HomeMy WebLinkAbout0058 CASTLEWOOD CIRCLE - Health 58�CASTLEWOOD DRIVE,HYANNIS :
—_—-- — -------- --- A 273-069 -- —— — — — — —— — -- — — —
1
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TOWN OF BARNSTABLE
LOCATION J ! C/ ,L (j(/f�®® C_j SEWAGE# aG pl
WII.LAGE rU/ ASSESSOR'S MAP&PARCELIy 7_?-7669
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)
NO.OF BEDROOMS
1
OWNER 0C v nA t p- /
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between e:
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
r
Edge of Wetland and Leaching Facility(If any wetlands ex&within
300 feet of leachmi facility Feet
FURNISHED BY
g2 �7
5-GI
33P
LEI
S
No. Fee Mo
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0ppYfcatiou for Migoaf �§pgtem Cottgtructiou Permit
APPliction for a Permit to Construct Repair Upgrade V, /Abandon El Complete System �ndividual Components
Location Address or Lot Nc $��/�'� Owner's Name,Address,and Tel.No��.�� 00)&F D
Assessor's Map/Parcel Q 6
3— 9 0
Installer's Name,Address,a d Tel.No C:;7/A)6 Designer's Name,Address and Tel.No./!r ��
VEi
C)
Type of Building: /
Dwelling No.of Bedrooms Lot Size ft. Garbage Grinder ( )
Other Type of Building S No.of Persons Showers( ) Cafeteria( )
Other Fixtures 7 p
Design Flow(min.required) gpd Design flow provided gpd
I
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ���Do U Type of S.A.S. /5—
Description of Soil
i
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 He Ith� g
SignedZ_Zt;r�_ , Date O
Application Approved by Date VIA
Application Disapproved by: Date
for the following reasons
i Permit No. d0 U
=.r
may: ,fi,+-*+;w.a;. Y ' �. � ' ro. -- � —_✓ .,,-t«... ..,, ..
}Fee av-
THE COMMONWNEALTH O.F MASSACHUSETTS ' Entered in computer: Yes,!
;.
PUBLIC HEALTH DIVISION.'- OWN OF BARNSTABLE, MASSACHUSETTS
T[pplitation for �Dligpogal J�pgtem Con5truction P'trrrYit
Application for a Permit to Construct( ) Repair( ) Upgrade�bandon( ) ❑ Complete.System dividual Components
Location��s or Lot No j' T Owner's Name,Address,and Tel.No.Z�,V9, OW/V) I�
Assessor's Map/Parcel 3— (owe T f cm
Installer' Name Address,a d Tel.No. Designer's ame,Address and Tel.No.
60
Type of Building:
Dwelling No.of Bedrooms Lot Size / �-2sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
�•- .. ... Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank SST Do U Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /Y -5/4-3 2 /0 17oX
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., � J r-
a Signed �� / �/ Date pC U
Application Approved by ( 14', z Date 6
Application Disapproved by: Date
for the following reasons
Permit No. 60 — Date Issued L G
"`" �•�_: THE COMMONWEALTH OF MASSACHUSETTS
B..AR�NSTABLE, MASSACHUSETTS
�e t tcatte of- ante
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ed - ) Upgraded ( )
Abandoned(��)by 144j I 1 G L - •
O G has been constructed in accordance
with the provisions of T.itle,5 and thee-f r-Disposal System Construction P rmit No. 11;)1UUC dated
Installer Designer
#bedroom Approved design flowl ` 0 gpd
The issuance of this permit shall not be construed as a guarantee that the system will un ion as designed
Date (f Inspector r/V�v '
No. Fee 1 0 ^-
+row•
IMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVYSTON.,BA�RNSTABLE, MASSACHUSETTS
�tg�ogaY �pgteri� �ottgtructto � �x �t-.__
Permission is hereby granted to Construct ( ) Repair (Upgrade ( ) Abandon
System located at -5—Z� C/I STD
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: Const ct'on must be completed within three years of the date of th, ps'e 7r•�it.
Date 0 Approved by
f
APPLICANT: n�' �� '"I ' M 6 &,�-
ADDRESS:
DESIGN FLOW: 3?26 gpd
REVIEWED BY: _ M,p,14 p� DATE: "741 L01
N/A OK NO
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220 4 (u)] X
Locus Provided 310 CMR 15.2204 t
Plan proper scale?(1"=40'for plot plans, 1"=20'or fewer for
components) [310 CMR 15.220(4) X
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- i not, a variance is required 310 CMR 15.412(4) X
Location of impervious surfaces (driveways,parking areas etc.)
310 CMR 15.220(4)(d)
Location all buildings existing and proposed 310 CMR
15.220(4)(c)] x
Location and dimensions of system components and reserve areas
[310 CMR 15.220(4)(e)] X
System Calculations [310 CMR 15.220(4)(f)]
daily flow X
septic tank capacity (required andprovided) �(
soil absorption system (required andprovided) �(
whether system designed for garbage grinder X
North arrow [310 CMR 15.220(4)( )]
Existing and ro osed contours [310 CMR 15.220(4)( )] X
Location and log of deep observation holes (existing grade el. on
each test) 310 CMR 15.220(4)(h) X
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)] X
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)] X
Percolation test results match loading rate?-[310 CMR 15.242] X. ,
Certification statement by Soil Evaluator 310 CMR 15.220(4)0)] X
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR ,
15.220(4)(n)]
Location of every water supply,public and private, [310 CMR
15.220(4)(k)] X.
Address Sheet 1 of 7
I
within 400'feet of the proposed system location in the case
of surface water supplies and ravel packed public water su 1 _ X
within 250 feet of the �o osed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells x
Location of all surface-waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. 310 CMR 15.220(4)(1) X
Water lines-and 6th6-subsurface utilities located [310 CMR
15.220 4 m) if waterline cross see 310 CMR 15.211 1) 1 ) X
Profile of system showing invert elevations of all system
components and the boitom of the SAS 310 CMR I5.220 4 o x
Stamp of designer 310-CMR 15.220 1 and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)] X
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2)or as
approved for an upgrade under LUA at 310 CMR 15.405 1 X
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103 4) x
Test Holes adequate to confirm adequate groundwater separation?
