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HomeMy WebLinkAbout0008 COUNTY SEAT STREET - Health -- vUIYTYSEAT HYAN�NIS A ' 2 1 161 LOT22 00 0 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/15/10 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A- General Information forms the o� computer, r,use 1• Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code If 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I 10/15/10 Inspector's SigKature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. • t5ins-09M _ Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. Cdyrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 every page. Cityrrown 1 Zip Code Daatete o of f inspection- State 0 B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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 t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) 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: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No :+ Backup of sewage into facility or system component due to overloaded or _ clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters i - •`�. 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 0 ® Liquid depth in cesspool is less than 6"below invert or available volume is less L • - • than Y2 day flow / Y -. ' '♦ t5ms•f)9i08 'i`. • Title 5 Official Inspecfion Form:Subsurface Sewage Disposal l • i 9 Po System•Page 4 of 17 y it I , Commonwealth of Massachusetts mom Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. Crtyr town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. For large systems,you must indicate either"yes"or."no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered'yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 every page. CltylTown 10/15/10 State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? I ® ❑ Was the site inspected for signs of break out? I ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® 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: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D BOX AND 2 500 GALLON CHAMBERS IN A 12.8X25X2 AREA Number of current0 residents: i Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): SEE BELOW Detail 08-129 09-158 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? . El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: OWNER PUMPED IN 2009 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and • maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ® Other(describe): t5lns•09M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: ACCORDING TO AS-BUILT CARD SYSTEM INSTALLED IN APR 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): I Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): I Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No .Dimensions: 1500 Sludge depth: TRACE t5ins•09A8 Title 5 OBgel Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 every page. Cityrrown 10/15/10 State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How 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.): SYSTEM WAS PUMPED IN 2009 ACCORDING TO OWNER LOOKS CLEAN AT THIS TIME Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09i08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•0901 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): BOX LEVEL NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: CHAMBERS NO OPENED DUE TO DEPTH NO RISERS FOUND (Sins•09iDH .- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 every page. CitylTown 10/15/10 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic-failure, level of ponding, damp soil, condition of vegetation, etc.): HAND AUGERED IN AREA OF CHAMBERS NO SIGNS OF FAILURE FOUND Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 - - Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 every page. Citylfown 10/15/10 State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):' f5ins•09j08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•W/06 Tide 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Properly Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 10/15/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 7 FT feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: OFF AS-BUILT CARD Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 6 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 COUNTY SEAT Property Address NOWAK Owner Owner's Name information is HYANNIS required for MA. 02601 10/15/10 every page. Cltyfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Dls g posal System•Page 17 of 17 -� TOWN OF BARNSTABLE ` LOCATION o u n <i �� °� CRfh o'�i� SEWAGE # ?wm —6 ?d e ^7or0 -Z9 VILLAGE 7C/0 ASSESSOR'S MAP & LOT. .oye rep r INSTALLER'S NAME&PHONE NO.-ZJ-7c or— A t c-a io C 9 '/9 a r. SEPTIC TANK CAPACITY 14,50 O Q e /• "``�, 2 . ?1' LEACHING FACILITY: (typz�,•SO D s/' (size)/ "k ZSk ao If•sI d b NO.OF BEDROOMS 0— 38 d.-A BUILDER OR OWNER 0 1,N PERMIT DATE: J/'/I ' O / • COMPLIANCE DATE: Separation Distance Between the: — �A`•.ray ,g � , ,L/v.9 5 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility O!' °r Feet o� Private Water Supply Well and Leaching Facility (If any wells exist ' Feet t e on site or within 200 feet of leaching facility) �1 o nr t-• F Fee Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet off leaching facility) �� ° Feet Furnished by ■. A COs-� C� C• tn•� y' 9� j y• O ® -f (D t ; Y� 3 O'q Z` ,-7 New Page 1 Page 1 of 1 -� 3 TOWN,Pf BARNSTABLE L LOCATION It-SEWAGE.#. ZItU -6 �T d 07e,o -A VELLAGE ASSESSOR'S MAP-& LOU gyr, s c.r INSTALLER'S NAME&-PHONE NO:Via-c Ac; A,,c. :(o : C -139 •/Q SEPTIC TANK CAPACITY 4,5700 q ♦ / LEACHING FACII.TTY:.(tyk j SOD 2 o/. •t . NO.OFBEDROOMS BUILDER OR OWNER yd/o N .5 -c-o PERMTTDATE: V'/Z ' O / COMPLIANCE DATE: Separation Distance Between the: AIV-93. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility w °` Feet E/r. Private Water Supply Well and Leaching Facility (If any wells exist W.o� 8Gs' on site or within 200 feet of leaching facility) //o ey c-. Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) IV ° Feet Furnished by C::), e� e-- X—' - �Cr /�ie�•y"f ® / 5 Z3. 3 ` Z.B. ` o. �• �"7,e 5' Z9'8 " �. 3 7. or -Z4q d b O , •� 8 � �• 3 ! • ' 1 ' http://www.town.bamstable.ma.us/assessing/2010/IB4display.asp?mappat=291161&seq=1 10/7/2010 F .. - I ` + �r J � �/V\)\V V ' � -� r .,_ r i No.Gi �Ls7.7 '`i l:B � FEE COMMONWEALTH OF MASSACHUSETTS Board of Health,�ZA'P*ST6413 L-E —I MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct,e air( ) Upgrade( ) Abandon( ) - PComplete System Q Individual Components Location �a✓ SL�f� Owner's Name Map/Parcel# Zq Address�a-7 AIVAI BaG4,—C�- &T A:9A 0 Lot# 141 Telephone# '7*f S —6 [4'Q Installer's Name Designer's Name Mao -S,4✓6 Address Address 1r0 Alf"I, Telephone# GG Telephone# �KO f?) Type of Building a Lot Size�6 yD sq.ft. Dwelling-No.of Bedrooms !7 0 goo VV1% Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( Other Fixtures e� Design Flow (min.required) 730 gpd Calculated design flow Design flow provided_gpd Plan: Date I//?, L2 Number of sheets Revision Date Title 5/y'5SSc ��- �LAv� LOL l4T150 COL)l�'T`�S AT ST/�ET Ci$!'1���/ICE /4d� .t. Description of Soil(s) �� Ln' Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigne agrees to install the ab destzi ed Individu Sewage Disposal System in accordance with the provisions of TTTLE 5 and further afire to to pla the em m;7on un' rtigcate of om fiance has been issued by the Board of Health. Signed ' No. � oowW T FEE COMMONWEALTH,.OF MASSAC19USETTS Board of Health, MA. APPLICATION FOR ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct/R air( ) Upgrade( ) Abandon( ) - AlComplete System O Individual Components Location �UvN%�Sr�A �_ Owrier's Name fl,4AGf'�(/,4' AAvj S `/641 Map/Parcel# 2Gi ( •� Addre'�s t'07 4A11VA6a.