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HomeMy WebLinkAbout0021 ELAINE ROAD - Health 21 Elaine Road _ -_ Hyannis o e 0 a N o ° y o ° a o O is Commonwealth of Massachusetts NIP �-V-1�e = / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -twilit for Vo!untary Assessments _ Property Address ON ner l ✓'G ✓ � _ Cat O �-2, av ner s Name information Is R �! requVedforevery 11 page. City/Town State Zip Code Date of4rIspection l:yM 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 A. General Information n the out forms o on the computer, 1 V use only the tab 1. Inspector: key to move you cursor-do not use the returnkey.. Nan*Ie of Inspector /' _ Company Name / Company Address Aty/Town State o < Zip Code L� � a 0 -- �?�d o-g � Telephone tuber License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 6(310 CM R 16.000). The system: C�Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority aspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. """"This report only describes conditions at the time of inspection and under the conditions of use' at that time. This inspection does not address how the system will perform In the future under. the same or different conditions of use. 0 VS t5rs-N13 Tile 5OffidJ Iris pecbcn Form Subsurface Sewage Disposal ystem-PagetoW 4 Commonwealth of Massachusetts Title 5 Offigial Inspection Form Subsurface Sewage Di '''6sal g System Form - Not for Vofunta sP Y ry Assessments Prop"Address ow ner Cw ner's rb� information is /�f,J required f or every G kiI'l1 s 1111,4 0�6 o1' a �� page. City/Town State Zip Code Date of I spection B. Certification (cunt) Inspection Summary: Check A,B,C,D or E /a/ways complete all of Section D A) 7h1 mfnot s: aound 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 ex0ain. 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): Ons'3n3 Tide50Mdallrtspocoonform SuosurtaceSowage0isposai Stamm•Page2of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form . Not for Voluntary Assessments 2c) Property Address U Gt DvI� Ow ner Cw ner's Name information is ) required forevery / ✓1✓1 rf / page. City/Town State Zip Code Grate o nspection B. Certification (cunt.) ❑ Pump Chamber pumps/al,arms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 pi pe(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): 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 envf ronment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in,a mannerwhich 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 19ns•3/1 3 T110 5 Official lrs pec tlm f am Subsurface Sere Disposal Solim•Page 3 of 17 r Commonwealth of Massachusetts mom Title 5 Official Inspection Form TSubsurface Sewage Disposal System Form -Not for Voluntary Assessments C� I -E/G1 1(iL� 1 ` Property Address Ow ner Ow ner's Name information is 17 requVedforevery ct 0 4f � oz 6 0 f / X-1, 'yA-6- page. Cityyfrown State Zip Code bate of fnspecti6n B. Certification (coat.) 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 sal 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 Beet 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 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 must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You gust 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 ❑ oa Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ �' Static liquid level in the distribution box above outlet invert due to an overloaded / or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than%day flow tins•Y13 Tile b Official Inapeo bon Form Subetrf000 Sovnge Disposal System-Noe 4 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form • Not for voluntary Assessments C2 / La i�� //�?C Property Address 0 Cf�e - Ow rter owner's Name Infomf is f ,� v a requirededforevery G ✓I�� page. City/rown State Zip Code Date of Ins pea ion B. Certification (cunt.) Yes No ❑ l� 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 tributaryto 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. ❑ u 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.] jhe'system is a cesspool serving a facility with a design flow of 2000gpd- ❑. 