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HomeMy WebLinkAbout0187 COMPASS CIRCLE - Health 87 Compass,Circle -� -- -- - Hyannis F/R_ A 310, 424.-' 1 4' 4' P e I it f TOWN OF BARNSTABLE LOCATION ��� �'�`> `'r`� SEWAGE # VILLAGE ���" �`'� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. L,.r,, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS C"�'�e•�"l %�� � BUILDER OR OWNER 6� PER I rr DATE/ sa ca COMPLIANCE DATE: 512,110 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 c/ within 300 feet of lea c ' g facility) Feet Furnished by � �"' � � ��. �-`� . r � a � i1 a r � �� r Y,. ry� � � �. ,..a � No. 3 J Fee ©�-- I► `r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricattou for Mtgpogar *pgtem Cougtruction Perron Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No..,..,;;),? d Owner's Name,Address and Tel.No. Assessor's Map/Parcel -1/0 Installer's Name,Address,and Tel.No. l Designer's Name,Address and Tel.No. Type of Building: qj�a fob Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building e&X- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow J.1a gallons per day. Calculated daily flow 3'-� gallons. Plan Date �'��0 Number of sheets Revis n Date Title _ Size of Septic Tank /� aeao 244 Type of S.A.S. L �_ Description of Soil: .7 13 X 2 Seri a r• S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuedY7 this Board of Health. Sig Date Application Approved b Date Application Disapproved for the following reasons Permit No. i 3 Date Issued c) No. �+'f�`✓„ b *,..., } Fee..-_ S 0 - —' -' f Entered in computer: THE°COMMONWEALTH OF MASSACHUSETTS Yes -PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 4 ZIppYication for Migpozal *potem Congtruction Permit Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,Oo�.7 Owner's Name,Address and Tel.No. G o�j f'�•r ��' Assessor's Map/Parcel �O T a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size * sq.ft. j�Garbage Grinder( ) Other Type of Building 40 e-T• 'No. of Persons Showers( ) Cafeteria( ) Other Fixtures { Design Flow - }� gallons per day. Calculated daily flow -15T gallons. Plan Date Number of sheets. Bevis n Date Title S \ ; Size of Septic Tank Fx/�PTZ /moo "A yp of S.A`.,S. Description of Soil 1 t 13 x 2q.. _ SP�2 l a.r• S . Y �Nature of Repairs or Alterations(Answer when applicable) yi/_.. "N,- V Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to pla&e the system in operation until a Certifi- cate of Compliance has been issued this Board of Health. Signed Date Application Approved by, ` -N Date Application Disapproved for the following reasons ` Permit No�_` :-� "�a=�--�5-———— �,,.•�--="- Date Issued —— !=,-�,�7 A) �—— ———— a 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 k.�^ Z e4961e4*',&' at / A 7 J-X G/LPG G(k has been construct d in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2,0 U 3-2 3 s dated S Z 03 Installer L Designer The issuance of this Permit shall not be construed as a guarantee that the system �igned..,o�._ Date 'S 2 1,0 Inspector ----------—� --------------- No. Fee .�- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigogal *potem Conotruction Vermit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon( ) System located at /eF7 Goi,�.o,,�✓'.!' and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction mu t be completed within three years of the datte f this pe it Date:_ SL � �7 Approved by r TOWN OF BARNSTABLE LOCATION �' '• SEWAGE # VILLAGE ASSESSOR'S MAP& LOT -0;�0-- J� INSTALLER'S.NAME&PHONE NO. SEPTIC.TANK CAPACITY /s3�e C*-xf��,✓r LEACHING FACILITY: (type) •�/ee i (size) i }c 2 � NO.OF BEDROOMS dr BUILDER OR OWNER J- ��-Jr �� t • PERMTTDATE-�� E COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom.of Leaching Facility Feet Private Water Supply Well and I LeachingFacility on site or within 200 feet of leaching facility) any wells exist Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leac )g facility) Furnished by •,�,�,, Feet I � 4 4 �. � 4 FAILED INI 77-- N COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 4�71 _ DEPARTMENT OF ENVIRONMENTAL PROTECTION M W � , d F RECEIVED OW J U N 0 4 2003 TITLE 5 BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLU14TARY ASSES Nr L ._TH DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner's Name: DEMENEZES Owner's Address: 187 COMPASS CIRCLE HYANNIS 02601 d Date of Inspection: 5/5/03 Name of Inspector: (please print) JOHN GRACI,INC. ® Ily � d� Company Name: SEPTIC INSPECTIONS