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HomeMy WebLinkAbout0109 CONNEMARA CIRCLE - Health ,1.0.9 ponnemara1Circleit Hyannis ;F/R 'A 290 136 _ , 0 TOWN OF BARNSTABLE y LOCATION 109 CONNEMARA CIRCLE SEWAGE# VIDLI AGE HYANNIS ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ELLIS BROTHERS CONSI 26-2 9237 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) X2 NO. OF BEDROOMS _ BUILDER OR OWNER { PERMITDATE: 7/a, 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 W � � f t.1. 1 � t OraA 3 '- �v N No.`� S / �3 rI I Fee THE COMMONWEALTH OF MAS CHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN O ARNSTABLES MASSACHUSETTS Rpplication for Migo pgtem Conotruction Permit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) E)Complete System O Individual Components Location Address or Lot No. �� Owner's Name,Address and Tel.No. /'v L°:�.t✓�✓�b�yA�is� u _, � Assessor's Map/Parcel VA 2-5J10 b Installer's Name,Address,and Tel.No. 9 0$� /fG- , ,Z Designer''ss Name,Address and Tel.No. el 70 Type of Building: Dwelling No.of Bedrooms 45;1 Lot Size /!e sq.ft. Garbage Grinder(wo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �. �� gallons. Plan Date 1�`—��S Number of sheets / Revision Date Title a /S/�—fc� �U l ' 7►�G, Y7 ' 4p&,A q A40 � !s t—iN Size of Septic Tank °J _ Type of S.A.S. ,% �✓� 2 Description of Soil, 140 Nature,of Repairs or Alterations(Answer%hen ap licabbll LZ' X b L�J�/ �1 J Date last inspected: Agreement: The undersigned agrees to ensure the c7womud ction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti Environmen ode and not to place the system in operation until a Certifi- cate of Compliance has been iss y thiof He Signe c Date Application Approved by Date a Application Disapproved for the following reasons Permit No. Date Issued 0 r _ _. „_.ti _,�.; .. .... . _ _ _ _.. a�. ��..-,.. .._ _. "- ---- . �. _- •- .. No. �" /6 Fee THE COMMONWEALTH OF M�AP ACH SETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN O �ARNSTABLE-'jMASSACHUSETTS Yes Z(PpYtcation for Wgpo bpgtem Cougtructton Fermat Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 9 j Owner's Name,Address and Tel.No. lv g `vN�0 M A/LA GI'1/ J/! 4 /A,, Assessor's Map/Parcel / 974L 13b Installer's Name,Xddiess,and Tel.No. S-0 9' �3fG- Y-M Designer's Name,Address and Tel.No. • c,aw s� c a - m �. .zyO J 23 A4. �qn,w 2 t.t 3-� .9.v i /yJq 2 -/'p Type of Building: Dwelling No.of Bedrooms Lot Size V-esq,ft. Garbage Grinder(Alb Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow =3 _ gallons per day. Calculated daily flow �J a 3`F gallons. Plan Date —US Number of sheets Revision Date _ Title �`ol�J c �f/�Lc% �l v72/e t/t �4 /a Z:: 0&,,Y1 A/LrA C �i• �`� .v,vf o �k Is h- Size of Septic Tank Type of S.A.S. 716e4A16111 .I Zf, k 2- Description of Soil es �9L-L S a � Natureof Repap or Alterations(Answer w en ap licab Ale GV e.� X� Date last inspected: Agreement: The undersigned agrees to ensure the cpas ction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title'5 of tjr Environmental-Code and not to place the system in operation until a Certifi- cate of Compliance has been issued�by thi ,Board of He �i �• Signed Date Application Approved by Date C� Application Disapproved for the following reasons Permit No. .3 Date Issued 0W G-5 —————————————————--- ——————————- - _ . - - 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 F at C&L0 AP S has been constructed in accordance with the provisy ns of Title 5 and the for Disposal System Construction&rmit No. dated Installer Z&>L-oS Designer .S ay/ The issuance of this permit ha Atbe construed as a guarantee that asyste 1.1 nction asde igned. Date Inspector No. �w.5j3---------------------------Fee ���� THE COMMONWEALTH OF MASSACHU ET'TS PUBLIC HEALTH DIVISION - BARNST s MASSACHUSETTS Mtgpogal *pgtem on5tructton Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at A. a W,A A—A /'Lit, NVA 66k/jb 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 ryst be completed within three years of the d fe of this p t. Date: )ra 1 U 5 Approvedny i .. TOWN O-F BARNSTABLE: 109 CONNEMARA- CIRCLE SEWAGE # b3 LOCATION HYANNIS VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONt No. ELLIS BROTHERS rnN I 362 624 SEPTIC TANK CAPACITY /06 0 LEACHING FACILITY: (type) }� /.t/ .7�7/L /%o/L C . (size) // X NO.OF BEDROOMS .� BUILDER OR OWNER PERMIT DATE: owl D 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 i Edge,of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by x`,. Y A3 03 i� ! 1 ' Town of Barnstable . y 0. FINE r o� Regulatory Services Thomas F. Geiler,Director �= �vsrAst�. = - 9SIAM Public Health Division Fpa . Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Designer: L /S,cl -. l/�,�5' Installer: A L 1 c 12go >P C.Al Address: �i—��41,V_1 SS Address: �3 CyT�'�P/��rs c 2�( On Z621 Z o S - gaoTkeel was issued a permit to install a (date) (installer) septic system at le Goti��i M�✓Cu ��2 based on a design drawn by (address) pia i - dated 10 LoS s' er.) V l 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& L&A—Regulations. Plan revision or certified as-built by designer to follow. b , (Installers rgnature) Q♦ RE1) signers S ature) (Affix er's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM' AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form N .. COMMONWEALTH OF MASSACHUSETTS • EXECUTIVE OFFICE OF ENVIRONMENTAi,AFFAIRS DEPARTMENT OF ENVIRONn[ENTAL PROTECTION ,;,RCEL. RZ'CLIVED o 02 90-T JAN 1 12005 TOWN OF BARNSTABLE OFFICIAL INSPEC TIE 5 HEALTH DEPT. TION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM PART A CERTIFICATION PMI"Address: /09 G 0k14e mP,, , r FAILED INSPECTION Owner's Name: Od 6 O/ G/2 o Owner's Address: Ap O a Date of Inspection; (D 02 0 88 D UARCEI Name of inspector:(Qleas�e,�riat) Company Name: �- 'lZ — Telephone Number _ �OZ 6�'Z •�� CERTIFICATION STATEMENT I certify that I have personally iris=W the sewage disposal system at this below is ttue.accurate and complete as of the time of the' address that the infommation reported �g and experience in the proper function and pencection.The inspections was performed based on my approved system inspector pursuant to Section 15.3 tie Son site CMa 1S isposal systems.I am a DEP The system Passes Conditionally Passes Further Evaluation by the Lora!Approving Authority Fails Inspector's Signature: P Date: The system huPoctor shall submit a copy of this' DEP)within 30 days of completitIS this' i specdon report to the Approving Awhorig,(Board of Health or gpd or 1 .the tnspection.if the system.is a shared system or has a design for and the system owner shall submit the report to the a flow of 10>000 DEP,The original should be sent to the system owner and copies sent to the buyerapp(iGable,and office ae of the authority. pproving Notes and Comments ''*""This report oily describes conditions at the time of ins time.This inspection do"not addregA how the system will inspection and under the conditions of use at that conditions of use. perform in the future under the.-ssame or different Pape 2 of I 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continuo Property Address: Oq G 0 i1✓Ie NO ajer c, , r. Owner: Date of Inspecdon: a, y Inspection Summary: Check A,B,C,D or E I ALW An complete an of Section D A. System Passes: 'have not found any information which indicates that my of t he fag 15.303 pr in 310 CMR 15304 exist. MR c terra described in 310 CMR �'n3' criteria not e"aluated are indicated below. Comments; B. S ZOE Conditiogalty Passes: more system cotaponettts 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 MCW or not)is unsound exhibits substantial infiltration or Urdbution or tank failure is imminea Syste Board of structurally em will existing tank is replaced with a complying septic tank as approved by th th Health. � Lon if the 'A metal septic tank will pass inspection if it is structurally sound,not lealang and a Cer if tificate a�f Compliance indicating at the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box obstructed pipes)or due to a broken,settled or uneven distribution box. System will pass' due to broken or approval of Board of Health): inspection if(with broken piPe(s)are replaced- obstruction is removed distribution box is leveled or replaced ND explaia The system required pumping more than 4 times a year due to broken or obstructed pass inspection if(with approval of the Board of Health); y ppe(s).The system will broken piPes)are replaced obstruction is removed ND explain; r I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTJFICATION(cotknued) PCQperty Address: 09 , Oft V`16►r01 rii s^ CKvver: Ar, ' Od 0 j Dste of Inspection: CCons Evalus�tton Is Required by the Board ofHealth:exist which require further evaluation by the Board of Health in order to determine if the system is failing-o grout f `health,safety-or the envhurdnen. L System will pace unless Board of Health determinea In accordance with 310 CMR U3030)(b)tl that system ii eot imetiaoing 1a e-manner which will protect public beahh,lafety aed the.euvlronnsbt;the _ Cesspool ar 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 i 2. System will fail unless the Board of Health(and public Water Supplier,if an system is functioning in a manner that protects the public health,safety and an do esi kr cnes that the The system has a septic tank and soil absorption system(SAS)an, the SAS is within L40 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. -- Ile system has a septic tank rind SAS and the SA3 is Ividun 50 feet of a private water supply well. _ The system bas 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&twgune disu= W**�system Passes if the well water analysis,Perfonned at a DEP bacteria and volatile or certified laboratory,for coliform ganic celnpoundsindirateS that the well is flee from pollution from that far' . the p"==of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 �and failure criteria ace triggered,A copy of the analysis must be attached es this form.'lrvided that no other 3, 