HomeMy WebLinkAbout0036 ELAINE ROAD - Health 36 Elaine Road,Hyannis
09
V
=t3 ZEI 2020 TO WN OF BARNSTABLE
LOCATION 3(p ELA)y-le- eD = SEWAGE#_ZO W 37-7
VILLAGE y 14+4 fl (S ASSESSOR'S MAP&PARCEL Z 8 O
INSTALLER'S NAME&PHONE NO. wbet_-- aJ. OUY- (506)Q"(7 - $8 17
SEPTIC TANK CAPACITY (000
LEACHING FACILITY.(type) SC.b qo.�. C,4A>Iyt13 (size) Z9'. S 9.9
NO.OF BEDROOMS .3
OWNER 3 0 E ME
PERMIT DATE: 10 ( IS Zp COMPLIANCE DATE: to ZO
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 Out Co.
6�2T" e
� M
ao r r- M M
N M Vc
rl M Q Ln �-
M
cr
r TOWN OF BARNSTABLE
LOCATION V hINI-t. EXJ , SEWAGE #
VILLAGE "qYt N N\S ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) e ts— (size) 1 on®G �
NO.OF BEDROOMS
BUILDER OR OWNER
PERPIITDATE: 0 (���j —COMPLIANCE DATE:
Separation Distance Between the: I
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -�L'2-0 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
i� Furnished by �' 'j
-�3
1 L 3
2H y
153- 31
�y fix.,- 45
TOWN OF BARNSTABLE
L06ATION 61(;jm-e- �i SEWAGE # q6�
VILLAGE 'hl ASSESSOR'S MAP Cz LOT
INSTALLER'S NAME & PHONE NO. . �- '0✓
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (sizelw�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: v[
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No.
11000'
- � d
r
f No.OWU _3 / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s
applirdtion for Disposal 6pstem Construction 3pPrmit
Application for a Permit to Construct( ) Repair(.JrUpgrade(y) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.36 EF L40 l9 Rdj Hymrv3 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel a q Rope MC�51 ACA 5ft'L I .SLV 36 y— f g8q
Installer's Name,Address,and Tel.No. ,$ve"(4T7- 977 Designer's Name,Address,and Tel.No. S�.�6 y 90 y6
R01064 g ouR 3 63 Whi ks Pc%W% Y►►vv)k Tom McLllw% I)®&Y 1163 E: ��s
Type of Building:
Dwelling No.of Bedrooms Lot Size 1 PL10® sq.ft. Garbage Grinder( )
Other Type of Building Rocs 2'l I No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 230 gpd Design flow provided gpd
Plan Date ]C�"'��—A09® Number of sheets Revision Date jdho�2' � _ ",J)T 0-1
Title T
Size of Septic Tank 1000 tal loin Type of S.A.S. Prece+s- c_havnb4/zS vY
Description of Soil Mod itl m .Sn CI S@Q 014,1)
Nature of Repairs or Alterations(Answer when applicable) ifs t'P( D (kr,M b e fj
_D-Box , 40 loco gc-,11 1) Sf® t k441C
Date last inspected:
Agreement:.
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date J0—7-ao a b
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. "'11 Date Issued -to
' Entered in computer:Fee
t /
THE COMMONWEALTH OF MASSACHUSETTS -�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s
Rpplir io Yor Misposal 6pstrut Construction Permit
Application for a Permit to Construct( ) Repair(;/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.36 5 Lai n e -Rd NY44 ills Owner's Name,Address,and Tel.No. .;!%'
Assessor'sMap/Parcel ;tq5 The melnCA Sa,Mt .5 -' 6y� IF" /
Installer's Name,Address,and Tel.No. S70e-477-6877 Designer's Name,Address,and Tel.No. ,S4*--'f6y-%98
berg &Quk 363 Whi4s Inc % YW,*,A Torn McLellaA , SOW 1163 F:Ty �e�r1�s
Type of Building: '
Dwelling Np.of Bedrooms Lot Size 10t fOO sq.ft. Garbage Grinder( )
Other T e of Building 9 A i No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 2p gpd. Design flow provided J gpd
's. Plan date 10--7—awl Number of sheets r Revision Date
Title
Size of Septic Tank 100o 44,110r\ ype of S.A.S. Rece-4 C hw yn k>�,f S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) prfa<l '- CkAM6F& ae1�
&K 4n ifig i 1$ 000 4; qA15e y` kc
W �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. ++
Signed Date lO— —aO a a
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued /) --
y
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓� Upgraded(X)
Abandoned( )by Rn 64 r V
at 6 ELrAine RCI i 1JV4 � S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NQXX —7 dated /1) ��7
Installer r 'Q ('l� Designer 64S ►Ver G ► 0.Q/1✓l 4
#bedrooms Approved design flow/---4 ??n gpd
The issuance of this permits all not b ;construed as a guarantee that the system ill functio s d ig ed.