10,000g pd. ❑ ��` The system bi . I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large>ystems, 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. tSns W3 TitleSOMciallrepectonFom GubsulawGavm*Dispos*System•Page 5017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address CP- I Z:Yci I V1 _Z�J_ 6--�-,DU ON ner C W ner's Name Information is required for every G,y1 N l s page. C ityrrown � State Zip Code Date of to lion C. Checklist Check ifthe following have been done. You must indicate'yes" or"no" as to each of the following: Yes o ❑ ump Ing 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) CJ, Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with 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: L'3 ❑ Existing information. For example, a plan at the Board of Wealth. 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)j D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ?? DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x #of bedrooms): t9re•3M 3 Title S official Ins owbon F o m Subsuia*Sewage Disposal S)ftm-Page 6 017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address G �O U2 ON ner Cw ner's Name requir atifo is every _L____ /�1� 6 p 1 2L-,2� required G✓►� S / ' page. Cilylrown State Zip Code Date of Ins tan D. System Information Description: / /So O 4"770✓f QO c� Number of current residents: Does residence have a garbage grinder? ❑ Yes C�No Is laundry on a separate sewage system? (Include laundry system inspection C] Yes No information in this report.) Laundry system inspected? ❑ Yes 09 U Seasonal use? ❑ Yes M-No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes R'No Cry//�►'►}" Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Ons•3n 3 Title 5 Officid IrspecEm F orm Subsutam SevMo Disposal SWam•Page 7 of 17 Commonwealth of Massachusetts 9 Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r; / .51cilvi-el Property Address Cwna information is O+v ner s Name information 0 p� 6 C/ required for every page. 5ylTown State Zip Code Date of I wtion D. Syste Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: ----� C` 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 S m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Ovarflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (descd be): 15n,3M 3 )Ao 50redal Ins pecban Form Sutaxfaco So"o,Disposal SystBm•Page S of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments o�- LL a f ,2� Property Address Ow ner U G,- e information is n�'s l required for every ✓t vt iJ '.-L page' C+7 Town State Zip Code Date lnspeo n D. System Information (cont.) Approximate age of all components, date installed (if known) and source of' fo ion: Were sewage odors detected when arriving at the site? ❑ YesQ Building Sewer(locate on site plan): Dept h bel ow g ra de: feet Material of construction: ' ❑ cast iron 21'40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: / feet 7ena1itruction: oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years f Is age confirmed by a Certificate of Compliance? (attach a copy of certificat ) El Yes ❑ No Dimensions: � �_� Sludge depth: t5ns•3M3 TWe50ffiaai inspecdonForm subswaw so eDi osd$wag sp )stem-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address c� 0 L42 Ow ner ON ner's Name information is2 required for every ✓� is page. Cty/Town State Zip Code Date of Ins tan D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle r� Scum thickness r/ Distance from top of scum to top of outlet tee or baffle ri Distance from bottom of scum to bottom of outlet tee or baffle n How were dimensions determined? , "le RG 5. ✓i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 77 i, 4,, G m c_ 4ZS t "/ CCo, dr //0'�t , 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 t5ns-y13 Title 5 OMciai Im pectm F am Subwf we Sev.