Q Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 /t ` Telephone Number: 508-564-6813 FAX 508-564-7270 ^�V CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionall Passes _ Needs Furth Evaluation by the Local Approving Authority X Fails Inspector's Signature: Date: 5/5/03 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. - Notes and Comments THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT WAS POND,NG WHEN THE COVER WAS EXPOSED-THE LIQUID LEVEL WAS OVER TEE IN SEPTIC TANK-LEACH PIT IS IN HYDRAULIC FAILURE` ****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. Titlr S incnPntinn Fnrm rii v,?nnn I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 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: THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT WAS PONDING WHEN THE COVER WAS EXPOSED-THE LIQUID LEVEL WAS OVER TEE IN SEPTIC TANK-LEACH PIT IS IN HYDRAULIC FAILURE. 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. n/a 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: n/a n/a 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): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 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. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 515103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE LAST YR.. X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 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. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with 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: Yes no _ X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):-n4a � •�c 1 U Sump pump(yes or no): NO co Last date of occupancy: n/a (( COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YR. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1979 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): THE SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND.THE LIQUID LEVEL WAS OVER TEE IN TANK-PIT IS IN HYDRAULIC FAILURE. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVER PIPE 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.): DID NOT EXPOSE PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6'X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS IN HYDRAULIC FAILURE-THE LIQUID LEVEL WAS OVER PIPE AND PONDING TO THE SURFACE WHEN COVER WAS EXPOSED.THE PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING AND NEEDS TO BE REPAIRED.BOTTOM IS AT 8' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a A Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TIONPART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 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. LM 0 0 o J6 QA 0 10 L� A3 q7 AC 0 �0 �a16 �� J3 6C I L CD Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS 02601 Owner: DEMENEZES Date of Inspection: 5/5/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from systbm design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY AUGER-NO WATER AT 10' tl COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION a m � , d O� v �41 yy O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner's Name: JUDY THOMAS RECEIVED Owner's Address: 16 HARED HALL RD STERLING CONN.06377 Date of Inspection: 4/19/01 APR 2 6 2001 Name of Inspector: (please print) JOHN GRACI TOWN OF BARNSTABLE Company Name: SEPTIC INSPECTIONS HEALTH DEPT. Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as'of the time of the inspection.The inspection was performed based on 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: X Passes Conditionally Passes _ Needs Furt Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4/19/01 The system inspector shall submit rcopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.THE HOUSE APPEARS TO HAVE A LEAKY TOILET. THE PIT HAD 6" OF LEACHING LEFT AT THE TIME OF INSPECTION. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 187 COMPASS CIRCLE HYANNIS, MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEMS USEFULL LIFE.THE HOUSE APPEARS TO HAVE A LEAKY TOILET.THE PIT HAD 6" OF LEACHING LEFT AT THE TIME OF INSPECTION. 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. n/a 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: n/a n/a Observation of sewage backup or breakout 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): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I1 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with 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: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 187 COMPASS CIRCLE HYANNIS, MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 2/28/01 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1979 Were sewage odors detected when arriving at the site(yes or no): NO A Page 7 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING THE SYSTEM NOW AND EVERY ONE TO TWO YEARS. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a I • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: nla n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: nla Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 611OF LEACHING LEFT AT THE TIME OF THE INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 3 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 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. 1�C'fL LM D O y AC Ge) U a3 m t� 6C . gp a7 i Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 187 COMPASS CIRCLE HYANNIS,MA 02601 Owner: JUDY THOMAS Date of Inspection: 4/19/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET L0' AT 0 SEWAGE PERMI NO. G VI.- LA t E INSTA LLER'S NAME i ADDRESS BUILDER OR WNER DATE PERMIT ISSUED 142 DAT E COMPLIANCE ISSUED I � v - J THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HE LTH ...... ...........................OF..... ........................... ........................... Appliration for Uhip ti ai Works Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an,Individual Sewage Disposal System at: .....L. .�r.....3..8: . : G ,e�.�. ................ ....... .. ...............-- ...•••. .. . ----------- LocationLA;ddres or Lot No. ...... .� ...... --•-------•-- ----------- ....... .... ......... ' -• - O ner Address a -----•............... - ------------• - - --------------•------•-------• .......-.-... � Installer Address d Type of Building Size Lot.....(.bt..T 1_0.....Sq. feet Dwelling—No. of Bedrooms---------- ............. .----..--.Expansion-Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building .. No. of persons.........L............... Showers ( /) — Cafeteria ( ) Q' Other fixtures -------•----------------------------------------------- W Design Flow......5 5...............................gallons per person per day. Total daily flow..........KID......................gallons. 1.W Septic Tank—Liquid capacityJACt .gallons Length...`......... Width---&i Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....q.21.....sq. ft. Seepage Pit No..................... Diameter.........---........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.._!✓���"1 Ate_._GHQ. �_.�!� !................ Date...../U� Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water.. rP?7�.......... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--................--.. a -------------------------------=--------- 0 Description of Soil-•--L e A s1.b_ a e..�........... ' -------------------•---•--•-------- V ........................................................................................................................................................................................................ W x -----•-••-•--•-----------------•••--------------------••-•---•-------•---•--------•----•---•---.....----••-•-----------------------------------••-•-•--................................................ V Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The°undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iLCI. th oar of health. Sig ------------_--. /._._� .. _. to Application Approved By...... _ .. .... Date Application Disapproved for the following reasons:.:--- ---- ---- ------------------------------•---------•-------------....---------------•-----•••••....•• ........................................................................................................................................ ............................................................... -----Date -- Permit No......................................................... Issued..... .................... --- Date i z> Fss..r..`:..:...' ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r .....................OF.-.-..4�=4 ......... ........_.....-.......----------............._.... _ Appliratiun for Disposal Works Tonstrurtiun Vvrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .. r `. Location-Address y f_ or Lot No. ........................................ owner f Address Installer Address Type of Building Size Lot..... ....Sq. feet U Dwelling—No. of Bedrooms.............................. .Expansion Attic ( ) Garbage Grinder ( ) -_--__. No. of persons.........