9ther. p9W4of11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM!INSPECTION FORM PART A CERTIFICATION(continued) Property Addrew 9 Coo vie rh pwvner. Gj e o nni D�6 t7/ Date of Inspections �d b D. SYlkin Failure Crikria applkabk to all sy*m, You=W indicate yirce� `Yes"or"Ile to each of the following for all inspections; Ye No _�of sewage into facility or system component due to overloaded or clogged or ponding of emuent to the surface of the SAS or cesspool `/U SASor cesspool !;round or surfacR waters due to an overloaded or Static liquid level is the distribution box alcove outlet invert due to an overloaded or clogged SAS or ✓�sP� — 4u�d dell►in=spool is less than 6"below invertor �l�d 8 more than 4 times in the last avarlable volume is less than%:day flow times l�Ped Year 1�OT due to clogged or obstructed pipe(s�Number -L�nY portion of the SAS,cesspool or pmry is below high w Any portion of cesspool or privy is within 100 feet of a surface wa�suppl Lion. A,ater mP*. Pp�'or tributary to a surface portion of a cesspool or privy is within a Zone l of a public welL _ y p�n Q a cesspool or Privy is within 50 feet of a private water supply well. cesspool or privy is kesa than 100 feet out greater than 50 feet from a private water supply well with no actable water quality analysis. [This system PaIJIft it the performed at a DEP certified laboratory,for Conform bacteria and volatile o well water oun analysis, indicates that the well is free from pollution from that facility and the rese roc compounds nitrogen and nitrate nitrogen is equal to or less than S P nee of ammonia are triggered.A copy of the analysis must. • pp°1'Provided that no other failure criteria y ' attached to this form}. MWNo)The system W .I have determined that o criteriafailure described in 310 CMR 15.303,therefore the system fails. exist as Health to determine what will be necessary to co The system owner should contact the.Board of rrect the failure. L Large Systems; To be considered a large system the system must serve a facility with a de sign esign tlow of 10,000 gpd to 13,000 You must indicate either"yW or"no"to each of the following; (The following criteria apply to large systems in addition to the criteria above) Yes no system is within 400 feet of a surface drinking water supply he system is within 200 feet of a tributary to a surface drii+leing water supply system is located in a nitrogen sensitive area(Interim Zo tI of a public water supply well Wellhead protection Area—IWPA)or a mapped n if you have answered"yes" to any question in Section E the system is considered a significant "Yes" in Section D above the large system has failed.The owner or operator of any I_ar��Sys tem s��acred significant threat under Section E or failed under Section D Shan u 15,304.The system owner should contact the a p�de the system in accordance with 310 C&M ppropriate regional office of the neparirtlent, page S of I 1 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertLIM s: 0 COnnev/ o-r� C 1 r,• G Owner. 4 F 60� Date of Inspt�oic j Check if the following have been done.you most indicate es"or"no"as to each of the following: Yes o information was provided by the owner,oocupaat,or.Board of Health _ w of the system components pumped out in the previous two weeks TsYs ten received normal flows.in the previous two week period rlvolomea of waxer beausintroduced to the system recently or as past ofshiis inspection bwhplansofthesystemobtainedanda mm;�p(Ifthey were not availablenote as N/A) facility or dwelling inspected for signs of sewage back up as the-site inspected for signs of break out ere all system components,.0duding the�,located on site the septic tank manholes uncovered,opened,and the interior of the tank of es or tees,maWdal of construction;dimensions,depth of liquid,depth of sludge for the road tiaa udg�e and depth of scum was the owner(and occupants if different f�owner)provided with information e o maintenance of sewage disposal�,� orn>ation on the proper The and location of the Sod Absorption System(SAS)on the site has been ddaminod based on: Yes -� information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to pact C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] r f PaFe6ofII OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM TS PART C SYSTEM INFORMATION PWopert�Addres:c 09 CoHnMrA�� Ct h - o�. Date of Insph; RTSIDENTIAL Vi►CONDITIONS N=mber of bedrooms(desigp). -3 Number of bedrooms(wt.W). 3 DESIGN flour based on 310 CMR 13.203(for example: 110 gpd x# mum). ,�� Nsa�mber off��, p Does.'eSideoce have a Wba�ender(yes of no):AV Is laundry on a La system (Y&eorsY es or no):yo y - on ti ). �'� e' requirA Seasonal use:(yam or no):If-a Suimp pump(yess or � e(last 2 years usage(gp�Y I.ast date of occupancy: -A - /y tea►- - o w►,c COAEWERCL41JMUST RIAL v` Type of estabashmat DOSigo IIow(based on 310 CMR 1-5-2 0-3)-. e,.d ° Basis of design flow(seawpersons/sgR,etc.): Grease UV pmern.