--� P,vf: ?OA 0 Lot# S ' Telephone# -7 7 5 0 (eo Installer's Name Designer's Name ,&K 90 S. " Address } .' Address 1 NOv57,4Y Rn AA/70V S Telephone# t Telephone# 15-0 12 2 g -dDS - Type of Building Lot Size (7{ 6 yV sq.ft. Dwelling-No.of Bedrooms �l/�00✓h Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),,Cafeteria ( ) Other Fixtures Design Flow (min.required) : !�770 gpd Calculated design flow 3 3' Design flow provided _gpd Plan: Date 1 1316 V 1, Number of sheets Revision Date { Title LvGt4TEn CvL)NTYSr_AT STiQEET S eArNERiNE i4t/� Description of Soil(s) � _ 1� L-14 A ) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation t ; DESCRIPTION OF REPAIRS OR ALTERATIONS 1 r The undersign grees to install the ab e•des ibed Individual.Sewage Disposal System in accordance with the provisions`of TITLE 5 and further afire t to pla the tem m a ion un ' 6rtificate of om 'fiance has been issued by the Board of Health. Signed _� y, bX rIiySptsG_E 614s` — ` �+ ; y r 1.- No. roi®rp, q FEE / �✓7J-��, COMMONWEALT14 OF MASSACH SETTS Board of Health,�A RIN 5-rA CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) A Complete System .� r The undersigned hereby certify that the Sewage Disposal System; Constructed ( -)/Repaired ( ),Upgraded ( ),Abandoned ( ) y:at has been installed in accordance with the pr-oovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application - Q �date 61� �Qoved Design Flow) � (gpd) Install AI ; r L,/ 1J A Designer: / Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No.o� FEE Vic'✓ Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system l at 4V t,/x!!f t:�e � s2' ` r ' / Y/ Ali,C as described in the application for Disposal System Construction Permit No AV dated f/ Provided: Construction shall be completedwithin three years of the date of this permit. All locaj con'litio s must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date / ) V-0 Board of Health _ 3 a - MAP 291 160 MAP 291 # 20 i ........ 161 P2 U 31 i MAP 291 T O W N O F B A R N S T A B L E G E O G R A P H 1 C 1 N F O R M A T 1 O N S Y S T E M S U N 17 N I Doi PRINTED SCALE: IN FEET *NOTE: This map is an enlargement of a **NOTE: The parcel lines are only graphic representations DATA SOURCES: Plonimetrics(man-made features)were interpreted from 1995 aerial photographs by The James w 1"=100'scale map and may NOT meet of property boundaries. They are not true locations,and W.Sewall Company. Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 1 ` e 30 0 30 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetrics,topography, and vegetation were mapped to meet National Map Accuracy Standards S ", , 1 INCH = 30 FEET * enlarged scale. on the map. at a scale of 1"=100'. Parcel lines were digitized from 2000 Town of Barnstable Assessor's Mx maps., L ."� �•r`.- ?i:�X.ri�F.i. '��•t ::' °• 5.'"s.� ...� -SF-{-Fet.:i �"r-. �"' t 1 .'•..., -. _ t �__ _ .Y....is'::a; TOWN OF BARNSTABLEj� LOCATION _. o 1 S� f�5�. .�rC7�/1 9--,—'SEWAGE # Z-rO -G ?d � ti VILLAGE ASSESSOR'S MAP & LOT,-. ire g/ INSTALLER'S NAME&PHONE NO.�c. ,s G i4 :7Z >C 339 '1, 9 aG'• ' SEPTIC TANK CAPACITY O O / LEACHING FACILITY: (ty z�, so 0 G a/. �' (size)/Z ' 8�k Z S x. Z NO. OF BEDROOMS 3 8 el J BUILD.ER.OR OWNER 0�5 X_ ,:'AJ , PERMIT DATE: Z ' © COMPLIANCE DATE: Separation Distance Between the: — Ar•:/may ,� �,��� /v,93 Feet . Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water.Supply Well and Leaching Facility (If any wells exist F ' i on site or within 200 feet of leaching facility) ^! ✓ �- Feet Edge of Wetland and Leaching Facihty.(If any wetlands exist within 300.feet of leaching facility). Feet Furnished by t< ,C �— ] ..:... .. .... .., .,..'ae..r .. o—� t.. ...::' :• .. .. .. ;-•! 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I ti AS LOT 160 PREPARED FVR PK SET /N PA VEMENT AS LOT 161 00 \ ��, ? O I U ir i o \ 15640E sq/ft \ \ cyaG,RAGE DARLENE DA VIS & ALAN BROWN / \ ;; •:;;,, ( � NO VEMBER 13, 2000 HSE I I �tN of I44S YANKEE SURVEY CONSULTANTS P. O. BOX 265 { WILLIAM 5, 408 INDUSTRY ROAD I UNIT o LIE©ERMAN y MARSTONS MILLS, MA. 02648 o\^ \ \ �� v 'V Lj�'' ° PH. 508 428-0055 - FAX 508)420-5553 . ETA- \ \ �,� A�.