Date � d Inspector
No. C ,� 7 Fee '
THE COMMONWEALTH OF MASSACHUSETTS
v PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
MispoBal 9ppstem Construction 3pPrmit
Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( )
System located at �,
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date_f c) �T Approved by �r
Town of Barnstable
' .� Inspectional Services
• Public Health Division
t�trrsraats, • -
039�.
A B' Thomas McKean,Director r
n 200 Main Street,Hyannis,MA 02601
h.
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form ,
Date: I® 'U`2® Sewage Permit# ZVZO -32—1 Assessor's Map\Parcel ?�1109
Designer: Installer: ibA&i2 Q - 0u.2
Address: P.a . 50>( 1163 Address: 3(a.1 W µ f reS PA-7-If
0 2-G(o
On 10 1 IS' I ZO 01-06 CSC B.Oc w was issued a permit to install a
(date) (installer)
septic system at 36 .6�AW P—D J4 4A 1A)I< based on a design drawn by
f (address)
�1l 1Z "a�IGI 7dated 10-7- 1 66 .U <
(designer) J
/ 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. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State&Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in compliance with the to rms of
the M approval letters (if applicable) js��A OF
THWASJ.McLELLAN
oy
0
civil,
(Installer's Signature) c��A9 Klo.38471
(Designer's Sin e) (Affix Designer's`Stamp Here)
PLEASE RETU O 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.
WoaldeptAHEALTHISEWER connecASEPTIODesigner Certification Form Rev&14-13.DOC
I _
COMMONWEALTH OF MASSACHt'SETTS t
ExECL'TIVE OFFICE OF F?Nti'IR0 \4E�T4L AFFAIRS
DEPARTMENT OF E'� ;IE\TAL .PROTECTION
M ONE WINTER STREET. BOSTON. NIA 02106 617•=S:•�:CMG
VITLLIAN'F.WELD •,. . _ TRLMY CGS=
Governc
ARGcO PALL CELLL'CCI = _ DAVID B STRCt"
Lt.Gave-nor (, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F07CM Carnrrissic:^c
PART A
I r` CERTIFICATION
Property A"dddre zok, i girNNtS Address of Owner: PAN L41S v
Date of Inspection: 0,1 Z � � GZ(�C' Of different)
az
Name of Inspector: P-6e .A e •o
I am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:fZ/ a c Ei+ P " '���
Mailing Address: 2 p Agnx e-379 4.4 H fJSf,/peQ- H /T (=7 2E4-47 .
Telephone Number: T_Ci
CERTIFICATION STATEMENT
I certiiti that I have pe•sonalh ir.speced the selvage daposal sv-stern at this address and that the information reaore-' be oM is true. accurate
and complete a: of the time of inspee,o-. The inspec;en %as pe,:crmer° baste on my training and experience to the proper cur c:c- and
of on-s-te sewaee d:sposa� systems. The R•stem:
Pastes
Concit-enai:\ Fasces
_ "Seec; Furthe- E,. t• at:e- 5. the Local Approving Authorir,
_ Fa.•s n
Inspector's Signatu - Date: (Jv
T,i2 S�Se Ins: Ge- sha'' Subm:: a copy pf this inspeG on reoCr tc the Approving Autheriry within th:r-. f301 days ci completing this
inspeG:cn. It the system is a share,-1 system or ha,
a ces,g•+ floe c: 10.000 gx or greater, the tnspe^.or and the syste-n owner s b!I submi,
the re.on to t^e acprepnate reg or.ai o nce of the Deparment of Eny:renmenta' Frotemcr. The erig:na! should be- sent to the system ew-z
and copes to the buyer, ii applicable. and the ap-croving authority
INSPECTION SUMMARY: Check A, E, C, or D
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as define= in 310 CNAR 13.3C•:
Any failure citeria not evaluated are indicate+ below.
COMMENTS:
Bj SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass- section need to be replaced or repaire?. The syste-n, upc.
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no. or not determined'(Y, N. or NDi. Describe basis of determination in all instances. If 'not determined',.explain why net.