(yes or no):- I�traal�e��g tank preset()es or no): Waft meW wasted i f arm the Title 5 system(yes or no):-Bs,if available: Last date of omup mcy&w: i OTHER(describe): Pumping Rftords GENERAL INFORMATION Source of informm: o Was system pumped as s y.,��cl If-yes,volume P�of the inspection(yes or no): /t-V Reason for -dons-How was quantity pumped deternwd? m SY STEM _ motion box single cesspod ,soil absorption system - _Overflow cesspool r Shared systm Yes Or no) o)(if Yes,a�l�ous any) y. Attach a inspection records,if obtaaned from system owner) COS'of the cunnent°Peration and maairttenan�contract(to be -Tght tai* _Attach a copy of the DEP approval - Other(describe): Appmximate,age of all compom date installed Ow(if lmown)and re.y. Source of information: Wene scwagie odors detected when arriving the site(yes or no):L(/o - Page 7 of I I • OFFICIAL INSpECTION FORM—NOT FOR SUBS VOLUNTARY ASSESSMENTS iTRP'A SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM FORMATION(com m,4 property Address: r Owner. G o ! Bo��OJ Date of Inspectoa BUILDING SEWER(locate on site Plan) Depth below grade:Materials of Duda=from private water non ` '`'—off(plain): supply well or suction line; COmmenTs(on condition of joints,venting,evidence of leakage~ )• etc. SEPTIC l mx._(locate on site plan) Depth below gm&: l? Material of cow; : _ot*(expwn) — —' - —_ e&ylene Wtank is mewl list aga: _ is a certi�e) , 00� b7'a Certificate of Compliance(yes or no):— SDfineasions:1 ��S ) (attach a copy.of �— S Distanwfmm top d sl%V to bottom a[outlet tee or baffle: 3/ t>gc>�ss: Dim f om top of scum to top of outlet tee or baffle: L ' Distance from bottom of scum to bottom —,• How were dimensions diced: � et tee or 6�81e: S Commences(on P�►Pmg rwommend..o� � as related to outlet im+ 1 "'1"ana ouuet or baffle conditiogctutal irate M = 9f yakaA etc.): lity,liquid levels coy, .410h /`D ��4,1. C'REA$E Tip to on Site plan) Depth below grade:_ Material Of Construction:__co (explain); n�--'�—�rBlass_�lyethylene—other Dimensions: Scum thiclmess; Distance fiOnm top of scum to top of outlet tee or baffle:_ Distance fmm bottom of scum to bottom of outlet tee or baffi Date of last pumping Comments(on pumping recommendadons,Wet and outlet tee or baffle condition, as related to outlet invert,evidence of leakage,etc.): q structura!' �h:liquid levels pale 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addcesx /09 Cowrwvlow,, 4�71 Owe: C4 L g.4 Od 6a/ Date of lospectiam /-L l TIGHT or HOLDING TANK:/jZ(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction concrete mew fiber81aw—p°lyetltl'leae olhe<(exPlain): Dimensions: Cap®ciit r 3311ons Design Flow: Vt day Alarm pint(yes or no): Alarm level:m Alarm in working order(yes or nor Date of last pun�ng: Comments(condition of alarm and float switches, )•etc. . DISTRIBUTION BOX�if present must be opened)(locate on site plan) ) Depth of liquid level above outlet invert: 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 worldng order(yes or no): Alarms in woddng order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 0"ICL"INSPECTION FORM—NOT FOR VOLUNTARY AS ` SUBSURFACE SEWAGE RLSPOSAL SYSTEM INSPECT SSSMENTS ION PART C RM SYSTEM INFORMATION(con&axM Property Addmw /0 9 CotiHev,o�,.� ct ' owner, A G 4 O� Date of on: / SOII.ABSORPTION SYSTEM(SAS): , (locate on site plea,excavation ant required) If SAS not loci Wqdain Wily: leaching — �l��er. x P cqs leachingdhambeM number: leg galleries,number lE number,length,;leaching number,dinlendow, frfi0w cesspool,number 1000vativetalte native system Tyw ame of technolo Cis(note condition of soil si �►: etc.). draulic failure,level of pon ding,clamp soil,condition of veget.Won, L,.., / w e,.. 5 ,� n ed pvgr l✓i{�r�: Veb- P / CESSPOOLS:�(/ (spool must be pumper as lit of inspection)(locate on site plan) Nuunber and confiiVmtion: Depth-top of liquid to iNet invert: Depth of muds layer: Depth of scum layer; Dimensions of cesspool; Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydra is failure,level of ponding,condition of vegetation,etc.): (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraWic failure,level of pone condition of v eGetaU04 etc.). • Past 10 of 11 r • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: /0 9 Con I°12p,&,?,, E r' Q 44#1 'J Date of Inspection: LUT-4110 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the.sewage disposal system inchxding ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. a - .21 40� - as ' pgg�e 11 of 11 • OFFICIAL INSPECTION FORM;-NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(conti mmo PrOPerty Addrem 7a .Nv1 a matern C��✓` Owner. Ct G ate of Bois 6 SIIM EXAM' ..Slope , Slsifaoe wale[ Check cellar Shadow wells , �( 3 Coo Estimated depth to Smund water feet / Please iIIdiCate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-H checkedk date of design plan reviewed se(abutftpopm y/obsservvation hole 150 feet of SAS) Checked with local Boardof Heath-explain: J�p S Chadmd with local excavators,ieaWers-(attach docuarerrt�ion) Accessed USGS database-explain: TpF You m 'be how you established the high vem4water on 01 `,y • r IQ 00 0 9 0 0 0 S• O 00 Q !