�.:............... Showers ( �) — Cafeteria ( )pa, Other—Type of Building ..1...:_t�:,t�c �- a' Other fixtures .................................. d -------------------•-------------------------- W Design Flow.......:.`...............................gallons per person per day. Total daily flow...........6... ._U.....................gallons. WSeptic Tank—Liquid capacity.`..L..S?s:.,.gallons Length............... Width...,...........Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area----- . -----sq. ft. > Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '"' Percolation Test Results Performed by '.'..' I."../I..-................................................ Date.......2 ................. ,.a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._.'.`'. ......... ..- Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 00 ............. l ............................A.......c.rf...r....i.".`f...........l._..)..,...7...!.�..-.r.i.-.�../ ........................•..................... Descripton o o1 :.. � Y....._ f ..G_ x . ...-- ...............�--�Ci-----•---•------•----------------•----•-•---------•-----................................... W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...................----.................-............................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the,provisions of TIT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the,boar.of health. / Sig 1 ��. ........ /�r�!rf/�� �..fir...-- .-------•--------- ii Date Application Approved By------ �'� 1 . ......................... "`'?01 " f Date Application Disapproved for the following reasons:............................................................................................................. - .................•-------........•-----.......----•...--------------------...-•--------------•-...........--••-••.........--•-•---•--------•-----...-------------•-----•--•- ----•--•---•--------•------- f:ilC C Date Permit No...................... ...-•-•-•-•-------•----------------- Issued....................................................... Date f THE COMMONWEALTH"OF MASSACHUSETTS ,ate -=--- ,BOARD OF HEALTH OF ... ................................�............ - �rrtifirtt#r of f�laaat�liaanrr " THIS IS TOG-.ERTIFY;' That the Individual Sewage Disposal System constructed ( or Repaired ( ) by `?r!� -....:vim✓.�. .a' _r ,...._..•.. ......................................•-•--•--...--•---................................... / Installer L. has been installed in accordance with the provisions of The, State Sanitary Cq as described in the application for Disposal Works Construction Permit Nog_.j .. ...... dated------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE...............^.............. ------------- Inspector... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �,�: ...........................O F... -_:........................................................... .......... FEE......C�:�.!.... Disposalorku,,�un tr�ttiun leranit Permission is hereby granted..., .........` 1...... .t�.�5 ., to Construct (�%) or Repair/( ) an Individual Sewage Disposal System ........................ ............. ............. ........'............................................................................_..................... ! Street as shown on the application for Disposal Works Construction Pe `it�No.... ... ........ Wed...../. --An.71--....... v d ealth DATE... -��----`-`-�•------•-----------------................................... FORM 1255 HOBBS & WARRENS,,,INC., PUBLISHERS x.M' 1 j 1 ' r� � Q • �Vc- . . 1 r ' f 1 C I i • I i ZS:Z Wd.�T�£T AdN J 9-JNiSH GVAVZ-- F-INISM COFAZ7E FIN/.rfF 61r?'4v F - Top -oF F�o�tvv. IrI . C L E✓.- �x v I �!.�.��-iJT � W►` �f''..�/i��:�y�.�ii��//l�.f/�.V�//3'J"N. �Jj�yll�"II,C��/!,��.!/T.�li•�'��'�:�w�,t;�`ty1.��\�Y�//1�t�71n,,��Y//X\�Y/!/\\yv� 6 i 4—C r- * —=- ----------"- ---- r „ ---------1 / G.N�fLt A'EEAEA �- --- . -- f/G. f L. 3 f'EABTa A4- CELLA R F`L /Lb0 6AL• i fi — -_ — - -- \ / EcEv- _ ;hcv_ D I S r b o x S-7-'d To CiE LEVEL t d (* i j` ( r�Es� G�✓ c,�� r�'�ift ` - G.HG- P�.L o To TAG Dfl/L - OA41- E 3G+Tl a:^0' .4)p, .4 SC v l f � � g" �) 1 { PE¢c loae GAt.. A5y, a SOIL 5 LQ—G 4c ,s-o as-o po's e� rP Tf a��O l 3� ACA~ t 3 L" ✓Y �. S3I�D� � � �v v; i I 1 r L�USe D.S�WA�� IOlSP4S,4L SYSTzM �'/PD/r'oS�I> �bIrEG L lNG /.t/.SPJq=reZ? AB MLAQ>eAy: f34>ZAI- at). �` .