_ The septic tank is metal, unless the owner or opeator has provided the system tnspec-,or with a copy of a Certificate of
Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; c
the septic tank, whether or not metal• is cracked. structurally unsound, shows substantial infiltration or exfiltrauon, or tang
failure is imminent. The system will pass inspe=ion if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FOR."
PART A _
CRTIFICATiON (continued)
Property Adduus:
Owner:
Date of Inspection:
ej SYSTEM CONDITIONALLY PASSE5 tcontinu,?d
Sewage backup or'breakout or high static water level observed in th distribution box is due to broken or obstructed
pipets) or due to a broken. settled or uneven distribution box. The/ ystem will pass inspection if(wtth approval of the
Board of Health). Describe observations:
broken pipe(S) are replaced /
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe!s). The system will pass
inspection if twith approval of the Board of Health):
broken pipets; are replace-
obstruction is removed f
J
r -
CJ FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF-HEALTH:
Conditions exist which require furthe• evaluation by the Board of Health in order to determine if the iystem is failing to prote,-j the
i public
I
ub c health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cess000l or pri-,ti is within 50 feet t7f a surface water
_ Cesspoo! or pri,,-,- is within 30 fee:o;a bordering vegetated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF h:EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCT1OtiltiG IN MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFciY AND THE
ENVIRONMENT:
The system has a septic to and soil absorption system (&ASi and the Sti felt to within 100 fe to a surface water supply or
tributan• to a surface wate supciv.
The system has aseptic nk and soil abscrpnon systern and the SAS is within a Zone I of a public water supdy we!(.
The syste-n has a septic ank and soil absorption system and the SA,5 is within 50 feet of a private water supply'well.
The system has a septa tank and soil absorption system and the SAS is less than. 100 feet but 50 feet or more from a
private water sup py e!I, uniess a we!l water analysis for coliform bacteria and volatile organic compounds indicates tha.
the we!I is free from . ollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to cr
less than 5 ppm. Methxr used to determine distance (approximation not valid).
3) _ OTHER
I
(revised o4:2s/j7) )sq• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Z�Prf,•
Owner: ftsA✓ —
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The fac+Irn or dwwellrng .vas inspected for signs o`sewage back-up.
_ The systern does not receive non-sanitar,• or industrial waste flow.
_ The site -,as inspected for signs of breakout.
_ All swsterr components. excluding the Soil Aosorptron System, have been located on the site.
The septic tank manho;es wwere uncovered, opened. and the interior of the septic tank was inspected for condition of
7 C baffies or tees. matenai o' construction. dimensions, depth of liquid,.depth of sludge, depth of scum.
/ The size and location of the Soil Absorption Svstem on the site has been determined based on
X _ The fac,l,cw o\.ne• nano occupants. if drfteren, from oww•nerr were provided with information on the proper maintenance of
Sub-Surface Disposal Svstem.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field of am of the failure criteria related to Part C is at issue, approximation of distance is
unacceotabie [15.302:3r,b1!
(revioad 04/25/571 page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: �—
DI SYSTEM FAILS:
You must indicate either "Yes" or "No' as to each of the follcwing:
I have determined that the system violates one or more of the following failu a criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be ntacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to n overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the gro nd or surface waters due to an overloaded or clogged SAS or
cesspool.
Static houid leyei in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below inve or available volume is less than 1/2 day floe.
Recurred pumping more thar. 4 times in the last ear NOT due to clogged or obstructea pipes .
Number of times pumped _.
Any portion of the Soil Absorption System, ce spool or privy is below the high groundwater elevation
Am portion of a cesspool or privy is within/100 feet of a surface water supply or tributary to a surface water supply.
Ant portion of a cesspoo' or prn,• is N ith/y�/. a Zone I of a public well.
Am perio- of a cesspool or privti• 1s wi film 50 feet of a private water supply well
Any por.or. Of a cesspool or privv is ss than 100 feet but greater than 50 fee! from a private water supply well with no
acceotable water quali, analysis. If he w=_II has been analyzed to be acceptable. attach copy of well water analysis for
cohiorm bacteria volatile organic c mpounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either 'Yes' or "No" as to each of the Vlowing:
The folioN;ng criteria appr% to large sys ms in addition to the criteria above:
The system serves a facilit\ with a de ign flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safer, and the env onment because one or more of the following conditions exist:
Yes No
the system is within 4 feet of a surface drinking water supply
the system is within feet of a tributary to a surface drinking water supply
the system is locat in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
public water suppl well)
The owner or operator of any such ystem shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 an 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) /
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTE41 INFORMATION (continued)
Property ddress: A PAn- R
Owner: f
Date of Inspection.�j 1/"�I-I' ,%
BUILDING SEWER:
Y(
(Locate on site plan)
Depth below grade.