�,�f?I•B �o�'�cis`r s� PAUL \ \ � \ �� / FSS10 N AL MEN"ew \ �l No. v� GRAPHIC SCALE __4411 ko U-POLE 30 0 ,s 30 60 120 / CERTIFY TNA T 1N/S`5 ND PLAN WERE MADE \ r /N ACCORDANCE. WI TN 1NE PROCEDURAL AND TFCHN/CAL \ \ STANDARDS FOR TN£ PRACTICE OF LAND SURVE "NC /N \ �\ TN MMONWEAL 7H OF MASSACHUSETT5 �,. �a- ze G WAAL M /I 6 ( IN FEET ) PAUL A. MER/THEW, P.LS. DA �. 1 inch = 30 fG SHEET 1 OF 2 45?r�48_ CB EL --100"MIN. 5 AVW REMOVE SOIL 5' ALL AROUND avvN 77 C7 AND REPLACE WM CLAWN GRANULAR MAMUAL IN ACCORDANCE A�W SSL^ W 15255 (3-BJ -7VP4O MUNDATION 20 MIN. 10" MIN. CONCRETE COVERS ; 4' SCHEDULE 40 P. VC MIN. PITCH 1/8 PER FT. e CONCRETE COVER 2 8'!-1 OF rll'OMA X. , , ELEV= 98" WASHED STONE 4' SCH40PVC(OR EQUAL MINIMUM P17CX 114 PER AT " 121O" 36 MAX N L/NEINVERT _ 8" EL=95.8" 14 _ EL.=_96.1 _ GAS INVERT �6 SUMP LEVEL o;:0 O O O O O C3 O O o 0 00 0 INVERT - BAFFLE EL.= 95. 65" INVERT o 0 0 0 0 0 0 8 _ IN o 0 0 00 0 — 93" EL.= 95. 9' -- EL.=9-4_ EL.=9m 15" 4' 0 4 (TO BE PLACED DN RRM BASE) DISTRIBUTION EL =95 3/4. 7V 1-112- A/ECHAN/CALL Y CONPACIED GYP 6' Or STAN£ BOX R'ASXED S7ONV GALLONS TO BE WA TER TESTED 12.5' X J5.5' X 2' TRENCH FORMA 710N (z Z SEPTIC TANK PLACE ON 6' STONE (H-10 LOADING) SOIL A BSORP TION S YSTEM (sA S) PROFILE 0 F ' BOTTOM OF TEST HOLE ELEV. =_A96'_ SEWAGE DISPOSAL SYSTEM . NO oesE % RVED WA (1Jo/2oo0) NOT TO SCALE OBSERVA 77ON HOLE 2 ELEV. - OBSERVA 77ON HOLE 1 ELEV.=98__ PERCOLA 77ON RA TE _S2_ MIN./ INCH A T 3*"INCHES DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HOR/Z 7EX7URE COLOR MOTT. OTHER zti 0"-6" A SANDY LOAM 75YR 4/1 ,z so /lrns 0"-6" A SANDY LOAM 75YR 4/1 -, mm /)1Ns 6"-28" B LOAMY SAND 7.5YR 516 O MED IPTNB 6"-28' B LOAMY SAND 75YR 5/6 O Mm IPYNs 8"-l44 C SAND.: 10YR 6/4 �Z c�RAV>lz�Ms 8"-144 . C SAND 10YR 6/4 � M1m Qv cRA GENERAL NO TES NO WATER ENCOUNTERED L NO WATER ENCOUNTERED (� I'3 1 A W RKMAN H/P AN MA R/A &_At-t J LL O S D IL" L S SHALL CONFORM TO D.E.P. I17LE 5 AND TINE TOWN OF __�Ag/y,�j� __ RULES AND /FP` ZIP REGULA 77ONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) ONE COVER ON SEP11C TANK SHALL BE BROUGHT TO DATE OF SOIL TEST /0/JO/2000 SOIL TEST DONE BY ►HLL/AM LIEBERMAN /or '�• z V/ILLIAI.T i W/7H/N 6" OF FIN/SHED GRADE, OTHERS WITH/N 12" WITNESSED BY: DONNA M&ROND/ � LIEot;+tiiary = c ;. J) ALL COMPONENTS OF THE SANI TAR Y SYSTEM SHALL BE CAPABLE OF A� .+� :3911 0 W1 THSTANDING H-20 LOADING. s T E DESIGN CALCULATIONS.' 4) ANY MASONAR Y UNITS USED TO BRING COVERS TO GRADE SHALL PERC.hf 9A971 _ N� BE MORTERED IN PLACE. NUMBER OF BEDROOMS . . . . . . . . 5) NO DETERM/NA77ON HAS BEEN MADE AS TO COMPLIANCE WITH - GARBAGE DISPOSAL . . . . . . . . . NO DEEDED OR ZONING REGULA 77ONS. OWNER/APPL/CANT /S TO TOTAL ESTIMATED FLOW OBTAIN SUCH DETERM/NA RON FROM APPROPRIATE AUTHOR/TY. INSTALL TWt7 (Z) ACME . - (110 GAL./8R./DAY x J BR.) JJO GAL/bA Y 6) U77LI77ES SHOWN ARE APPROX/MA TE ONL Y" EXCA VA 77ON CON TRA C TOR 500 GALLON LEACHING REQUIRED SEP TIC TANK CAPA C/TY /500 GAL lS TO CALL "DIG- SAFE" A T 1-800-J22-4844 A T LEAST 72 HOURS CHAMBERS WITH FOUR FEET SOIL CLASS/F/CA RON . . . 1 PR/OR TO COMMENCING WORK ON SI M STONE SIDES AND ENDS Q£S/CN PERGOLA TTON RATE t 2 MIN./IN. 12.8' x ?5' x 2 DEEP .74 GAL/DA Y ,,T) CONTRACTOR /S TO VERIFY GRAOES AND ELEVATIONS AS WELL AS �EFFLDENT LOADING RATE . . . . . . /S.F. SI TE CON0177ONS PRIOR TO COMMENCING WORK ON SITE - 4:y LEACHING CAPACITY (AREA X RA TE) J.J8 G/D 8) PARCEL /S /N FLOOD LONE____ C____• - RESERVE LEACHING CAPACITY . . . 11-3) LOT IS SHOWN ON ASSESSORS MAP __ 291 AS PARCEL ___161_. • - �(12.8X 25 X .74)f(12.8'f 25'+ 12.8't 25)(.74)(2) SOB NO.. 52548 i f j - I i - a . E - i OA O ; f �I 5 l 1 sQ i = i � � . i Q i - i v I too 07 00, 7-7-1 of 1-d of 17, �-p_ • � � I I o i 'tea a ,t 07; vif .a s Li �