test Pit.................... Depth to ground water........................ fYi ----------------------------------------- ------------------------------------ -•------------ ---------------- •----- -•----- ......._.................... 0 Description of Soil.................... ------------------•----•------........---•----------------•--------------------------------------•--------------------••••-•-•••............•-••••- x U ---------------------------------------------------------•------..........-----------.....----.....-•-------•---------------•-•--------------•--------------------------------------•--......•----••.... w ---------------------------------------------------------------------------------•-----------------------------------------------------------------------------------------.................-•-••-..... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•--•-------------------------------•--...--••-----...-------------------•----•--•-••-----•---...........------------------------------....••••-••-••-•_._.......••••••••-•••--•••-------........ Agreement: e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with th p visiol of ilTt 5 the State Sanitary Code— The undersi ed further agrees not to place the system in e ion a Ifi f Compliance has bee issued by the boa of health. ......... .................................................. •-•-•• 1....fS. ijat� Aplic io p rov .......... •••. ••••......................................................••-••-•---•--- ...)•••••. ... .................... Date A I' tion Disapproved for the to ' g reasons:-------•-------•---------------------------------------•----...-------------•--•----------------.........------. ----------------------•----------------------------------._...------------...----•--------••--•--------...---•-•-----------------•---------------------------------------..---.......................... Date PermitNo........................................................ Issued....................................................... Date Noo..j.......�.L...f .............. THE COMMONWEALTH OF MASSACHUSETTS 80ARDjQF HEALTH ............OF....; ... . ........ ....... ..................................... .�i!&'>o�l, Appliration for Uiiipoiial Workii Tomilrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .......................... .............................................................. .................................................................................................. Location-Address' or Lot,No. /;. ................. ................................. ................. -- --------- ----------"...............*........... Owner Address ................ .......... ............. ............. ........... ................. ..................... ................................................ ✓ Installer Address Type of Building Size feet U Dwelling—No. of Bedrooms..........'n...............................Expansion Attic Garbage Grinder a, Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow......... .......................gallons per person per day. Total daily flow........... ,. " � . .........................gallons. 1:4 Septic Tank—Liquid capacity.,!.-...-.,2.gallons Length................ Width.............___ Diameter__-____......... Depth....___......_.. Disposal Trench—No. .................... Width_._..___.._.._._._._ Total Length__....__.._...._.... Total leaching area....................sq. ft. Seepage Pit No.___-{_._.. .___:':.. Diameter.................... Depth below inlet.._....._........... Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit___.__.............. Depth to ground water.._._..______........__. Test Pit No. 2................minutes per inch Depth of Test Pit..._..........._._.. Depth to ground water........................ ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ x U ................. ....................................................................................................................................................................................... ---------­---­---­­-------------------------------------------------------- ............................................. ....................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..... .............................................................................................................................I.................................................................... Agreement: e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with visions =PT th /d, s of , j 5 the State Sanitary Code— The undersigned further agrees not to place the system in r A. I per ion u fi Compliance has been issued by the board of health. o ......................................... ..... at APic o p rov ...... .... ....................................................................... ... ........... Date A [* tion Disapproved for the to i g reasons:............................................................................................................... ......................................................................................................................................................................................................... Date PermitNo..........................................