Material of construction. _cast iron _40 PVC _other (explain',
Distance from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: 6
l n'
(locate on site p
Zit
Depth below grade
Material of construction' Aconcre:e _meta _Fioergiast _Polyethylene _other(explatn
If tank is metal, list age /_�, Is age conf;rmec o\ Ce^:fica:e of Compt(ance _(l es.:No
Dimensions antfA 17 I
Sludge depth all ,)
Distance from top o: s!udee to bonorn or oune: tee o, ba'�e �
Scum thickness 0rt
Distance from top of scum to top of outlet tee or bade 16
tf
Distance from bottom of scur^ to bo-on o, outlet to c• bane �y
Now dimensions mere determinec
Comments
trecommendation for pumping, condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural
int gri ev i e ce of I aka e, etc.)
�.I LI in
01 lq
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:
(recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level.in relation to outlet invert, structural
;ntegrity, evidence of leakage, etc.,
(revised 04/25:9,) Pag• 6 of 10
SUBSURFACE SEWAGE
DISPOSAL SYSTEM INSPECTION FOR.tit
PART C
SYSTEM INFORMATION
n�,,I/_
Properts Address: - (e ail si��
Owner: tCV 510-
Date of Ihspection:P 11a�(J
U
FLOW CONDITIONS
RESIDENTIAL:
Design floe. .o.d..Ibedroom for S.A:S
Number of bearooms
Number o:current residents3
Garbage g,; der (yes or no�:_D
Laundry co—ected to system (yes or no!
Seasonal use Ives or no-:I—)
Water meter readings, if ava [able (last two i2l year usage tgpd). (�
Sump Pump (yes or no):
Lac: date of occupancy �iv1
COMMERCtAL'INDUSTRIAL:
Type of establishment
Design fio\ ga!ions)da%
Crease trap present Ives or no*_
Industna! %Taste Holding Tani: present. ,ves or no_
:on-san,tan v+aste dscnargea to the T!the 5 system. ,ves or r.o_
\%ater meter readings. if ayailabie
Las:pate o; o
OTHER: .De:cribe
Last aate of occupant,
GENERAL INFORMATION
PUMPING RECORDS and source f information
System pumped as par, of inspection: tves or no.
If yes, volume pumped gallons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pri%y
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no',
(revised 04/25/9"7)
Page 5 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART C
SYSTEM INFORMATION (continued)
Property Addr-ss: � l/
Owner:J�A3hUC4,,
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): J
(locate on site plan, if possible, exca,.at on not required. but may be approximated by non-intrusive methodsi
If not determined to be present, explain:
Type:
leaching pits. number. ({�(
leaching chambers, num r:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, damensio.n.s
overflow cesspool, number
Alternative system
Name of Tecnnolog�
Comments
inot condition of soii, s!gr.s of hydraulic failure, level Qi ponding, conditio of vegeta n, et ..
Ent
tA
CESSPOOLS:
(locate on site plar.
Number and corfigura:,on
Depth-top of liquid to inlet Inver,
Depth of solids Jaye,
Depth of scum layer.
Dimensions of cesspool
Materials of constructior.
Indication of groundwate-
inflow• (cesspool must oe pumpec as par, of inspection:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:�J
(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.)
` (revised 04/25/97) page s of 10
II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
2 SYSTEM INFORMATION (continued)
Propem ddress: ✓� �`�J
OH ner: �✓� , I
Date of Inspe on:
TIGHT OR HOLDING TANK: (� 7ank must be pumped prior to, or at time, of inspections
(locate on site plan,
Depth below grade.
Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions.
Capactr - galions
Desig^ floe gahons,da,
Alarm level Alarm in working order _ Yes, _ No 1
Date of previous pumping
Comments
(condition of inlet tee. condition o- alarm and float switches etc.)
DISTRIBUTION BOX: �S
docate on site pan T
Depth of liquid level aoo,a outle: in\e C'ij�
Comments
mote :f level and di�;nb. ton s epua. vidT C 1 sol1ds carmlover, dence of le g �n r out of box, etc.)
�, r.
r
PUMP CHAMBER:
(locate on site plan. \
Pumps in working order: (Yes or No,
Alarms in working order (les or No-
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 01/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert+Addrese•
Owner: tAIIAhUAI
Date of Inspection: n 12`
Depth to GroundwaterL2� Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property. observation hole, basement sump etc.)