� r � � , o o C - o J L ra �•� . i� tT Z!� S E3 ID�n ,per s 0W ' 'j- ,ATRRHSTABLE -\ COMMONWEALTH OF NU§A &i CtiH�J �T' S ?: 14 3 ExWuTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION- DIVISION 4OAP 3 iVj LOT I J TITLE 5 . OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address 10 d L rc�e ,tennis,AM 0a60 1 Owner's Name: 6611 Owner's Address: O If Date of Inspection:_-S'-13-D'/ Name of Inspector:(please print) SSW/i Company Name: S, n � I5e.S Mailing_4ddr+ess: Q Fu S36 Telephone Number: SOB-S/9S-0 96 — 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 iuspector pursuant tr,Section 15340 of�Title 5(310 CMR 15.000).• The system: 1/ Conditionally Passes Al JF Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:. Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(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 gtea er,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. / L Notes and Comments 6tci i n /.-/i e Oil le.c`j D i T 6 Gt- 5-a"", //eta U•,n5! 0�0"� D Irrec ;5UGce _ equa>' fy Dt'1e �f{ DF d- �oL,) ""This report only describes conditions at the time of inspection and under the conditions of use at that time.—M5 inspection does out addresi.how the system will perform in the future under the same or different conditions of use. Page 2 of I i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �o S< Owner: Date of Inspection: inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _3 t have not found any information which indicates that any'of the failure criteria described ut 310 CNIR 15.303 or in 310 C141R 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 tfie septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiluation or tank faihree 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. N-D explain: Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)of-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 distn'bution box is leveled orreplaced ND explain: The system required pumping more than 4 titres a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): j broken pipe(s)are replaced _obstruction is removed ND explain: Page 3 of 1 t OFFICIAL INSPECT40N FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART A CERTIFICA.TION.(continued): Property Address: of ca'"PAOS 6 r-rl , Owner: Date of Inspection: 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 CIIR 15303(i)(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 f�e*ortnore 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 and volatile organic,compounds indicates that the well is five from pollution from that facilityand 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: Page 4 of 11 OFFICIAL INSPECTFON FORM—NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SERFAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /04 COMDaSS_ Owner: Date of inspection: �l•[3'0�/ D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for ail inspections: Yes No/ _ t/ 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 _ V/ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/:day flow — Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ _V 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. _ _✓/Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspoul or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds inditai@S that the well is free&otu pollution"m that fauuly arid the presence of ammonia wit- t ed 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 forai.J LQ (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. 1s. 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 Iin addition to the criteria above) yes no the system is within 400 feet-of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 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. I Page 5 of 11 OFFICIAL INSPECT-SON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART•B CRECKLIST ;. Property Address: t7 y COM S c rile Owner: Date of Ynspectiou: S!•C3'�'( 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 T V Has the system received normal flows in the previous two week period? V flave large volumes of water been introduced to the system recently or as*pan of this inspection Were as built plans of the system obtained and examined?(if they,were not available note as NIA) t/ Was the facility or dwelling inspected for signs of sewage back up? V — Was the site inspected for signs of break out-? V Were'all system components,excluding the SAS,located on site? V _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of res 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 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 I 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)j310 CMR 15.302(3)(b)J Page 6 of I I OFFICIAL INSPECTON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:105 e6S ".-C/2 YawJls ' Owner: Date of Inspection: ''-/3-D q FLOW CONDITIONS —RESIDENTIAL Number of bedrooms(design.):a Number of bedrooms(actuai): DESIGN flow based on 310 5.