-------------- IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdifiratr of Tomphatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by..........OeIA........................I. .......................... -----------------"----------------­------­-----------------­--*......*--------------- staller 4 L_. at............ ... .....;.. ... ............... .... ................................................... ....... .... ......................... liee-,e with t y has been installed in aa6orda e with the provisions of TIT 5of The State Sanitary Co0 a de in the In arc il W ks Construction -7- application for Dis os, Permit No..--rY .......... dated ........................... T IS CERTIFICATE THE ISSUAN F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................KIXIK�.............................. Inspector----- .......... ............................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF................................................................. .................... FEE.E.40............. Elhipoll6a rks Tonatnution "prrmit Permissionis her eb by granted....... ............................................tv........................................................................ to Construct ( j4kg2!repair an ual posal System at No...... 'r an ua al Works Street as shown on the application for Dis osal W orks Construction Per o ... .............. Dated.._......._-____.._.__.................... ......... . ....... -.:.r_/d/_ f-,el Board of Health DATE............... .................................................... FORM 1255 A. M. SULKIN, INC., BOSTON 5I► 6LC- FAMILY WO "GAIiOAGE Ow IIU x fS x z30G.P. D, o is►LY F -- SEPTIC TA►JK = 330x15o /. �197G.P. 0 5L USE- %00o GA>-. o15Po5Al. PIT �5E ►vo0 GAL_. y$rF. S►D4WALL A¢.EA = �50 S.F; X 2.5 t 3�5 G.PD 'izo(� o ,. 50TTOM AQEA- • Y0 S.F. O PIr o ;_ f F ; -T oT A 1•- C>S. I G N = .g-2 5 (,.P. D. ' -T OT AL. D A I Y F W - 330 0711 „; w a+'^ PE2COLATION RATE : 1"IN 2MIN o�-1-�55 'r• �vv�1�ATlo� /��/.n(TL ., 4F�tH OF M4S �'Ei `H ; I ; i-I�,i OF M v� AICHARD �t�G #• - �I A. DAVID C. . BAXTEP u, o THULIN .�i�0 ►Q + " f�10•:40480 No. 29 -976 y OO •O G7 i 7 CISTER�b4- �F U T I ��tr.,4vQ AND SUn'I�y NAL E #" TOP FNU- S-7 WOO:.- 12-1 -Bg rL:y, ,,,.,- - 1Nv, 54 r E LOAM 1000 $� D►4T. a�.INS' SEPTIC. 53.8 Z 1000 INV. Bu�c 63•G -rAµK s � s ,. . LC A, INV. INV. 51•L S3•ar •r Y' rt 7 WASK6D 6Tv r16 �,'it. I, ryl��' GERTIFIGf� PL��"t� PI..AIJ SA�� PRt�PILG 11 z l•0 L A-T 10 N 4'3 ('; Wo 5CA.LE 5CALE III 40 DATI'c A-v�-Ael. o WATL`�IL q^. GE RTIt=Y THAT THE I'�' ��0Q SNo�YN KE2EoW COMPLYS YJITN THE S l o6L_1N I oT 2vG A►JD SE'TeAGK RR,,6Q011L oF 'TN� To W N o F �$A R/J`7Tla>- A►�� I S �pT T,L LOCp.TED MIT IIJ 1A-s GL000 PLAIN v DA'T 1r -2 4 C,l RLEG 15Z F--2.E.'D'I-AN o s v MY EYoeS Tins PLo,KI ►5 WoT 5t -5c rU pId AN os-rEczvILLF • N�AS5; I� IN5TR.uM6N7- SQZVe`( 'rHE 101=F,SET5 6WOUL3> N o'T C�t~ U 5 E O T 0 D E"f E.FZ/^I►,l E L.c-T- %-I H E-'j A P P L I C A►`f r i• k,3"- L%OCAT10 SEWAGE PERMIT N0. _.. Lot #266 ar�es- tis Rd. 84- 44 V1LLACE Centerville I N S T A LLER'S NAME & ADDRESS Robert B. Our Co. INC. Great Western Rd. North Harwich y, B U I L D E R OR OWNER Alan Small 1�kDATE PERMIT ISSUED OD AT E COMPLIANCE ISSUED r ��...�K y, � x, � a.� '�� 4 Rr NOTES:MAP : TEST HOLE LOGS ` PARCEL : (p l) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE . (�p(� t, S01 L EVALUATOR : I.�_ C f 5`�._ BOARD OF HEALTH REGULATIONS. I�►�Z 51 rIn WITNESS : NQr r - � REFERENCE O'j ]GJ DATE : F�^R,� 7� C� 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, ' L iv1t� SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO R11 PERCOLATION R TE : !f tNG{� `�2 — Pd INSTALLATION. ++ — 3 THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION tC 't � TH- I � �� TH 2 �I<- 5'�,yS' L ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE � (pP1Mif � � L OAAA �S DETERMINATION. a p w L<A-v OF C 1 r I D h � �,.__I,)(- +t o GET � 4) . ALL. PIPING TO BE 4" SCHEDULE 40 @ 118 "/ FOOT. . .(UNLESS MUS x s u i ... ? I t . LOAPA�SPfrJD SPECIFIED OTHERWISE) (Q � U 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A L O CA T O N MAP N T• +i I , ++ ' GARBAGE DISPOSAL: 1V M MEDIA 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON 06 ..SAW 0 '5 �J•1p Z< A BASE OF 6"OF CRUSHED STONE. Y �� rF 5`� tc t 1T_ ✓, I 100.00 f 7 X c1 -t.0 7D - _ Pv ._f cute I S f jo P41 ognE ��� W/,-r' /.�U._OF P4P • ��-G- 7�J _ o _ SEPTIC SYSTEM DESIGN 9A15 Ft FLOW ES';'I MATE t� L O� of- -mwty o� 20 Ft l ) l/ i1f ►eQM T� y -- BEDF OOMS AT 110 GAL/DAY/BEDROOM - ?J GAL/DAY �loYl� I C�7 3 a 3 SEPTIC GAL/D1,Y x 2 DAYS - ��0 _ GAL 11) 4 Njlz �PT?"CC-. tilt 0 r04 6?yf . 6E,t77::.: USE 1 000 GALLON SEPTIC TANK --eXIS77N 1jjoo (q I r) I SOIL AB ORPT I ON SYSTEM 4l� Un!Y1SIZ ?. U5& 5) 1 N I� 1 t�Tt�w a 301;0 UN rT5 VVI 3.9 Z, JTaa •,ry ...r ��•- 4+. .`... f ,..:.. 5•+, ,. ,,, .� - ". _ - _ _. _. ._. .. SIDE AREA:' `/-7'r- i ff BCTTOM AREA: Z5-x, 12, X ZZ7 INS v I , 1I - L ING II 1 . 3( Ct..� ' A e E � SEPTIC SYSTEM SECTION OTP OF FNDNW r , EL- Q 1 . . a u t+1 n tr�' 4�lHf 36rr � III � I►�t r � I �Xl��N � Irt.S7�'t<f /4 � ,!� E(,,�S,�S a 4; 1, 000 GAL 35 I Bt vh C I(/ SEPTIC TANK l i 100.00 .F EDGE OF PAVPMENT, `"� c H'I Nq 6k05's 56e p O/V 7 .J MEN Q T 1 TTcL p 9, rQRSITE AND SEWAGE PLAN DOU61c EYES ' rn°� Nca Ala n — -- (A1� �fr. LOCATION : Z.�J JOyI ?77 �1 rn O 3c ►6t �tD ® 47 90 7 t a � � PREPARED FOR : Klo hfzL of kec�u r4C DARREN M. MEYER, R.S. scALE w DATE :OL'48-06 a P.O. BOX 981 EAST SANDWICH, MA 02537 w DATE HEALTH AGENT Ph: (508) 362-2922 _ w Z