310 CMR 15.103(3) x
Benchmark within 50-75'of system 310 CMR 15.220(4)( ) x
Materials specifications noted? [various sections of 310 CMR
15.000] X
System components not> 36" deep(unless Local Upgrade
A roval or LUA requested) 310 CMR 15.405 1 b x
,A
'r
I
i
I
t
• � n
Address S9 60 7zt-,wQO!�21 . Sheet 2 of 7
i
r
Size OK? _[310 CMR 15.223(1)]
Inlet tee located ten inches below flow line 310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5"per foot for increase ft depth [310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)]
Note regarding instal.lation on stable compacted base [310 CMR
15.228(1)] X
Separation bettiveen inlet and Outlet tees (no less than liquid
depth) 310 CMR 15.227(2)
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permifted for
upgrades under LUA [310 CMR 15.405(1)(k)]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1)and 310 X
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater) -
middle access at leasf8" (b 7/07) [310 CMR 15.228(2)] X
Access to within 6 " of grade - one port for systerri9<`1000gpd,
two fors stems>1000 gpd 310 CMR 15.228 2 �(
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)] Y X
> 10 ft from building foundation [310 CMR 15.211(1)] X
Buoyancy calculation Required/Done 310 CMR 15.221(8) X
H-20 Where appropriate? 310 CMR 15.226(3)] X
Setbacks from resources [310 CMR 15.211 X
Required when other than single-family dwelling or flow>1000
d [310 CMR 15.223(l)(b) X
First compartment 200%daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2) and 3)]
"U"pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15.224(4)]
Address C woo fir!P_ Sheet 3 of 7
Located atleasi ten feet from any water line? [310 CMR
15.222(2)] x
Disposal piping at least 18"below water line (when water and
sewer cross, see 310 CMR 15.211 1 1 ) X
Cleanouts required/provided ? 310 CMR 15.222(8)
Thrust blocks specified in force mains?310 CMR 15.221(6) c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)] X
Proper pitch on all runs?(.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9)and 310 CMR 15.252(2)(c)] x
Siphonproblem/ leachfield below pump chamber)
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252 2) X
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed) X
R3�2 7
,.
Jill
7f. 5,
Stable compacted base [310 CMR 15.221(2)and 310 CMR
15.232(2)(a) )(
Splash plate or baffle tee required on inlet/provided?(when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)] X
Riser if deeper than 9" 310 CMR 15.232(3)(f)] X
Inside minimum dimension 12" 310 CMR 15.232(2)(b)
Minimum sum 6" [310 CMR]5.232(3)(e)]
Watertight cover if Q000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)] X
Capacity(emergency storage above working=design flow)?[310
CMR 231(2
Pro er setbacks 310 CMR 15.211 same as se tic tanks)
Watertight 20-in minium access manhole at least 20"MUST BE
TO GRADE 310 CMR 15.231(5)]
Service components accessible (not too deep,with piping,
disconnects accessible
Alarm floats-alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. 31 Q,CMR 15.231 6) and (8)]
Stable Compacted Base r310 CMR 15.221(2)]
Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)]
Address C ���l000 rip—,� Sheet 4 of 7
i
a
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(l)] X
Required separation togroundwater? 310 CMR 15.212).] X
Aggregate specified-as double washed [310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241) x
Inspection ports specified and within 3'final grade? [310 CMR
15.240(13)] . X
Breakout requirements met?(No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and X
Guidance Document]
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)] x
Each structure with one inspection manhole (if>2000 gpd must
be tograde) 310 CMR 15.253(2)] X
Aggregate 1'minimum-4'maximum. 310 CMR 15.253(1)(b)
2'sidewall credit maximum [310 CMR 15.253(1)(a)] X
In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)]
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)]
100 feet-maximum length 310 CMR 15.251 1) a
Minimum separation 2x effective depth or width whichever
eater 3x if reserve between trenches 310 CMR 251 1)(d)]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
minimum 2 distribution lines 310 CMR 15.252(2)(a)]
Maximum separation between lines 6' 310 CM R15.252(2)(d
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)] X
Aggregate depth below discharge pipes 6"minimum, 12"
maximum. [310 CMR 15.252(2)( )] Y .
Separation between beds 10' minimum. [310 CMR 15.252(2)(f)] aC
Bottom area used in calculations only 310 CMR 15.252(2)(i)]
Address 1N�YJ G4I2 Sheet 5 of 7
Pressure Dosed System ? Provided pump and piping
calculations as rpmwired.f 310 CMR 15:220(4)(r)
Pressure dosing required on all systems>2000gpd or alternative
systems undlWmmedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals] X
If used in gravelless system -make sure jet is directed as not to
scour soil interface [Guidance Document] t44
Inspections once per year(systems<2000 gpd) or quarterly
>2000 d ood to note on lan 310 CMR 15.254(2) d
Construction in fill -Did the plan specify that the fill shall meet
the s ecification of 310 CMR 15.255 3 ? X
Im ervious barrier and/or retainingwall ? Guidance Document X
Impervious barrier installation must be supervised by
desi ner 310 CMR 15.255(2)(b)] x
Retaining wall must be designed by Registered Professional
En ineer[310 CMR 15.255(2)(a) x
Side Slone not exceed 3:1 ? 310 CMR 15.255(2 X
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document X
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [3,10 CMR 15.255 (2)(e)] -
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface X
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
i
Any alarms involved on se arate circuits
Did the applicant submit an operation and maintenance
manual?
Has a licant submitted a coy of a maintenance
Are the variances listed on the plan ? [310 CMR 15.220
(`1)( )
RLS Stamp necessary on plan if a component is within five
feet of property line f 310 CMR 15.412 4)
New construction or increased flow proposed- [Refer to 310
CMR 15.414]
Address
Sheet 6 of 7
. ...:
mom
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ? X
[310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CMR X
15.216(1)]
Pumping to septic tank? [ 310 CMR 1-5.229 X
Shared System [310 CMR 15.290] 1 x
J '
Address S� �'�F�'7L [lV U?71� - _ Sheet 7 of 7
I'
Town of Barnstable
�'ME Regulatory Services
Thomas F. Geiler, Director
• AAt4MfAIi L
MAX Public Health Division
%639.