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: - Does residence have a garbage grinder(yes or no): /4t° ' Is laundry on a separate sewage system es or no):_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Q' Water meter readings,if ayaiiable(last 2 years usage(gpd)): Sump pump(yes or no): 0, Last date of occupancy: '7-•/= COMMERCUL4NDUSTRIAL Type of establishment: Design flow(based on 310 C1VIR 15.203): Qpd Basis of design flow(seats/persons/sg1%etc:): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_. Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL.INFORMATION Pumping Records Source of information. 0 W AC P ,:(-e w m a',AAo 0 Was system pumped as part of the i&pection(yes or no):_ If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: /V(ca.a+eotuN e� 17E OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology-Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all compoveuts,date installed(if lmown)and source of information: Were sewage odors detected when arriving at the site(yes or no):ho Page 7 of 11 - OFFICIAL INSPECT40N FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSL-tFACE'SEWAGE'DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 Co/n Hass L! Owner: Date of Inspection: $-/3-Vq BUILDING SEWER(locate on site plan) Depth below grade: _ t Materials of construction:._cast iron 40 PVC_other(explain): 02 O P UC Distance from private water supply.well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): E SEPTIC TANK:—(locate on site plan) Depth glow grade: 6 ri r Material of construction: onctete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Y"10" --- i 000 GC41 ,1 N Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6 rr Y Distance from bottom of scum to bottojp of outlet tee or battle: 16 „ How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(oti pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): , , Page 8 of I I OFFICIAL INSPECTgON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 161 ' Q as 4 re It Owner: Date of Inspection: -13-6`/ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(expiain): Dimensions: Capacity: sallons Design Flow: aallonslday Alarm present(yes or no): Alarm level: Alarm in working order(yes cr no): Date of last pumping- Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: '✓(if present must be opened)(locate on site plan) Depth of liquid level above outlet invem Comments(note if box is level and distribution to ourlets equal,any evidence of solids carryover,any evidence of leakage A ada into or out of box,etc.): - ox , ge Ce•+c�:f:�„ PUMP CHAMBER.—(locate on site plan) Pumps in working order(yes or no): Alarms in wmicing order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTTON FORM—NOT FOR VOLUNTARY ASSESSMENTS., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)., Property Address: /0 f C.-rele Owner: Date of Inspection: T -0 SOIL ABSORPTION SYST&M(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type V leaching pits,number. '. =leaching chambers,number tcaching galtcrics,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 ofponding,damp soil,condition of vegetation, etc.) .•a C at �l a e' ace h: eg u s b e-" c' - CESSPOOLS:—(cesspool must be pumped as pan of inspection)(locate on site plan) Number and configuration• Depth—top of liquid to inlet invert- Depth of solids layer. ' Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 4 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.): Page 10 of I I OFFICIAL INSPECTIbN FORM—,NOT FOR VOLUNTARY ASSESSMENTS" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: COrn a Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks_Locatc all wells within IGO feet.Locate where public water supply enters the building. 6)m piss w b d Frant (� a 77 F A±- 37' F i r Page I I of i I OFFICIAL INSPEC,�ON FORM-NOT.FOR VOLUNTARY-ASSESSMENTS, , SU`W ACE,SEWAGF DISPOSAL,SYSTEM INSPECTION FORM;-; SYSTEM INFORMATION(continued)- Property Address: D 1 Co r n Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells , .,. ., y-'J,,- I,$ Estimated depth to ground water o feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed. — Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ^,Checked with local excavators,installers-(attach documentation)" ✓ Accessed USGS database-explain: You must dperibi how you established the high groupd water elevation: q(01Ant7 W r WOOS M ' C i Gro,,d le,e' to o� P;t d 4fm ocri 4` Title 5 Inspection Form 6/15/2000 11 t O, a kj I ' yro,,�, Wafer g� to r►h o os 5� g 0 S ,f l"A �i�'}r'Y.�y.s Yxy,.•� _� ; -�` J Sa � -k"Y�w' _ gip/' ,. r - V ♦ a3 � �.... } f �' J Tj\ `ram .. • 1 , i _ 040Un40AT/,OA/ s Z9.7 i 80.o o EERT•-IFIED PL\OT PLAN L O C.AT 1 O N SCALE: emu_ 30 DATE. G�Zlo Js�' R E F E R E N C E : ,BE/NCr' �oT 8 3 "95 .Sydu� ✓ o ^1 �c:.q•..o co �2T c•qs� ,� z7o9_59 5>:!'':HEREBY•, CERTIFY THAT THE 8 U I L D I N G REG. LANO SURVEY R SHOWN O•N THIS PLAN I S LOC ATE D 0 N THE GROUND AS SHOWN HEREON A N D T H A T I T CONFORM, To THE �.