Determine it from local conditions
Cnec'K %+nth local Board o• nea.!,.,r
Chec'K FENtA Wraps
Check pumping records
Check local excavators. installers
t_se '1.SCS Data
r•
Describe in %o.,, o�%- v.oras no•.+ +o: es:abhshed the `-iie" Groundwater Elevation. (Must be completed:
CXdol c� �U(ZV��j f fL� �Q(���c '(�Q.S�I-�'-f��Q E 40C 6qq --
lr
(zevcsed 04,2519- Page 10 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I%FORMATION (continued!
Propert} ddress: RAUO
Owner: t�h�o�.
Date of In,pection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
](6z -Zy
31
(revised 04125/57) Page 9 of 10
CONINIONAVEALTH OF MASSAC14USETTS
EXECUTIVE OFFICE OF ENNIRONMENTAL AF 8
1 t=
DEPARTMENT OF ENVIRONMENTAL P CTION '9
ONE WINTER STREET. BOSTON. MA 02108 61%-_9_ 5;t:
oho r,�O
V1'ILL1AM F WELD �► y�lry9gy ,l9 1 COKE
Govemc- �FjO a""- 99 Se.retar\
ARGEO PAUL CELLUCCI ��I B.STRURS
Lt.Governor SUBSURFACE SEWALE DISPOSAL SYSTEM INSPECTION FO Commissioner
PART A T+ t
r- L CERTIFICATION .
Property Address: 3to 1J1%tuC, 1��1�"`'^'` :MR' Address of Owner:
Date of Inspection: "I`Aon (If different) y t ?%ex ST
Name of Inspector: tMv car.asL� 1�c�-2,C4W "$¢eotc,l.��,� t M ri , OZI\-X to
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Pup-r y0
Company Name: _PyTun C. 'Q_It(vr?diuUy ,,t) *I
Mailing Address: 'P,O_ISok 2,14�%,t% ,r"lo►chtD2tt V-�tar 02l�4°I
Telephone Number: ScxD 411-1d LC�
CERTIFICATION STATEMENT
I certify that I have personalh inspected the sewage disposal system,at this address and that the information reported below is true, accurate
and complete as of the time of inspect,o".. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposa+ systems. The system
_X, Passes
_ Concdit,onaii\ Passes
tieeas Further Eval,jauor, By the Local Approving ,Authont%
_ Fa. .
Inspector's Signature: AAAL Date:
The Svsterr In5Decior shal' submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system o, 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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buye,, if applicable, and the approving authorm.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined' explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(r*,•.med 04/25/97) Page 1 of 30
DEP on the woad wide Web rim./rwww magnet state ma.usroec
Pnntec on Recycied Paper
SUBSURFACE SEWAG: DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES tcontin.,-d
Sewage backup or breakout or high static water level obsery in the distribution box is due to broken or obstructed
o
pipets),or due t.o a broken, settled or uneven distribution bo . The system will pass inspection if(with approval of the
Board f.Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replac
The system required pumping more than four times a ear due to broken or obstructed pipe(sl. The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF EALTH:
Conditions exist which require further evaluation by t e Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALT DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH ND SAFETY AND THE ENVIRONMENT.
Cesspool or priv1 is within 50 feet of surace water
Cesspool or prn� is within 50 feet o a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD F HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MA NER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank a soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tnbutary to a surtace water su plv.
The system has a septic tank nd soil absorption system and the SAS is within a Zone I of a public water supn'v well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tan and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, nless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollut on from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate either "Yes' or "No' as to each of the following:
I have determined that the s\,stem violates one or more f the following failure criteria as defined in 310 CMR 15.303. The oasis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system c mponent due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the s rface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static l,ou,d levei in the distribution b a 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 112 day flov..
Recu,red pumping more than 4 ti es in the last year NOT due to clogged or obstructed pipe's.
Number o:times pumped
Any port,or o`the Soil .Absorpt, n System, cesspool or privy is below the high groundwater elevation
Am pomon o�a cesspool or p ivy ,s within 100 feet of a surface water supply or tributary to a surface water supply.
And portion of a cess000: or riv\ is .%rth,n a Zone I of a public well.