Thomas.McKean, Director
200 Main Street,Hyannis,NIA 02601
Office: 503-362-3644 Fax: 503-790-6304
Installer & Designer Certification Form
Date: 4 Sewage Permit# D � Assessor's Nlap\Parcel � 06
Designer: I Installer: /�'+E: 1* E�K,
Address: d Address:
06-( VV 1 0 _AIA 107A, O-V&0-1
On w►, �/ /✓1 was issued a permit to install a
(date) (installer)
6S 64 S�1r wove Ct Q, s
septic system at based on a design drawn by
a
�J 'n� (address)
✓I�IPk '" I ►"I �✓ dated 07 31 v�
(designer)
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. -
o DREN
'ER
(Installer's Signature) No: 1 40
I ,pECIsiE
MNITWP� I
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNST rBLEPUBLIIC HEALTH DIVISION. CERTIFICATE OF
CONIPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Health/Septic/Designer Certification Form 3-164doc
Department of Public Health - Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly:Incomplete or illegible forms will be returned.
Lead Paint Inspector P /'lm,o N'k-M-t'h License Inspection.�Date
Property Owner 4NO Ma l N/?U#v
Property Owner's Address a )65-.2 /,;y�y_ /y�� ^Zip Code
Authorized person performingwork: a 2ANgw�
Lic#/Auth.# 11093— �1 rr►
Address of authorized person u X 3 Al+ 1vj" Zip Code 0 1
Telephone Number q4Y) 7 75=J 0,00
Address where the work will be done:
Building Name(if any) Floor
Street Address S ASIl wao-9 &f4 Apt No.
City Zip Code D;) b I' The property is a_multi-family gle family.
Deleadine Method(s):
❑ Making paint intact(high risk) ❑ Making paint intact(moderate ❑ Applying vinyl siding on exterior
❑ Demolition risk) ❑ Component removal (low risk
❑ Scraping ❑ Liquid encapsulant components)
U01"Component removal/replacement . ❑ Covering ❑ Other:
❑ Dipping ❑ Capping baseboards
The work will begin on�/.?yam and will finish by 9 14 The work will be done in the �_pm or_weekends.
In Case of Emergency Contact G q(z i GaA A, -
Daytime Phone Evening Phone 6)? - 737-L y a o
The Property Owner must complete and sign the following information::
I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
'Prevention and.Contiol Regulations, 105 CMR 460.000,will conduct deleading work. I further certify that'the authorized
persons)will not exceed the scope of his/her authority.and will be performing only those activities indicated above. All of the
information contained in this document is'true and correct to the best o. y owledge and belief.
Date �� Signed j✓
The following people/agencies must be notified ten days before beginning work:
o E3
I. Occupants of the dwelling unit N
cn .
O
2. All,other occupants of the residential premises;if any.work will,be done in the common areas
v �
3. Childhood Lead Poisoning Prevention Program, DPH Fax(781)774- 700
MWRHO �
5 Randolph Street, Canton, MA 02021
N
4. Asbestos and Lead Program,DOS N
1O Stamford St, V Floor, Boston,'MA 02114 Fax(617) 626-6965
5. .Local Board of Health/Code Enforcement Agency
'If the home is on the State Register of Historic Places,call the MA Historical Commission at(617)727-8470.
I
I
Town of Bk-nstable.
Department of Regulatory Services
• ' ' Public Health Division Date �bL
• $ Zoo Main Street:Hyannis MA 02601
•6J¢ �s
pia NI1�r' .I
LLA Tee Pd. !d
. Date Scheduled Time— •
' I
Foil Suitability Assessment for Sewage Disposal
Witnessed By:
Performed By. J.
LOCATION& GENERAL INFORMATION
Location Address Owners Name F-VT'C He
$ C5TZ-FVJ )00 tieP,:-
i 6s U l (a4S Si .,Su I tc 130
RY&-tj0IS, ��, Address Rk JC,t•1c COCAMOIZA Ut `11736
Assessor's Map/Pocel: Engineer's Name C)#"Q-Ce^ M"V
NEW CONS' UOON REPAIR �_ Telephone# SOB 3t�
2- 2q 22Z
'��l Q✓i f'1 / iL Surface Stones r Y o n Q
Land Use Slopes(95) ,
> ! > ft Drinking Water Well :�V ft
z ft Possible Wet Area
Distances from: Open Water Body t
>l D b ' >l y ft other tt
Drainage Way ft Property Linc
•I
SKETCH:($tenet name,dimensiods%f lot.exact locations of test holes&perc tests,locate wetlands in proximity to holes)
(V 6e 99.42 ft r
EL .............................................-......-._..-._..-._-._.._.._.._..�_�
NJ
U I !
ti j I —I
'v i WATER LINE '^
Q W J ! I z
V -7 Z 70 11
4 ( I
- 0W W (f) � 4�
O Q- �, i 1 W o
X to i =
Ir
o cl t S a
w
o W C' w
I
O
j v! r
W o Q �': /
w CLi-CAS1INE_
PAVED DRIVEWAY
--------- -- I \,06
1 �0�1 }�g� _ +�5
J (0o
99.28 ft
t
Parent material(gedlogic) Depth to Bedrock� �S�
Deptb to GroundwaWr. Standing Water in Hole: ll i Weeping from Pit Face -T
Estimated Seasonalajigh Groundwater N lA !
DR SEASONAL ffiGI�'WATEIt T'Ar3LE
tnRKNTION FO
Method Used: io. Depth to sell mottlt:s:
Jn.
Depth C14erved standing in obs.hole: I in. 0mundwamr Adjustment •
Depth toiweeping from side of obs.hole: , p�,{actor,...�.�- Adj.(ltwundwater Level,,.,.
Index Well# — Reading Date index Well ievil i
P]ERCOLATI+ON?'EST • Date----• 'x —
Observation - ! I Time at 9"
Hole# 4Q It
D Time at G" .-�-------
Depth of Pere
t I �� i Time(9"-6"
Start Pre-soak Time o r I
• !
End Pre-soak
Rate MinJlnch
Site Suitability Ass0smeat: Site Passed____�—
Site Failed: Additional Testing Needed(Y/N).T._-
Original•.Public Hedlth Division
Observation Hole Data To Be Completed on Back
***If ercola ipn test is to be conducted within 100' of Wetland,.-You mint first notify the
p wedk prior to beginning.
n......ctot.ta r ftervation Division at least one(1)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munseil) Mottling (Structure.Stones,Boulders.
Consistency. Gravel)
A kL Lyle toy
5 B Su to
2,Sn�/
i
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders.