��N OF As`et. ZONING BY - LAWS OF -THE TOWN OF .e �4�^/ST�9E3G E W H E N C O N S T R U C T E D. F JOSEPH G� \\ o MONAFIAN, v _ WARNS-FABLE SURVEY CONSULTANTS, INC . �e _���y© WEST YARMOUTH. MASS . '.su1 _= No..------ - 3 FEiz /-9................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HALT 13 ort i-7� Appliration -for Di-gVvii al Works (� aastrurtion rruid ` �� Application_ is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: •-- ------ 5--s-/- "� ..... �............ acatiy`..r \ 0. Q or t No. t\ Owner w Vb Address f 'C�1 =�....---- •--•----'--------------•--'...._ ...........••••--"••'-•----'---_.....----•--•-----'----......_ ` ----- •- M Installer Address Type of Buildi�n�— Size Lot... &).��_.....Sq. feet �-, Dwelling V No. of Bedrooms....__.___________________Expansion Attic Garbage Grinder .(A/)O aOther—Type of Building ...................... ----- No. of persons---------------------------- Showers ( 1 ) — Cafeteria ( ) Q' Other fiat res ....................... W Design Flow-----------_----��__._�___.__..._ _ all er person per day. Total daily flow........�_ .............gallons. P4 Septic Tank/Liquid capacit _ _ga s Length---------------- Width................ Diameter................ Depth................ Disposal Trench—No ..._.._._..�...____ N�1Iid �_ _______ _____/To Length....._..__......._.. Total leaching area....................sq. ft. Seepage Pit No._... Diameter-_�t_�� Depth below inl f........ T al leacliiila : e:t.. l---••--_...sc it. z Other Distribution x ( ) Dosing tank ( ) /C_ aPercolation Test Results Performed by.......................................................................... Date_................................. Test Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ LT, Test Pit No. 2................minutes per inch Depth of Test Pit................... D th tgund water......................... 9 11 ......--- -_---•--------- x : f So. il_O Descript �} ��-�°'i -- � _.......�...�.....�..._...._._ .---'----- d -___----� --•----'-'------•-----.._..--•...............................................'--------..__._.__....._ - 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ed.-.. bl- ...._• ------ ---------- .... ................... Date Application Approved By.................. .. . ... ...... - ---••- '= 71, - Date Application Disapproved for the following reasons:...................................... -•---•---•-•--....----------------•'------•---••.......__-••-- ................•........-•-_.._.....-----•-••----------.........-•-------'------••-•--•••-•-----•------•..••--••----...-•-•••--.......-••--•--........_--.-----•--------•'.._........--'-.•----------_.. ,JDate " Permit No......................................................... Issued...... - % uce17�1 No........: Fs$...�f,1............... THE COMMONWEALTH OF MASSACHUSETTS BOARD X HEALT .� slirtttiuu "for Bi_npuittl Worku (n uitrurtiou Permit Application is hereby"made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at C ty.0 a-.. C% 4 c I--t- � jA 1./ N 1 S ---------------•-•------•-----•---------------------------••-•---------. ---•-----------------------•---------------- ._...__ mit��Address/) or t o. Owner ) Address p Installer Address + Type of Building oo" Size Lot__-li G)W ......Sq. feet Dwelling( No. of Bedrooms..".._..., !"""':...................Expansion Attic 1l Garbage Grinder (JVX! Other—Type of Building -.______"____ a g _____•-----_--- No. of persons---------------------------- Showers ( � ) — Cafeteria ( ) Q Other fiItres ---"- -- ----------- :._.. ----- Design Flow................ _.______ _ 11j4er person per day. Total daily flow__._...�t�-.__�__:.0..___-.--_"_..gallons. WSeptic Tank �Liquid capacit/ __ __ga Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No ____________________ Wid 1. ktoAL-.ength.................... Total leaching area_-__-'-__-__-______sq. ft. Seepage Pit No-------� Diameter.:.. ........ ... Depth Wow in ...... T 11 leachincr• ea___ ..........sq. ft. z Other Distribution box ( ) Dosing tank �. Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water.........____-__-_-__--- fXq Test Pit No. 2................minutes per inch Depth of Test Pit-..._...__..____dDeth to ground water__-____-_____________-"" 4 Descriptio f Soil-- -----------0 -_____�, . �---•-.ors. ....................................." 1 V ----------- ........ . . ... .....................--•----._._.._.____...---•--•---------------._._.------...-•------•---._._...._...... e. 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in' operation until a Certificate of Compliance has,be n issued by the board of health. ed..... - !.--`tY--------- - ---------------- ----- •► -------------"- •�g � ate • Application Approved By-------------- ._. ._. ------ - fi.�_ /.l s._ 1 . ' Date Application Disapproved for the following reasons_________________________________________ ............................................................ ' ---------------------------------------•-----------"------------------...-----------....