Am oo^,oc 0' a cesspool or pri%�, is within 50 feet of a private water supply well
Any pon,or: o;a cesspool pri,.-�, is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water qualm a Ivs!s. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform, bacter;a. volatile rgan,c compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No' as t each of the following:
The foiiov`;ng crite•;a appi\ to lar e systems in addition to the criteria above:
The system serves a facilm with design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public health and safery and the nvironment because one or more of the following conditions exist:
Yes No
the system is within 4 feet of a surface drinking water supply
the system is within 2 feet of a tributary to a surface drinking water supply
the system is located i a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply w II)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert> .Address: 3 V �-�A�"-�•�j
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have beer pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection
Y _ As built plans have been obtained and examined. Note if they are not available with N/A.
The facdir. or dweliing was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakou•.
Y, _ All s\stem components, excluding the Soil Absorption System, have been located on the site.
�•. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, materia� o- construction. dimensions, depth of liquid,.depth of sludge, depth of scum.
—The size and location of the Soi! .Absorption System on the site has been determined based on:
The facility ovine, ,ano occupants. if differen: from owneri were provided with information on the proper maintenance of
Sub-Surface Disposal Svstem.
_ Existing iniormation. Ea. Plan at B.O.H.
�( Determined in the field :r am of the failure criteria related to Part C is at issue, approximation of distance is
unacceptabie [13.302:31:b']
(revised 04/25/91) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.ti1
PART C
SYSTEM INFORMATION
Property Address: 2W
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design iioH 33O g•p-d.,-bedroom for S.A.5
Number of bedrooms O
Number o-current residents Q2-
Garbage g,; der (yes or no! Njo
Laundry co—ected to system Ives or no' L ,,
Seasonal use Ives or w
Water meter readings, if available (last two (2: year usage (gpd): N`A .
Sump Pump Ives or not aD
Last date o�occupancy
COMMERC1460NDUSTRIAL:
Type of establishment
Design fio%% galions/da\
Grease trap present. rues or no'
Industrial \taste Holding Tani; oresent. .ves or no
Non-sanrtary Haste discharged to the Tree 5 system ,yes or no
%%ater meter readings. if a\ailabie
Lasthate o: o ;cpahc.
OTHER: Describe
Last date of occuoanc.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
-?VV NQtC1 It,-, 0'� t ->uSTLWr Sho.��d �L\2 Puv,nCs�-� uv \ y,ft_ Z
System pumped as par, of inspection: Ives or no:
If yes, volume pumped gallons
Reason for pumping
TYPE OF SYSTEM
_ Septic tank/distribution box/soil absorption system
Srngie cesspool
Overflow cesspool
Prny
Shared system (yes or not (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ± ab gee.
o!J -D-OCA� i%r
Sewage odors detected when arriving at the site: ryes or no) NO
(zovimed 04/25/91) Pag• 5 of 10
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM
PART C '
SYSTEM INFORMATION (continued)
Property Address: uto
Owner: t..Cw2v�1p�
Date of Inspection: .,
BUILDING SEWER:
(Locate on site plan)
Depth below grade.
Material of construction: _ cast iron _ 40 PVC _other (explain'
Distance from private water supply well or suction Ir-,
Diameter
Comments: (condition of)oints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan
Depth below grade �ZK
Material of construction: kconcre:e _meta' _Fiberglass _?olvethvlene _othertexplaiw
If tank is metal, list age _1 Is age confirmed b, Certdicate of Compiiance _(Yes.;No
Dimensions IOMSt$4`
Sludge depth %Z'(
D)siance from top of sludge to bottom of outie: tee or ba^e 1;•57
Scum thickness 6 Ig
14
Distance from top of scum to top of outlet tee or ba^ie X7—
Distance from bottom of scum to bor.o�r of outlet tee o, bane 21y
How dimensions were determined
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invertp, str�u"ctural
integrity, evidence of leakage, etc.) Uo. kxrdl td ��� T C A.%-T w%'A_— s r^+ �T �T_Cb---�hree
GREASE TRAP:—LID
(locate on site plan!
Depth below grade:
Material of construction: _concrete _,metal _Fiberglass _Polyethylene _otherlexplain)
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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.;
(revised 04/25,'97) page 6 of 10
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3V Otrhs-f—
O%ner:
Date of Inspection:
TIGHT OR HOLDING TANK: 6X 7ank must be pumped prior to, or at time, of inspection)
(locate on site plan,
Depth below grade.
Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity, gallons
Design floe. galionvda�
Alarm level Alarm in working order_ Yes; _ No
Date of previous pumping
Comments
(condition of inlet tee. condition of alarm and float switches etc.i
DISTRIBUTION BOX:
(locate on site pia'
Depth of hauid level above outie; imer
Comments ,
(note d leve! and distribution * eoual. evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:�C�
(locate on site plan.