36u 'B �h 1,°4-'4 /0V I r V
3(0 IVY L Mel S'un� Z� �
DEEP OBSERVATION HOLE LOG Hole# A
Depth from' Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Muosell) Mottling (Structure,Stones,Boulders.
toGravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Ho Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munselp Mottling (Structure.Stones.Boulders.
Flood Insurance Rate Man:
Above 500 year flood boundary No— Yes/
Within 500 year boundary No X Yes
Within 100 year flood boundary No k Yes
Depth of Naturally Occurrine 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?
If not,what is the depth of naturally occurring pervious material? .___._,
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed by me consistent with
the requir 'ni ,expe 'se and experience described in 3.10 CMR 15.017.
Signature
Date ? 1 D
i
Town of Barnstable Barnstable
Regulatory Services Department e V
U"STABM
9� b 9 ,0� Public Health Division
�FDfA°�A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70062150000210418672
4/14/2009
Citi Residential
58 Castlewood Circle
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 58 Castlewood Circle Hyannis, MA was last inspected on
January 8, 2009,by Shawn Mcelroy, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action. .
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. CityJTown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General Information }
1. Inspector: 3I
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
CitytTown State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
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 my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Ev ation by the Local Approving Authority
1-8-09
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"*"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
• VV I
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is H required for annis MA 02601 1-8-09
y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System 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:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
" A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years.old is available.
ND Explain:
i
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
I
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5lnsp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
ef
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ~
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced '
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of-Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ " Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
T ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp official document-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
I . n
Commonwealth of Massachusetts • . �'
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir •'
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less-than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
* This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections: .
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or 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 '/ day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number.of times pumped:i
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is.within .100 feet of a surface water supply or
tributary to a surface water supply.
t5insp official document•0=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/rown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
t Yes
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
For large systems, you must indicate either`yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ _ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered `yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts t
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M r~ 58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have"been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑- ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
' ❑ - ® Has the system received normal flows in the previous two week period?
❑ ,® Have large volumes of water been introduced to the system recently or as 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 of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ,❑ Were all system components, excluding the SAS, located on site?
® . ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
. r
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
0 • ❑ 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(5)]
t5lnsp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is Hyannis MA 02601 1-8-09
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 12-08
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
- 4• + t
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,,if available: .
Last date of occupancy/use: Date
Other(describe):
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection* Form
Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
I
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? '
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ -Overflow cesspool
❑ Privy
I
ET 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1993
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document•03M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is Hyannis MA 02601 1-8-09
required for y -
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
21"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition..
Septic Tank(locate on site plan):
Depth below grade: 15
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 Gal
Sludge depth:
16"
Distance from top of sludge to bottom of,outlet tee or baffle
16"
Scum thickness 6
Distance from top of scum to top of outlet tee or baffle 4
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Tape
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts -
u Title 5 Official Inspection- Form
R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed. -
Grease Trap (locate on site plan):
Depth below grade: feet
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
r
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
I
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•OW08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
j Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ Teaching pits number:
® leaching chambers number: 3 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Infiltrators had clear signs of being filled beyond capacity due to hydrolic failure.
t5lnsp official document-03/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
'
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 ❑ 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 of ponding, condition of vegetation,
etc.):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis n MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building. °r
a
A v c
o A -D Xa
}
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
iJ
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Castlewood Cir
Property Address
Citi Residential
Owner Owner's Name
information is required for Hyannis MA 02601 1-8-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope '
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers-(attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USGS maps show groundwater at 20'.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
aY3
19
00 � o
BORTOLOTTI CONSTRUCTION, INC. 4► �f9
765 WAKEBY ROADo MARSTONS MILLS,MA 02649
508-771-9399 509 4284926 FAX: 508428-9399
1p �~
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO `
PART A
CERTIFICATION
Property Address: '
Date of Inspection: j,0Z2QZM Inspector's Na
Owner's Name and Address:
c i1l�/rtiix oLi�irn� _1Q. O/70r
CERTIFICATION CTAT . ENT•
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below4s;true;accurate and complete as of the time of inspection.The inspection.was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal jgUems. The System:
r/ Passes .
i Conditionally Passes
Needs Further Ev tion ocal Aproving Authority
' Fails //
Inspector's Signature: Date: 0LW{'!-,f'���,
The System Inspector shad submit a copy of this inspection report to the Approving authority within thir-
ty(30)'0ays.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 io 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 SUMMARV:
i
'A)'SYNI PASSES: ,
I have not found any information which indicates that tite system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated fit
below. ;
B)SYSTEI11I CONDITIONALLY,PASSES; i
� One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection. ,
Indicate yet nor,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,cracked,structurally unsound,shows substantiai infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection U the existing sep-
i tic""is,replaced with it conforming septic tank as approved by The•Boird ofI#eilth.
Sewage backkup.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):
1
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
% PART A
► t CERTIFICATION(continued)
Broken pipe(s)replaced
� a Y
' • r'• Obstruction is temoved ` ` ,
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 Wks)are replaced
Obstruction is iemoved
C)FUR#ER EVALUATION IS REQUIRED BY THE BOARD OF HEMAHs "
Conditions exist which require further evaluation by The Board of Health in order to determine if
if . !
I ro,?• 4'S t �1 1'�'.��4 iJ�y'd7i�t `ti >� ! !,
the system is falling to protect the public health;safety and the eMir�nmeht
1)'SYi°I'EM WILL#Ass UNLESS'BOARD OF HEALTH ES`T$AT THE .
4 SY$#M°'IS NOT FUNCTIONING IN'A MANNERWHICH''W1L1b'TiR6'1'ki'1
'PUBLIC HEALTH AND'SAFETY AND THE'ENVIRONMENTs
ii , Cesspool or privy is within 50 Feet of a surface water T
_ Cesspool or privy is within So Feet of a bordering vegetated wetland or,a s df h:•i•'.'
Z)SYSTEM WILL FAIL-UNLESS THE BOARD OF HEALTH ,(AND' U$1 'V ATER
Sj*IER,IF APPROPRIATL)'DETERMINES'itAT THE SYSftMg&WNGT ON
ING.IN AdMA>!iNER.THAT PROTECT THE PUBLIQHEALTH AND SAF'�il'YrANDr t
ENVIROIVIE 'I' ' '"'. P'3.}.? ", ^ :,� :r :r. ,
The system has a septic tank and soil absorption system and is within 100 Feet to a surface.
water supply!or tributaryto a sur ace water supply.
f
'` t The system has aseptic tank and soil absorption system acid is with i &ne,1 o'a•pilb�ld..
a t4 r r .,'r r Ir , ?t t?°,.iro. t t::r'1 Ytaltgt _ t�:•i
water supply'
well ) dd
The system has a septic tank and soil absorption system and is wlthf n Sb Feet of a•p
water supply well.