%e 01spead System•Page 10 d 17 commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner CI t�!/1� 1q, information is Cw Hers Name information requiredforevery q N rJ V�6 D� p(yL� page. (�tylrown State Zip Code Date Ins'! _ pectan D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e\iidence 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 woridng order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t9ns Y13 TidoSOMcial Mspoo ion Form Subsu1aoe SowaBeDisposal S"m•Papa 11 of 17 i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments/ Property Address aN ner ON ners Name information is Al/,� required for every ✓�"I I/ I oc�6 t7l page. City/Town State Zip Code to f Inspection D. System Information (cont.) 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.): z (/Pi /lam S 0/1 s Z/o Z—e a 1-r PumpChamber locate on site plan): ( P ) Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): K SAS not located, explain why: c9ns 3013 TItlE 5OMda Impecton F omr SubsWace Sewage Disposal Sptem•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner O t,.f infomration is Owners Name . required for every HC17 G A4 CJ�6 0/ a2 `f /fir page. iT/Town State Zip Code Date o Inspection D. System Information (corn.) Type: ❑ `Teaching pits number. ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altematire system Type/name of technology: _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �N A/o LS4r,V L/ 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 t5m-3H3 TO50M06Ir%PMbCn F am SubsulaW SewageDispmW Sysrom-Page 13 d 17 Commonwealth of Massachusetts ug� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � / �/ Property Address �r OW Rif �LA Qv nets Name infomlation is requ'vedforevery / G✓1✓l l �� ���0/ a� i" page. Cy/Town State Zip Code Date f InSpectan 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.): t9ro•3'13 . Tito 50fflda inspectonForn Sub$Wacs SewageDispoeal S)Mm•Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth • Not for Voluntary Assessments Property Address QN ner bw her s 14ame requir reqtionuired is ooZ 0/ oL re�quae�d for every ✓l r j page. Cityrrown State Zip Code Date of lnspeotlo D. System Information (cunt.) 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 =tch water supply enters the building. Check one of the boxes below.in the area below ❑ drawing attached separately ��f•H Q4L✓ Y Oil] U J ✓. A C r3 3�'�•, r3. 3= Nye. dJ A.S-- r , r3 tans•y1J Tlae 90fM1dal Impeetlan Fame$ubsulme SewegeDlspmo SyMm-Paga 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C-�-1 E�Gr�c Property Address O.v ner ON ner's Name Information is required G�0 required for every G✓1�if page. 5 /Tbwn —' State Zip Code Date oVInspectlot D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells //� 1 Estimated depth to high ground water. 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 ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked 7trial Board of Health -explain: kU4 4LJ21-e<- ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must d be how yo establis ed the high ground water elevation: / 7 f 0 C �- • 7,7- 11�v— 1<:2 4 0 Aeo 1'� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6ns-W13 Tine 5 0iliciel lrspection F arm SuRwfmo sewage o(spaid Sysmm-Fags 18 d 17 Commonweatth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Prverty Address Ow ta+r Wom�ation is Owner's game required for every ✓r oil Lfy Q�6 z 7 �r page. CAy/Town State lip--Code --2 — Date of lrigp on E. R.eport Completeness Checklist t� Inspection Summary: A, B, C, D, or E checked ff tnspection Summary b (System Failure Criteria Applicable to All Systems)completed ®.,-'S�Ystem I nonnation-Estimated depth to high groundwater d" SK ch of Sewage Disposal System either drawn on page 15 or attached in se parate file I tSito-Y13 Ti0050M0W MGpececnFart[sutwface sewe eotopm Snbm-PWO n of 17 TOWN OF BARNSTABLE LOCATION SEWAGE#. �)O 67 