Pumps in working order: (Yes or No'
Alarms in working order (lees or No,
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
I
7 I
SUBSURFACE SEWAGE DISPOSAL SYSTEM
S EM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3L ��tiLtiN�,R,c�
Owner:
Date of Inspection: , ►�g,
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods,
If not determined to be present, explain:
Type:
leaching pits, number.
leaching chambers, number:
leaching galleries, number:
leaching trenches, number length
leaching fields, number, cli nension.;
overflow cesspool, number
Alternative system
Name of Tecnnologv
Comments:
mote condition of soil, signs of hydraulic failure, level of ponding, condition of v etatton etc.!
Jv o 0
u
CESSPOOLS: uC�
(locate on site plan
Number and configura:,on
Depth-top of liquid to inlet inver,
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwate-
inflow (cesspool must De pumper as part of inspection),
Comments:
(note condition of soil, signs of hydraulic failure, level of poncing, condition of vegetation, etc.)
PRIVY: &Z
(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.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM [NFORMATION (continued)
Property Address: 34
O%ner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reverences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
t
ASS (5Z-- A'6a
3 ` 3i"l u 135- Aol
(zevioed 04/25/57) Page 9 of 10
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3�. �'�"''��
Owner: k_,
Date of Inspection:
Depth to Groundwater IFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation of Site (Abutting property, obsen•ation hole, basement sump etc.)
Determine it from local conditions
CnecK with local Board o: neafin
Check FEMA Maps
Check pumping records
Check local eaca%ators. installers
Use L ECS Data
Describe in \our own \%ooro= no. �o:, established the High Groundwater Elevation. (Must be completed:
V.g.cveoloatMAI ���<..,` t, l4-yc���►oottv =4'' J�����T�o�
(revised 04/25'97. Page 10 of 10
r
No....7K.-31 7 Fic$......3JC9........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrttrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (_,.),�'an Individual Sewage Disposal
System at:
Location-Address or Lot No.
.......
MIX.T`.L_t. }_. 111XC, ........................... ......................5!p!. .....----.....--------•--•-----------------..._.-...--•---
Owner Address
aS,9-f� .�-!a�!ti3O.... G= � .......�A!! : 4V---
Installer Address
Type of Building Size Lot................:...........Sq. feet
U Dwelling—No. of Bedrooms...._...—'A..............................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .
W Design Flow.......... .�.................gallons per person per day. Total daily flow.......�_ ..................gallons.
Septic Tank—Liquid capacity............gallons Length-------_------- Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No------- (?-------------- Diameter..... . _......... Depth below inlet.... c ............ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank'( )
aPercolation Test Results Performed bY............................................----•-----------•---••-•-----•- Date..........-•------•---------------•----
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
G%, Test Pit No. 2................minutes per inch Depth of Test Pit______4............ Depth to ground water--__-___-______---_-___-
--•-----------------------------------•---------------------------------•-•-----•-----.-------•-----------•-•------...----........--•------.................
0 Description of Soil...............................................................................=........................................................................................
.
cxj ---------------------------
•---------------------------------
•---------------
-----------------------------------------•-----------------------------------------•-•-•-••-•--
W
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- --...---•-------
Nature of Repairs or Alterations—Answer when applicable_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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.
Signed......
Date
Application Approved BY ... ..t ----------------- . -- ------.--....--------------- -----�-- q
Dare
Application Disapproved for the following reasons:'-----------------------------------------------------------------------------------------------------------------------------
- - ----------- -- -- ----------------...:---------------...----.....:......------------------------------ -------.... ------------------_--_---------- ........................................
Permit No. �G .....3.7..1. Date
Issued
THE COMMONWEALTH OF MASSACHUSETTS a
BOARD OF HEALTH
TOWN OF BARNSTABLE
P
ApplirFation for Dhgpv� al Works Tnnitrurtiun rrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (. )an Individual Sewage Disposal
System at A ----------------- .............
..._ y.
Locati n-Address or Lot No.
1r � 1L " y C to
.. ............. ............................................................
y ti � Y— -.........