The system has a septic tank and soil absorption system and,is,less d=100.Feet,but.50.' ,
Feet or more from a private water supply well,unless a well, )►sis> irol
bacteria and volatile organic compounds indicates that the well is froe, rom poliutio 5om ;
ro �� AN
the facility and the presence of ammonia nitrogen and nitrate nitr�ged i9 equal o��
p "`..
D)SYSTEM FAII.Ai� , r:
I have determined that the system violates one or more of the following failur6;dd aria as defined '
in 310 CMR 15:303. The basis for this determination.is,identified below:.The Board ofipealth
+o , t 4 �jp
should be contacted to determine what will be
necess&f to correct the�1hi
t'• °Backup'bf sewage into facility or system component aue loan ovenoa� or clogged�SAS. �r
O[OeSSp001: ' , ,s rk•.,tram t re!rtl a ►t1 tVE ?c
Discharge or ponding of efluent to the surface of the ground or surfacer waters dingoAaPAW
t;.. r E r.
overloaded Or clogged SAS or cesspool: kt i ,, � '•�3n ,„ i3
Static liquid level in the distribution box above outlet imeit due to an over�oade�or clog
:i•9�`�A��dl?�.� 1 t, � '•,"-� _i' .. ., r? .. :a) ytt,l}%'r 6�.,......a...»f..v. •.i '
Poo
LLLuquidpdepth•in cesspool is less than 6"below invert or avdilahle volumb le
I ss is, than:1/1 ! �+'1 4 °day'a llow:. ;k} t�N'h�r•t ,, ,.. . .. ,' ,��' ' r , jb t."}sai•f 'fY
t ! x` `Required pumping more than 4 times in the last year Na due id cloggetl,or hlrsttir .W
•tl,,
! pipe(s). Number'of times pumped
tl
• i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
;• CERTIFICATION (continued)
! 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.
{i Any pordon'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 FALLS:
The following criteria apply to a large system In addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is'a eigdificant.
' th'reat to public health and safety and the environment bedause one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking watdr supply}`° f• 'ti ". ',-�.� '
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,P.rotection,Area,i�; ,f
(IWPA)or a mapped Zone II of a public water supply well'1 110"44-J;fV
The owner or operator of any such system shall bring the system and facility into hill coinplienbe vvith'the
groundwater treatment program'requireinents of 314 CMR 5.00 and 6,00. Please consult the local'
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done: r F ;�
✓Pumping information was requested of the owner,occupant,and Boaid,of Health,!X* :'.
"None of the system components have been pumped for atleast two weeks aitd the sy0m11Mt'
been receiving normal flow rates during that•period: Large volumes-of waterihave°ribt.been.
introduced into the system recently or as part of this inspection.
J/' As-built plans have been obtained and examined. Note if they are not available•WithSN/A.,,.
_ The facility or dwelling was inspected for signs of sewage back-up. -r,t,l.
_,LThe system does not receive non-sanitary' or industrial waste flow.} f' r rah .;•,
The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption System,have been located on site.
iThe septic tank.manholes were uncovered,opened,and the interior-of the septio•tankNvas;lu
• �=spected for condition of baffles or tees,material of construction;dimensions,depth of}liquid,
✓ depth of sludge,depth of scum. r,,
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
i
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
i . !/ The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
1' FLOW CONDITIONS a .
RESIDENTIAL-
Design Flow: ions Number of Bedrooms: w .Nu r of Current Residents:CJ
Garbage Grinder: _ Laundry Connected To System: Seasonal flse: Q.
•.Water Meter Readings,if a • 'Table; t
Lest Datg of Occupancys
^w ,.
' Ty�of1'rstablrshmeptt'.1.' +•J400sxr .,«.� }y:?;', ,.d ,,!''.••.' .. !. .. .r. x•,+. s,+#. _ ,.
Design F"low.�^ ,. aallondday,'Grease Trap Present: (yes or no), _ . , 1•,• - �
IndustrW Waste Holding Tank Present:
.,Non-Santo*,?Waste•Discharged,To,The Title V,System:, ,..,,•:.:, .r .,.,.,��icr c
Water Meter Readings;If Available:,•, Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
• fir . , , . . , ,:.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection: yip yes,-voidne :.
Reason for piimpingt*" 1!r•; . Y, t •_ ,r t�; :{,-°,;rrg�t,
TYPEdF•SYSTEM:� ., ,,�,r, �.•,,, r. ,, it=ju .t�+"1 '�t ,
Septic TanWistribution Box/Soil•Absorption System t s;t•�?r�
/
S
'�i
�n�gle Cesspool �•,- , i :y;
CWrflow•Cesspolol
1 Privy
I' Shared System(If yes,attach previous inspection records,if any)
Other(explain): „ + { _, .:•, A r y 1' �'t' +
Iak• `5"�•'1;`'r, t1•�"{I 'tf?tt{ !i{ryta a •v„i�r,�.•,= t•_ '' • ,-' !`i' 4l1?Ir%;'`�Jl6Ce3�'^k'��#�A►.. �}:- ,
APP=OXMUTE� E of all componentsj date installed(if known)end source of�iitfohdtip,Ltt,t �, ZI
Sewage odors detected when arriving at the site:
1
- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
' SEPTIC`TANK:
:;. Depth below grade: 16 Material of Construction: /concrete metal ,.FRP_Other.,
(explain)i
Dhnisions:5?.5'kle'X S' Sludge Depth: Scum Thickness:
}' Distance from top of sludge to bottom of outlet tee or baffle: 3
'. Distance from bottom of scum to bottom of outlet tee or baffle: e r
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,,depth of Hquid�
. ..) 1 1 i re.lado to outlet Invert,structural inte ity,evidence of leakage,etc.) 'J -
I S / /
r t •,�5: 1 L&.
,
(, GREASEiTRAP: 00
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Otlier"
is (explain)
;;.. Dimensions: Scum Thickness:
.;.:� Distance from top of scum to top of outlet tee or baffle: - .wp.A:.<r. .