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �X S k) 6/- tJy tS (size) S ►v;�� NO.OF BEDROOMS OWNER �� PERMIT DATE: 1 J I`I P l o y COMPLIANCE DATE: t l'l d � Separation Distance Between the: Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility d O r/ 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 '9. A P fI - d T R� �1 9P PP y GI II �' y Lo a TOWN OF BARNSTABLE LOCATION /J ` b SEWAGE #47 116 VILLAGEy �� ��ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. /Xn�/ Ae d� �'- �c� L• SEPTIC TANK CAPACITY 6 U LEACHING FACILITY:(type) �Dby 5 �- size) 4- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERy DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C� a t� No. — L w Fee t 1 00.' '. .. 10 ?. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEa MASSACHUSETTS ZIpplitation for MtgpooaY patent ougtructfott erm it Application for a Permit to Construct( )Repair(9)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components . Location Address or Lot No. Owner's Name,Address and Tel.No.5',5�-_)7�-(7S`T4 Assessor's Map/Parcel��F ,_I '22 l �,p 1 Installer's Name Address,and Tel.No. 0 — �� Definer's Name;Addre1. 1.d Tel.No: �f,30.0 t1 l 14 Type of Building: Dwelling No.of Bedrooms_� Lot Size sq.ft Garbage Grinder Other TI pe of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alteratiops_(Answer when ap licable)�ns� " � n� � -COS Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system I 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 issued by this Board altha Si ed Date llepj — Application Approved Date f 0 Application Disapproved for the following reasons Permit No. 7 R Date Issued --------------------------------------- \ � �r. r � y�.,. . ,y,E r`...� �y„r���:.*cn�'w�z�+:�, -_::r►-v'`'�'�,.�-v .,���„ ,,,�.y ' No. 97 — 4)-7( 1,.. Fee loc./ THE COMMONWEALTH OF MASSACHUSETTS - Entered in computer: w.�. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppricatton for Migooal *pztem �Con5trurttott erlYiit Application for a Permit to Construct( . )Repair( X Upgrade( )Abandon( ) D Complete System D Individual Components Location Address or Lot No, Owner's Name,Address and Tel.No. 5��{• j l2 `C(%nf_ZOC_6, �M`'G�—Ga.aUE-��#{.. Assessor's Map/Parcel a L`% ) '�, p �' ��,n e lam`I L3 Installer's Name Address,and Tel.No. 05' � 0 Designer's Name,Address and Tel.No. �—3�p 7 V��q Co --F Type of Building: T Dwelling No.of Bedrooms �'� Lot Size sq.ft. Garbage Grinder( A Other Type of Building No. of Persons Showers( )':Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �nSA� a.-- LA5 �C� S 0 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 issued by this Board Health. Sig ed Date //' -(Sl - Application Approved b Date 1 �)k O g Application Disapproved for the following reasons Permit No. _ 7 Date Issued �- U THE COMMONWEALTH OF MASSACHUSETTS GQ0L)e-+-�-� BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that th On-site Sewage Di s sal System Constructed ( )Repaired ( Upgraded( ) Abandoned( )by M I-: 01 5 C, at C9 \ t-_- t 0 _ a N r N h��been constructed 'n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0dated 'a �j Installer V0:)i r`� Designer The issuance of this permit shall not be construed as a guarantee that the sy[m will ftrnc ion as designed. " Date L �'� �� Yc� Inspector --� ` � - --—— No. aGoe -�J 7�f _ — —Fee w Q`i THE COMMONWEALTH OF MASSACHUSETTS UP UBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpozaf *p$tem Con5trurtton Permit Permission is hereby granted to Construct( )Repair( Up r de( )Abagdon( ) System located atvzo o�n n� . 