----------------•---------•-------•----•-••-----------------•-- ........................................... Date Permit No................................. --------•............... Issued............................=......•--........ ------- Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD:g HEALTH OF. Tutif irate of Tompliam T S I TO CERT That the Individual Sewage Disposal System constructed ( eor epaired ( ) by Q'�-- �� ----- Install, - ---- at_..4... .._. .. - ----�Y�rty� has been installed in accordance with the provisions of Article XI of The State Sanitary Code s ib`e to the. application for,Disposal Works Construction Permit No_____________ _ _.__._.;_ dated--- 3 __. ...:__________. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR-A TEE THAT THE SYSTEM WILL FUNCTION "SATISFACTORY. DATE................................................................................ inspector.............:........................................................................ f G. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OA HEALTH ; ....OF_:..... .... /40 B�i? ' ` FEE__ Biivrrlia u SX strurtion Permit Permission i by granted-- '----• - -'-•--•---- .' �.: ......... :.•-- -..__r_..- ........................... r '"td Construe or Re t ( ) an Individual Sewag isposal Syste j atNo..---�- -�---- � �- -- ...................................... Street as shown on the application for Disposal Works Construction Per o-______ ._ .__ ed........................................ e. Board o Hea th' J DATE • FORM 1255 ,HOBBS & WARREN. INC.. PUBLISHERS j • !_ "'.ate � � t EXISTING 1000 GALLON TANK DISTRIBUTION BOX HIGH CAPACITY INFILTRATORS CROSS SECTION LOCUS PLAN NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE 100.0 MIN 2% SLOPS-> 100.2 28 COVER TO BE WITHIN 6"OF GRADE �\\ T INSPECTION PORT TO BE%WITHIN 6" OF GRADE 4"SCH.40 P.V.C. 3"MINMUM MIN,12"COVER r- 4'SCH 40P vC 4"SCH.40 P.V.0 3" 1f8"-1f2< WASHED.STONE, _-_._._ s-0.01 MIN. „ =0A1 N-QN. EX1sr1NG 13" 3" t�1` _ O t 4" 97.8 a 3 5 itebell's yB;�S 96.8 \ ay onnemara 4.0' 96.6 6.2 0' .y2 10.0 94•2 \ 74''=:1 1.f2".D�LIBLE V/ASHEL}STONE > 1.08' MIN / / 4 8.0' 1.5=- 25,0' lts 4' 2.83'-- 4' { 28.0' �OTTOM OBS 89.2' 10.83' ' SITE SPECIFIC NOTES j DESIGN CALCULATIONS GENERAL NOTES FLOOR PLAN GAS BAFFLE TO BE INSTALLED NOT TO SCALE ALL PIPING TO BE SCHEDULE 40 P.V.C. EXISTING BEDROOMS 2 ® 110 G.P.D.= ALL LOCATIONS OF UTILITIES SHOWN ARE AS INSTALLER TO NOTIFY DESIGNER24 HOURS PRIOR 220 G.P.D. ( 330 G.P.D. REQUIRED) MARKED BY DIG-SAFE AND ARE TO BE TO BEGINNING OF JOB TO COORDINATE I VERIFIED BY INSTALLER PRIOR TO INSPECTIONS N290 P13G NO. OF UNITS 4 CONSTRUCTION DEPTH BELOW INV. 2' THERE ARE NO KNOWN WETLANDS WITHIN P# 10 ��� WIDTH 10.83' 150' OF THE PROPOSED LEACHING FACILITY FIRST FLOOR LENGTH 28' UNLESS SHOWN. SIDEWALL AREA 155.32 SF THERE ARE NO KNOWN POTABLE WELLS W BOTTOM AREA 303.24 SF 150' OF THE PROPOSED LEACHING FACILITY. 24 ACRES TOTAL SQUARE FEET 606.86 SF THERE ARE NO KNOWN IRRIGATION WELLS WITHIN 50' OF THE PROPOSED LEACHING LIVING STAIRS CAPACITY SIDEWALL 00.74 114.94 G.P.D. FACILITY ' ROOM IO BEDROOM THIS PROPERTY DOES NOT FALL WITHIN A sMxr CAPACITY BOTTOM t�D 0.74 224.4 G.P.D. CAPACITY TOTAL 339.34 G.P.D. FLOOD ZONE AS SHOWN ON FIRM MAP THIS DESIGN DOES NOT REQUIRE VARIANCES THIS SYSTEM NOT DESIGNED TO SUUPP EM NTAL REGULATIONS.) OR BARNSTABLE ACCOMODATE A GARBAGE ALL CONSTRUCTION SHALL BE IN ACCORDANCE KrrCIEN DINING DISPOSAL WITH TITLE 5 AND BARNSTABLE SUPPLEMENTAL Room =BEDROOM REGULATIONS. BATH IN-LINE ELEVATIONS PROPOSED AS-BUILT SURVEY INFORMATION JBH I INV. 0 HOUSE PROPERTY LINE DATA FROM INV INTO TANK 97.9 CERTIFIED PLOT PLAN JUNE 25, 1974 PROPOSED INV OUT OF TANK 97.8 (EXISTING) 4 INFILTRATOR INV INTO D-Box 96.8 PLAN TO BE USED FOR INSTALLATION IN A INV OUT OF D-BOX 96.6 OF SEPTIC SYSTEM ONLY 2' X 10,83' X 28's:': INV INTO INFILTRATOR 96.2 TRENCH BOTTOM OF INFILTRATOR 95.28 NOT FOR DETERMINING PROPERTY LINES BOTTOM OF STONE 94.2 BENCH MARK - a BOTTOM OF OBS HOLE 89.2 2 I'(`RNFR OF I?111,KHEe,rt _14n.0 (4$cUMFn) LEACH PIT TO DATE: OBSERVED BY: WITNESSED BY: BE REMOVED SOIL LOGS Jan 11, 2005 LISA C. LYONS DAVID STANTON 'SOIL EVALUATOR BOARD OF HEALTH EXISTING i000 OBS. HOLE #1 OBS. HOLE #2 GAL TANK TO 1 ELEV. DEPTH ELEV. DEPTH 100. 0" 0.0 0" REMAIN. ° FILL INSTALL GAS 0 ��- t 99.7 A LOAMY SAND 6" BAFFLE BM 10YR 3/2 DECK 99.5 B LOAMY SAND 8 1 OYR 516 98.0 26° C MEDIUM SAND 2.5Y 516 44" 89.2 56" #log 32" D GROUNDWATER ENCOUNTERED f PERC RATE<2 MINS.i INCH GAS CONNEMARA C4IRCLE ,, SH M a gS .as... q 00.c,'`I��I PLAN SHOWING: C. •�' ' PROPOSED SEPTIC SYSTEM REPAIR IN BARNSTABLE V +YON5 ; FOR: DRAWN BY: LISA C. LYONS i f/1 DOUG MacLOUD DESIGNED & CHECKED BY: talc, : LISA C. LYONS f 1 01143+ LOCATION: REVISIONS: DESCRIPTION: DATE: '•.9 109 CONNEMARA CIR HYANNIS ����pA #som #@ �P�,,** LOT o Pi 6 DATE:JAN 18, 2005 IN11111�,, LISA C. L S, R.S. 3 SCALE 1 ' 20 1 CERTIFY THAT THIS PLAN CONFORMS TO LISA C. LYONS R.S. (508) 790-9270 TITLE 5 AND BARNSTABLE B.O.H. REGULATIONS HYANNIS, MASSACHUSETTS (774) 487-1638