Comments: (recommendation for pumping,condition of.inlet and outlet tees or baffles,depth of liquid,
level in relation to outlet inveri,structural integrity,evidence of leakage, etc.) ,
TIGHT OR HOLDING TANK:,A2d—
Depth Below Grade: Material of Construction:—concrete_metal_FRP Other(explain)
Dimensions: Capacity: gallons Design Floe`: gallons/day
Alarm Level: �7 y
Comments: (condition of inlet tee,condition of alarm and float switches.etc.)
IRA_ E
DISTRIBUTION BOX: AM
_ i
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.)
I
PUMP CHAMBER:[)
` 'Ptunp is in:working order:
Comments', (note condition of pump chamber,condition of pumps and appurtenances,etc.)'
I
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM SAS
(Locate on site plan,if possible;excavation not required,but maybe approximated by non-intrusive..
methods)•s If not determined to be present,explain: ! �'x� •�i s r�
:Ct
Leaching pits,'number: Leaching chambers, number:Leaching gsllenes,number
Lac trenches,number,length:
Leac fields;number;dimensions:
Oveiflow Cesspool,number.
Comments:(note condition of soil;signs of hydraulic f ilure level of ponding,condition of veg tati0t'i3'w
etc. -
CESSPOOLStj
Number and donflguration: Depth-top of liquid to inlet invert ' .
.of sCurii layer: Dime
(, �. "gc3 ! 1 „ n, a: ,r"tr f,•rr, II, '_., i; F.`�rt;
Depth of solids layer: Depth' nsion's of(`,esspool. 1
r Materials of construction: Indication of groundwater:
Inflow(cx spooI must be pumped as part of inspection)
Commend: (note condition of soilk,signs of hydraulic failure, level of ponding,,condition¢of-vefdaationt,
etc.)
�aL ' J rpnlA
PRIVY
Materiaikof 6nstruction: Dimensions:
Depth of Solids:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;"' .{
etc.) �! tX
.;� i R•_((1"'i? 1.
is .,.. ,• I��r.
6 ,. r}
• 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
i SYSTEM INFORMATION (continued)
1
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
�r
i
a
�. .n._.. ... rr• I•f l� ''. y J f� f (i��1 �'~ ..rT'. ..... A .l�• .� ,i - k.�fY� l..
DEPTH TO GROUNDWATER:
:Depth to groundwater: /s Feet /'
Meth of Dete.rminatiop or Appr xi don: O Q Y'I�O/►J �f , 5: d. �'—"
f
i
I -
-7-
f
I
' 1
�i TOWN OFBARNSTABLE
,LOCATION' 5d .��eG �t%�.�ilr�� SEWAGE # 3 t�
VILLAGE ASSESS9 'S MAP& LOT
ESQ. 70R3'NAME&PHONE NO.
SEPTIC TANK CAPACITY MOO
LEACHING FACILrrY: (size)
NO.OF BEDROOMS��
BUILDER OWNER
PERMTTDATE: 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
_ _ ,_ ,� ,
�` �`
_� c
f,�D
��
�.
_ I
•�
� - _.
' - WN OMBSTABLE,
,OCATION AS C �' SEWAGE #
IILtAGE ASSESSOR'S MAP&LOT
NSTALLER'S NAME PHONE NO.
iEFTlC TANK-CAPACITY , /00- 61
,EACHING-FACIUM (type) �"� O /'``(size)
fO.OF'BEDROOMS 3
MILDER OR OWNER
)ERMITDATE:_ ._ ;_COMPLIANCE DATE:
>eparation Distance Between tbe;
vlaximum Adjusted Groundwater Table to the Bottom of Leaching Fatality Beet
}rivate Water Supply Well and Leaching Facility (if any wells exist
on site or witbin 200 feet of leaching facility) Feet
-Age of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
�usnishcd by
0 0
n
rlx
� a
cr`
.y l�
'r -
TOWN OF BARNSTABLE
"'`LOCATION SEWAGE # j3- I9_7
VILLAGE / yCcn`llS ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.6hr&I I A Carls�iuc��aV 7�$'�9ix 6
SEPTIC TANK CAPACITY ovo Gam,
LEACHING FACILITY:(type)-Lw S (size) -7X,2 7
NO. OF BEDROOMS PRIVATE WELL O UBLI ATER Y
I
BUILDER OR OWNER
DATE PERMIT ISSUED: 0 f3
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ��
S
r q
_ x
oQ
S
• 0.
4
k� .
No. 7,?=-- ..-....._
THE COMMONWEALTH OF MASSACHUSETTS APPROVED
BOARD OF HEALTH Wtsta se Conservation Department
TOWN OF BARN!!§TABLE
oeW
Appliration for Diripwial Works Tnu rnr# n t n
Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal
System at:
_S�- O ............../......-- -•-••-•-......4�Jn1 ,5.......................................................
tia o.¢
_Address
1J.4/� L) ..... •.7 a �
191Gfc3
Installer Address
Type of Building Size Lot...._ ! - ....Sq. feet
,.. Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.....................--..... Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow.................... .........gallons per person per day. Total daily flow.............. 0...............gallons.
WSeptic Tank—Liquid capacity/ ..gallons Length................ Width................ Diameter..........--.... Depth................
x Disposal Trench—No. .......Z........ Width.......7------- Total Length..!F?� Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.....--............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( .. )
Percolation Test Results Performed by........................•------•--•--•••------•-•-••---••-•--•-••-•-•----- Date........................................
a
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water.........
i, Test Pit No. 2................minutes per inch Depth of Test Pit.....--.......--.... Depth to ground water........................
....................•--........__...... .....
O Description of Soil................................ l.......GQI ?^1... c.SvI 4pi .........1-- .......
x
.....--•-------•-•----------------------------------------------------•---------------•---......---•------------------------•------•--------......--------•-•-------..................----........_..---..
W ------•••-•------------------------------------•-•------------....-----•...------------•-- •-•.........•-=------......-•--------•----•-----•-•--•-••-----------------•----------•-.....-••--•-----.._.
U Nature of Repairs or Alterations—Answer when applicable.... > ...... -..!. ��..--T ? + ...
1a.................- .1 e. - ......................................................................... ...........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as b en ' sue by�hoard of health.
Signed ......... .. ............................ :. ...... .............. . s .to� ...
Dace
ApplicationApproved By ............ ... ].. .............................................................................. ...... .: �..�..
Due
ApplicationDisapproved for the following reasons: ........................................................................................................................................