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 must bq completed within three years of the date this pen] -t Dater 1 �' �� Approved by '—� -TowwofIL Regulatory Se ces a Thomas-F er .Dfrwtor -� ®� Public Health Division g� Thomag=McKean,Director 20.M2in Strome#,iyanns,MA 02601- Office: 508462-4644. Fag: 508-790-6304 Installer+&_Designer Certification Form Date:•.j l 1. G. Sewage.PermW Assessor's MapWarcei Cqy 7 )�1 Designer: cn Instafler. Address: C),-v was issued.a permit to.install a (date) septic.system at( El a� l"-05J; 1�v 1�S based on:a design drawn by (address) - h -71 dated p a 5=a (designer) _ I:certify-that.the septic system referenced above was installed substantially according to the.design, which may-include:mindr approved changes.sucbCas-lateral relocation-of the: distci'bution box andfar:septic taFtk: :: i that the septic.system certify ep .reference�l above was installed with major-changes (i.e:_ greater than-.10' lateral relocation of the SAS or any vertical relocation of any componen# certified-as-built-by designer to follow. �,�A OF Af4 � DA R N y YER. . ' No: 1140 . (Installer's Signature) qF p GISTS agNrTAR�►a (ASS (Designer's:Si re) .. (Af fix-Designer's Stamp_Here) PUASE REIMN TO :BAMSTABLE BMJJC HEALTH:..1VM0N. CERTMUNIE OP COMPLIANCE WELL NOT---BE-ISSUED-.UN1EL BOTH THIS FORM ACID,AS-BUILT CARD ARE. RECErVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU t�:Healtii/SeptiC/Designer C Cation Form 3=2 .d4c Town of Barnstable P# gyp'' Department of Regulatory Services Public Health Division Date oz_-( r 2a?5 00 Main1 a Hya i MA 02601.dffl� - Ep M/tl r f Date Scheduled .� Time J / � . Fee Pd. Soil Suitability' ty Assessment for Se e Disnosal o Performed By: MI L/"`� I y Witnessed By: PQ LOCATION& GENERAL INFORMATION Location Address Ti `1 a i H e Owner's Name-61 rRR 4('mil }� r1 Address (I�r Etin," ,e (M� (f�G�� . . r Assessor's Map/Parcel: 2,�T� 1615, Engineer's Name NEW CONSTRUCTION REPAIR l/ Telephone# Land Use _ S►(AQlq/ t I r , Slopes(%) 0 Surface Stones Distances from: Open Water Body (VV{ ft Possible Wet Area 00 t ft Drinking Water Well ®�f ft Drainage Way 01 ft Property Line 10 t ft Other ft - %Ons of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) 105.00 Ff -- �2 r 7 GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL ml m t j BASED ON TOWN OF BARNSTABLE i GIS DEPARTMENT RECORDS. t Rj V INDICATED GW 20.00 INDEX-WELL MIW-29 I ZONE D I READING DATE SEPT. 2008 READING 8.7 j ADJUSTMENT 5.0 II ADJUSTED GW 25.00 105.00 F6 EL�IINE ROAD Parent material(geologic) r® t�` 0(l fa5�l Depth to Bedrock Q Depth to Groundwater. Standing Water in Hole: WOO e Weeping from Pit Face Estimated Seasonal High Groundwater See Glb®Ve- DETEATION FOR SEASONAL HIGH WATER TABLE Method Used: G(?,V 41#0 V e Depth Observed standing in obs.hole: __ in, Depth to soil mottles: in, Depth to weeping from side of obs.hole: in, ©roundwater Adjustment ft. Index Well# Reading Date: Index Well level- Adj,factor- Adj.Groundwater Level PERCOLATION TEST Date iD '<•lme 1`Y;0 Observation Hole# Time at 4" Depth of Perc & 1 b Time at 6" WA r Start Pre-soak Time @ (jj' 0 Time(9"-6") _, h _ End Pre-soak V Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC ATE SOIL TEST LOG DO L EOVALUATOR: DAVIID DR COUGHANOWR. R.S. WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. ' PERC NUMBER: 12402 NO TEST PIT I PARENT MATERIA EPROGLAC ALD OUTWASH PERC AT 66 in - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 50.35 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-7 Ap -LOAM 10 YR 2/1 NONE FRIABLE 46.60 7-45 B SANDY LOAM 10 YR 4/6 NONE LOOSE 38.85 45-138 C MEDUIM SAVD 10 YR 6/3 NONE LOOSE TEST PIT PAARENOTU MATERIAL: PROGLAC ALD OUTWASH PERC AT 60 tr - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 50.15 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-8 Ap SANDY LRAM 10 YR 2/2 NONE FRIABLE 46.65 8-42 B SANDY LRAM 10 YR 4/6 - NONE---,--- LOOSE 42-132 C MEDUIM SAND 10 YR 6/3 1 NONE ILOOSE 39.15 I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA} (Munsell) Mottling (Structure,Stones,Boulders. Con i to c Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Tex:ure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No V Yes Within 100 year flood boundary No-Z Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? certificationN0V M I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CMR 15.017. ',�_ — � ZN OF MgSs Signature • C'�''""" LS� V44I Date �cf DAVID 9cyca, D. " COUG ANOWR Q\SEPT IMERCFORM.DOC `s0 /CE N S<;V Q" ,� eV AM' Z _ o woln < o z W Lo o< a_ _ 0Ofo W � z)- Lli p6p U O O O N W� U G�JSE\S 0' �o W (j 0 O J cn U Z o 0 F >� W d (n O O �� W� U yP ?