��'>bc- ,egTE s��.v�,✓. sc�o L�..'. '�� 3.`' OW/VEP : c�=7c,,.-7 ez .=�,c�!►`.�' .E'.r�i�x:�•: , z.=„�,;�. _ Yri� �\ 0� �� y'� y _...:..a,.--..•,...,..,r.-••.--w..-.v,^.....---w----�T-'z•,^-,. _.:-r..-�-:+f"-.—— �±-s>�� ........, NOF AXFi tir f+oRNA o�ose+u+,N wROSSMAN R. o C,STEP r4`` 'L � � /"� �'. _ � GEJt{TG�"1E�V�L �. i�li�J.� • 1 L '�1' - a.� ; .� °y. fir'., -t •- .{' , '^ � � 1 1�+ to ,„r rt�¢ I ^' _ .� ''�' •.�`tea � .� - �" - � .. - M` - `T'•Iv I •"�, A_.. �� � .. • .. rr.' .v.. 5.7.IR'' •j a: 1 ..- _�- i " 'ClIMARK 1`EST SOIL TOP OF FOUNDATION 20 FT. MINIMUM FROM .CELLAR - , = 100.00 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST ELEV. CLEAN SAND SOIL TEST DONE BY SIB ENGtNEEB1IG (ASSUMED)' CONCRETE WITNESSED BY COVERS INSPECTION PORT 4 SCHEDULE 40 PVC-PIPE LOAM AND SEED OBSERVATION H= 1 Et EV.= _97.00 MIN. PITCH 1/8" PER FT. " PERCOLATION RATE _<_ MIN./INCH AT.' 4_1 INCHES 2 LAYER `OF 1/0"`TO 1/2" DEPTH HORiZ TEXTURE COLOR MOTT, OTHER f, - 97..50 MAX , .WASHED. STONE - 3.00 - - " VENT 0-8 A LOAMY SAND 10YR4/2 NO ROOTS 4" CAST IRON PIPE (OR EQUAL) MINIMUM 95.25 MIN. NOT REQUIRED PITCH 1/4" PER FT. z LEGEND: 8-�28 H LOAMY SAND 10YR6/6 5% COBBLES EXISTING SPOT ELEVATION -0.0 FLOW LINE in 28-132 C COARSE SAND 2.5Y7 4 5% COBBLES _ 4, EXISTING CONTOUR -___00____ / .ELEV. OQ_ 10' FINAL SPOT ELEVATION -TMIN. 2, " o o n FINAL CONTOUR "' t" i ELEV. 900� LELk �� c . 10� , r� o - SOIL TEST LOCATION ELEV. ffi �>� •_1Z_ ADD GAS .40 6" SUMP ELEV, = _94.23 � aar � a o ELEV. T93.17 UTILITY POLE ELEV. $ __ BAFFLE TOWN WATER -W W DISTRIBUTIONELEV. CATCH BASIN �j 1 LIQUID OUTLET n HIGH C ACITY INFILTRAT NTH GAS LINE G- DEPM _� �- STONE IN A 4 FEET 14 INCHES (EXISTING) TO BE WATER B0 TESTED , � 7.17 CESSPOOL �P 5 FEET 24 INCHES 1000 GALLON FORMATION CLEANOUT ------e'' C.0. IF MORE THAN ONE OUTLET 5 FEET 19 INCHES 11 X TRENCH FORK 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) SOIL BSORPTION' WELL N/A NO WATER ENCOUNTERED AT 132__ ELEV. _,.. 8LM 8 FEET 34 INCHES SEPTIC TANK ZONE 3/4" TO 1 1/2" CLEAN S TEM (SAS, INDEX DOUBLE WASHED STONE ADJUST FREE OF FINES & SILT DESIGN CALCULATIONS US S PROBABLE WATER TABLE ELEV. = __-- NUMBER OF BEDRgOMS 2 DEWN FOR 3_ _.. SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED ATER TABLE NOT TO SCALE / / ) ELEV. = GARBAGE DISPOSAL UNIT -..1�..- BOTTOM OF TEST HOLE ELEV. _ QQ_ TOTAL ESTIMATED FLOW ( 110 GAL/IM/DAY X _.3 OR.) _3 4� GAL./DAY REQUIRED SEPTIC TANK CAPACITY GAL. ACTUAL SIZE OF SEPTIC TANK (EXISTING) �„j GAL. SOIL CLASSIFICATION DESIGN PERCOLATION RATE _ MIN./IN. / C = EFFLUENT LOADING RATE _11-4 GAL./DAY/S.F. 3 Z z( 4Lt� SO. FT. (llX36)F(47X2X10/12) HING CAPACITY AREA RATE) -MtDQ GAL./DAY Vey 4 . �.�-- 1Q�� RESERVE LEACHING CAPACITY NONE . GAL,/DAY C C NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. x 97.7 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO 8.0 WITHIN 6" OF FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF. .8 98.2 WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 8o4p• 10 FT. OF DRIVES OR PARKING AREAS, H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS, 4, ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN_PLACE. - _" t). NO DE1'1=:�:MINATION HAS BEEN MADE AS 70 COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER / .APPLICANT- IS TO • 97.4 �r"9 OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. tp 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION J CONTRACTOR IS TO CALL "DIG-SAFE" AT 1-888-344-7233 ' * -97.3 / 99.0 ---9. 6 97.5 AT LEAST 72 HOURS PRIOR TO COMMENCING' WORK' ON SITE. 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ( 7►7L 1 j ANY VARIATION IS TO BE BROUGHT TO THE "ATTENTION OF . CJ i w Q9.0 THE DESIGN ENGINEER IMMEDIATELY. 8. PARCEL IS IN FLOOD ZONE ,_.._..Q ____. rr,^, 9. LOT IS SHOWN ON ASSESSORS MAP 310_ AS PARCEL .. M.- rJ I 10. EXISTING LEACH PIT IS TO BE PUMPED AND REMOVED. i♦ ( ` t� { c� 1000 GALLON '7 C9 O /f, t=( t 98.1 SEPTIC TANK T.A. l M 97.0 Aft C g u DU'�ll r 61 APPROVED: BOARD OF HEALTH TE 1T11R% 98.0 BH. K 97.7 DATE AGENT 97.7 PROPOSED SEPTIC DESIGN FOR D. BOX ISRAEL DE MENEZES ,k \PIT RdU I'� t LOG • 96. •8 � � SOIL 36.Od, ' `� m BARAB� MASS 97.3 TEST A HYAIVNIS �7 coi" 0 235 GREAT WESTERN ROAD AREA 10,880 f S.F. ,. i�L'V V�7 508_ P. O. BOX 713 epoo• ® SOUTH MASS. ; x 96.8 398-3922 02660 DATE MAY �I 6, 2©03 SCALE 20i REVISED +LOB N0. 782.�..00 _ LOCATION - MAP REVISED [SHEET 1 OF G.- 5-8 PROD 5682-C10 dw 5682-170/DWG 02003 SWEETSER ENGINEERING