.............................................. ........ /1. .
....................................................
....... zz Dare
Permit No. � J..-..... 7..................... Issued ...............................................---..................
Dare
�) 4f F},l^3�,(�y"" ..iJ w�w �7 v ✓ k�'�:,t�_;J c.� ° C=�1..��✓ �)` `r�-S t✓' S c-�-.i' r`�?�;.�slr."'.r..i-:���`�{ Z;,+U" u.-�� �, �. � ,-. '4�
�� 7 ,- �7� DloC7 FICB.—.! —.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ��Tj� - G ,P3
Appliration for Diripooul Works Totiitrurt"tun /"rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
: .... -•-------.....-/%i.........f...I........--•-•---------------------•--•--•---•....------...
Lo iti i-Address or Lot o
: ' ........� __ Z. . �%""���` D r'1 ' '!lf1 y
Owner Address
Installer Address
UType of Building c� Size Lot------�-h . .....Sq. feet
�.� Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a'I Other fixtures ..................
d ------------------------------------------------
W Design Flow.....................S�......._..gallons per person per day. Total daily. flow.,............: A...............gallons.
WSeptic Tank—Liquid capacity Z000-.gallons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench— No. ......./-........ Width...._.. _.:---_ Total Length._ r:�.2�Total leaching area....................sq. ft.
f
� Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
I Z Other Distribution box ( ) Dosing tank ( )
0.4 Percolation Test Results Performed by.......................................................................... Date........................................
,.-I Test Pit No. I................minutes per inch Depth of Test Pit.....................Depth to ground water.........................
L7. Test Pit No. 2.........:......minutes per inch Depth of Test Pit.................... Depth to ground water........................
x .......•-----•........................•-•-•-------.........................---.........................................................
O Description of Soil........................
V .............................................•-•^•......-•---.........-•--••---........---------.................--•-•-----...---.....-----......._._.....----.........................---• --•--•••.
W ..------. ..._._�®............. 1.
U Nature of Repairs or�Alterations Answer when applicable---- ?��1��....... ......
!.> .� 1 .1.� _.._W
- ----- - ----
..................7.`�o�.. = ?1�ti1.�._�......••-------•-•...................
Agreemen,v-
The undersigned agrees,,to4i'nstlill the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE:5 of the State Environmental Code—The undersigned further agrees not to place the
system in}op�erauon until a Certificate of Compliance,has been issued by tthhe�_ oard of health.
Signed ..: /�:.`��/ ..../......(. ..Lr2✓�_............... .....5, 10 ... ...
Dare i
ApplicationApproved-By................... ..... .. ,. .............................................................................. ......45"- � ..-.. �'
............................................................................................
II Application,Disapproved for the following reasons: ........................... .
� ................................. � �..-.....(...`�....�...'.....:........................................:............Issued .................................................................---..'........
Permit No................................................................... e �e
THE COMMONWEALTH�M� NWEALTH OF MASSACHUSETTS
'f4� �U'`BOARD OF HEALTH
TOWN OF BARNSTABLE
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired,( r��)
b ici�L/ n.l.: ................. .(J. ,ST�LtJc_-r.lsJ .........................................................
y ...................................................................., .
at .............................................................................. 5- ....... �.. ...l .�f�/ ............6. .!..11. ........./ .`V'4^.�^...�.0
has been installed in accordance with the provNisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit N�� .�fr�..-r�.?................ dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE RSHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
1
DATE.................... ...'..a�5✓...a...`.�.._ .:....... Inspector .............. : ................................................................
..
------------.--.--..—.—�.9.��5�..-j—, �---—.——_ ---_------ -- —-------,---—a —————--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �73_ p lo5
G TOWN OF BARNSTABLE
No...-/-. .-.�9 7 FEE. ............
%Vouttl Workii Tonotrttion "rrmit
Permission is hereby granted U l ---...---- /)r /....:
to Construct ( ) or Repair an Individual Sewage,Disposal System
atNo........................................................:!!5 ....---- e/' .....JOC1 k. ...... /U ------------
Street
/ L�.....
as shown on the application for Disposal Works Construction Permit No.?37:/_9-,). Dated...........................................
.�
� Board of Health
DATE............ i 3 ..
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
�.� _ LEGEND
f ;, • . _ �d^ ;'err ,`�O,.�
PROPOSED CONTOUR 5 I .
® PROPOSED SPOT GRADE• ;Rif
98 —— EXISTING CONTOUR
+ 96.52 EXISTING SPOT GRADE
W— EXISTING WATER SERVICE
A WATER a BENCH MARK
O
cATE PAINT SPOT ON TEST PIT
CONCRETE SLAB
ELEVATION = 68. 44
BARNSTABLE CIS DATUM
r II 'l y
LOCUS MAP N.T.S.
�^^�� GENERAL NOTES:
ALL CHANGES OFPLAN
DESIGN ENGINEER THE LOCAL.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE. TITLE V. AND ANY APPLICABLE
/.� �O LOCAL RULES AND REGULATIONS.
� ( 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
2� TO INSPECTION AND APPROVAL BY THE.BOARD OF HEALTH AND THE
Cps Ile ��• 68 DESIGN ENGINEER.
TH-1 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
/L � \ 0 9' ENGINEER BEFORE CONSTRUCTION CONTINUES.
//• LOT 1 9 ( F� �(v� ? 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
AREA = 7632 sf +�— )r a —2 /i 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
i HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
i trap7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
�•. �� ! THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
�• :�^ 10. EXISTING LEACHING TO BE PUMPED AND REMOVED. FILL WITH CLEAN
MEDIUM SAND PER TITLE V.
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
926
0 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY rf•� >>�/ i AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING
�'�• i 1 14. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED OTHERWISE)
�•� % 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW
` FOR THE USE OF A GARBAGE GRINDER
Existing Leaching 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING
(No t 10)
•� ! 17. PROPERTY IS IN ZONE II OR NITROGEN SENSITIVE AREA.
OF {lqt.
PROPOSED SEPTIC SYSTEM UPGRADE PLAN
J' DNoO 58 CASTLEWOOD CIRCLE, HYANNIS, MA
MAP.273 Prepored for: Mike Dedecko
SURVEY REFERENCE: LOT' 069 Engineering by. Surveying by: SCALE DRAWN JOB. NO.