� O �6 � W N z 0~�0< > O� m W Fo Q O U� ❑ O� `" o �w��� cri e O O ' L w z g z u, >- U e co < w cD �W L > a z �a ZW oo w o ¢ L1 = w Cf) ❑ W LCl � ozw z Ltjp� Lu oz s o cD � w Z J W Cfl e N w0w� w U �' Z Y W U{- ~o r 0 v •� J O O �-+ O O W >cn �- z -� O cncn OZ v OIL- O �N e LLJ �N�Wwp O �'� -LJ, O X < � Z � N W �000� Q e O 00-0 w E W U W < O W Ln CO N t- w 3 u ? > deb �w c.n w � —�} -< (.0 O w(L Z w� (- �-tn Ow w Y Js��zs N o > °� � W= L jw<uw J m� �W UW mI e PGA o w O .� �- o U O X~Uujcn ❑ In� <U �� ?b oo ' 00. 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R.S. DESIGN CALCULATIONS - WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 12402 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD NO GROTUNDDWAT AL ENCOUNTER LD OUTWASH SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 USE 1500 GALLON TANK (MINIMUM ALLOWED) PERC AT 66 to - 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET D-BOX ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: SEE DIAGRAMS BELOW 50.35 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Vt = 0.74 X 476.195 = 352.364 GPD > 330 GPD REOUIRED 0-7 Ap LOAM 10 YR 2/1 NONE FRIABLE 46.60 7-45 B SANDY LOAM 10 YR 4/6 NONE LOOSE 3B.65 45-138 1 C MEDUIM SAND 10 YR 6/3 1 NONE ILOOSE CONSTRUCTION DETAIL LEACHING GALLERY NOT TO NO GROUNDWATER ENCOUNTERED USE SHOREY PRECAST 500 GALLON SCALE TEST PIT 2 PARENT MATERIAL: PROGLACIAL OUTWASH LEACHING DRYWELL (H-10 LOADING) PERC AT 80 in - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DRYWELL USTTON DRYWELL UNIT STONE 14.5 f (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING t 50.15 0-8 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE m co 46.65 8-42 B SANDY LOAM 10 YR 4/6 NONE LOOSE ui L. 39.15 42-132 C MEDUIM SAND 10 YR 6/3 NONE LOOSE m R m `� 1500 GALLON SEPTIC TANK DIMENSIONS AND DETAIL NOT TO 4.0 ft 8.5 ft 4.0 f! 3.0 ft 8.5 ft 3.0 ft USE SHOREY ST-1500-H-10 SCALE 16.5 Ft 11.5 f t INLET CENTER OUTLET FiOTTnM ARFA = 16..5 x R..S = 140.25 sP BOTTOM AREA = 10 x 14.5 - (2.5x1.5) = 141.25 sf END COVER END - J' SIDEWALL AREA = 4(16.5+8.5) = 100 sf SIDEWALL AREA = 2 (14.5 + 10 + 11. 5 + 3.91 + 7.5) = 94.82 sf TAPER 3 IN DROP TOTAL AREA = 240.25 sf TOTAL AREA = 236.07 sf -► /l FLOW LINE FROM BUILDING 10 in 14 TO 5 ft- 48 in In o-eox 500 GALLON DRYWELL CROSS SECTION VIEW O 8 1n LIOUID GAS DIMENSIONS AND DETAIL LEVEL BAFFLE USE H-10 L"T INSTALL ONE INSPECTION 2 In PEASTONE 2 in PEASTONE RISER TO WITHIN THREE INCHES OF FINAL GRADE O �0 AND INDICATE LOCATION 24 Y CROSS SECTION VIEW ON AS-BUILT PLAN 28 -!iz � a�THr 1-112 u TO 26 In !n In 43 In 58 In 43 In 33 144 In Alo'- 2) OVED GEOTEXTILE O In FABRICINSTALLINRPLACE O MAY BFSTHE 2 n. PEASTITUTE AN RTONE LAYER SPECIFIED. � �Op QQQNOTES000001) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK.SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). GROUNDWATER ADJUSTMENT SEWAGE DISPOSAL SYSTEM PLAN 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. EXISTING GROUNDWATER LEVEL -TO SERVE EXISTING DWELLING 51 EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED. BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. GIRARD & CAROL GAOUETTE 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. INDICATED GW 20.00 21 ELAINE ROAD HYANNIS, MA 7) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES INDEX WELL M1W-29 AND .APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. ZONE D READING DATE SEPT. 2008 EEO-TECH ENVIRONMENTAL 8) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH ADJUSTMENT 5.0 43 TRIANGLE CIRCLE SANDWICH MA 02563 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. ADJUSTED GW 25.00 FETE-3045 OCTOBER 25. 2008 1 1212