AN T60 LCP: CERT#161704 DARRENM.MEYEK R.S. Bea—� Bovranmenhd 1"=20' DMM
Its PLAN OF LAND BY MERCER ENG. CORP. PDBaK981
DATED: MAY 1965 �� Oct EASTS4NDIN04AIAGW7 (508) 364-0894 DATE: CHECKED SHEET NO.
s0a,V2-2n 07/31/09 DMM 1 Of 2
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:65.09
FOR A PERIMETERTOFCTTHEFS.A.S.�0UN0 THE
15* i
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.
T.O.F. EL=69.03 INSTALL'RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER `1� OFOUTL �S,p
F.G. EL.=68 5f� AND SET F.G.TO 67 EL.O67F�OI�H GRADE SET TO F G OF G 67DEOt ONE CHAMBER (MIN.) AND SET TO 3*EL: 68.0(MAX) OF F.G. �. '� DA�j�t EJ�
/- MEYEIR•
`� " No. 1140
L m 10'"t 6 MIN COVER/ L - 32' L - 10' MAX) INSTALL TWO INSPECTION PORTS MIN.) 0
04'SCH40(PVC) 36" MAX COVER O S-1A (MIN.) TEE O S=1R((MIN.) ( '�NITA���'�
4'SCH40 PVC 4"SCH40 PVC
ip
14• 11.3" TO
\INV.= NV
65.57 48'LICIAD INVERT 1 z'21LEVU
I .=65.32
PROPOSED INV.=64.80
CAS BAFFLE D-BOX 3 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE - 32.0'/ROW
INV.=65.0 DB-3(H-10) INV.= 64.70 SOIL ABSORPTION SYSTEM (PROFILE)
i EXISTING 1.000 GALLON SEPTIC TANK I
I RESTORE VEGETATIVE COVER
EXISTING SEWER OUTLET
BACKFILL WITH CLEAN PERC SAND 75"
TO TOP OF CHAMBERS 01
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING r. .; .,. .r ...,..... .
PIPE INVERTS PRIOR TO CONSTRUCTION
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=65.09
GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 64.70
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 63.7E EXISTING SUITABLE
310 CMR 15.221(2) 2.83 MATERIAL
3) REPLACE EXISTING 1.000 GALLON SEPTIC 5' MIN. ABOVE BOTTOM OF EFFECTIVE WIDTH = 3 x 2.83' 8.49' f. 76" - I
TANK WITH 1500 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W.
IF FAILED, DAMAGED, OR LESS THAN 1,000G IN CAPACITY. (7.76' PROVIDED) USE 3 ROWS OF 5-HIGH CAPACITY
4) INSTALL INLET & OUTLET TEES AS REQUIRED BOTTOM OF TESTHOLE EL.=56.00 _ ADS BIODIFFl1SER UNrrS-NO STONE PROFILE
W/ CONTOURED WEDGE
SEPTIC SYSTEM PROFILE
TYPICAL SECTION 16"
N.T.S. KTA 11.2"
DESIGN CRITERIA SOIL LOG P#: 12651 A,
NUMBER OF BEDROOMS: 2 BEDROOM EXIST./ 3 BR DESIGN DATE: JULY 31, 2009 --34" �
SOIL EVALUATOR: DARREN M. MEYER. R.S., CSE. SECTION N AP
SOIL TEXTURAL CLASS: CLASS I WITNESS: DAVE STANTON, BARNS B.O.H.
DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 G.P.D. Elev. TP-1 Depth Elev. TP-2 Depth 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT
DESIGN FLOW: 330 G.P.D. 68.0 A 0" 68.0 A 0"
SANDY LOAM SANDY LOAM MODEL 16" HICAP
GARBAGE GRINDER: NO (NOT DESIGNED F f_GAS GE GRINDER) 10YR 3/2 10YR 3/2 LENGTH 76"
PROPOSED SEPTIC TANK: USE EXISTIN , 00 GALON CAPACITY 67.50 s" 67.50 6• " NOTE: UNIT WITHO T NOTICE.
AND AVAILABILITY SUBJECT
B g EFFECTIVE LENGTH 7$ TO CHANGE'WITHOUT NOTICE. PRODUCT DETAIL MAY
SANDY LOAM DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
LEACHING AREA REQUIRED: 330 = 445.9 S. SANDY LOAM
( ) Ito()
�� O 1oYR s/e 10YR s/a SIDE WALL HEIGHT 11.2"
.74 / OVERALL HEIGHT 16
DISTRIBUTION BOX: 3 OUTLETS (MINIMUM) 65.08 C1 35" 65.0 C1 36" OVERALL WIDTH 34" 4640 7RUEMAN BLVD
PRIMARY S.A.S. 13.6 CF 0919mo HILLIARD, OHIO 4302E
2.5Y
USE 3 ROWS OF 5 - 16" ADS BIODIFFUSER H-20 UNITS-NO STONE M SAND MEDIUM SAND CAPACITY (101.7 GAL) AwAN= oRAma sYSTEMs. INC.
AND EXTENDED0.75' Wf CONTOURED WEDGES sY s/4 2.sY s/a
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) PROPOSED SEPTIC SYSTEM/SITE PLAN
(BIODIFFUSERS). 15 UNITS x 6.25 LF x 4.70 SF/LF = 440.63 SF 56.00 144" 56.00 144" 58 CASTLEWOO D 'CIRCLE HYAN N I S MA
(CONTOURED WEDGE) 3 ROWS x 0.75' x 4.70 SF/LF = 10.58 SF PERC RATE <2 MIN/IN. ("C" HORIZON)
TOTAL AREA = 451.21 SF NO GROUNDWATER OBSERVED Prepared for: Mike Dedecko
DESIGN FLOW PROVIDED: 0.74GPD/SF(451.21 SF) = 333.89 GPD > 330 GPD req'd Engineering by: Surveying by: SCALE DRAWN JOB. NO.
DARI4ENM.MEYER R.S. Bco-Tech EhVhwnMej2w NTS D.M.M.
• I. Darren M. Mayer. R.S.. CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 po 901 (508) 364-0894 to conduct Boil evaluations and that the above analysis has been performed by me consistent with the DATE CHECKED SHEET NO.
requirements of 310 CMR 15.017. 1 further certify that 1 have passed the Soil Evol. Exam in October. 1999. EA3TSAIVDHAfA01337
.,�� 07/31/09 D.M.M. 2 of 2