Owner ` wAddress
W �.ta�L' 3t! i� "a•e tit._.�_r.— .W.,._'__!.`...... 1+� ft �(� CAr l�' NMR%f
—Installer W / Address :_...... .a(-___.
d Type of Building Size Lot....._....._:�t.............Sq. feet
U Dwelling=No. of Bedrooms...._ ....r.........................Ex anion Attic Garbage-Grinder
Other—Type of Building
p,, yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
�
, Other fixtures .......................................... -----------------------------------
------•--------•-...'------
W Design Flow__________ ___ ......_......___._...gallons per person per.day. Total,.daily flow------- ..................gallons.
x Septic Tank=Liquid capacity.............gallons Length................. Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Width.....__._............ Total Length......:_............ Total leaching area....................sq. ft.
Seepage Pit No.....V........... Diameter-___�. ... Depth below inlet__T:, ,t....... Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.................... -•-------•--------------------------•---•--•--•••-•-• Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water---_--__-__.•-_-_._____-
-------------------------------------------------------
•-••............:........................-----...------•-----------...._....-------••------_...--
0 Description of Soil.........................................................................................................................................................................
x
W
V Nature of Repairs or Alterations—Answer when applicable_..---_tji
r +' _�__ .'. *y._;
«r ter- ... : i.._
Agreement: !
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place'the.
system in operation until a Certificate of Compliance has been issued by the board of health.
_ -` Signed ... _
z. e-
......................................
A lication Approved B �! .
. Date
Application Disapproved for the following reasons:' ------------------------- ---------------------------.................. _
. ......................................................................................
� 35-7 � � Date
PermitNo- -------- ------ -------------------------------------- ---- Issued .................................................---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertifi ate of (�IImlaCianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b '1.. 7 ,-. .:Xl..V!..:'nc--- -t............
� " - ------ -------------------------------------- -------...----------------............----.......................................
y............................ _
..."s +„s-� tr Installer's-.-
at . - Via_ . _
has been installed in accordance with the provisions of TITLV 51 F'-he St t vironmental Code as described'ib.
the application for Disposal Works Construction Permit No. ....: .../....�>.... .... dated --------------------------- ----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE $ Inspector--- ------:.... �/ Inspector .............. ,.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No...�� _ 2F TOWN OF BARNSTABLE 3
.......... J FEE...................:....
Disposal urho- Tuns#rurtion "truth
Permission is hereby granted_____. .. ?' ° +I° �+ ._: � . .!.............
.............
to Construct ( ) or Repair ( �).-an Individual Sewage D>sposal System
[(.
at No........... F 4� = �r.Cq r'''y `/i.4�/ f (---of`,`,7�.. ^ j ............. ................................
as shown on the application for Disposal Works Construction Permit No..,l_.-._____��Dated..........................................
f • tl ----•---•................r. -?.—...••---...........--•---...........---•--•---•----
Board of Health
DATE.................. / l ( --------------------------------- Tf
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
N /\ EXISTING CONTOUR: ---- SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION
4ti/q�hT PROPOSED CONTOUR: 2"PEASTONE OR FILTER FABRIC
EXISTING SPOT ELEVATION: 25.5 FLOW ESTIMATE: FIRST FLOOR
COVERS WITHIN 6" 3/4"-1 1/2"DOUBLE
p PROPOSED SPOT ELEVATION: 25.5 3 BEDROOMS AT 110 GAL/DAY= 330 GAL/DAY TOP OF
LOCUS OF FINISHED GRADE
TEST HOLE:-�- Q WASHED STONE
rn� q UTILITY POLE: -a- FOUNDATION,` ����� �� r--
m �� FENCE LINE: SEPTIC TANK: �- s;;„f ,a FINISHED GRADE INSPECTION PORT
` --. ����, ELEV=99.17
HYDRANT: 330 GAL/DAY x 2 DAYS= 660 GAL g MAX-M
RETAINING WALL: ® USE 1000 GALLON SEPTIC TANK (EXISTING) 100-1JELEV. a 1/4"per ft 'OVER IN)
�qG LEACHING AREA: Q ELEV. 1/R per ft
O (EXISTING) 98.65 98.48
29.5' USE 3-500 GALLON CHAMBERS(8.5'x 4.8'x 2'EFF.DEPTH)WITH 9 0 ELEV. ELEV. 96.34
LOCATION MAP ELEV. 0-BOX H H ELEV.
LOT 25 (10,500 SF) 2.5'OF STONE AROUND SIDES AND 2'AT ENDS (29.5'x 9.8'x 2'DEEP) (6"STONE UNDER) 2'-2.5' 2'-2.5'
ASSESSORS MAP:24 PARCEL:109 °0 1000 GAL 29.5'x 9.8'
PLAN BOOK:165, PAGE:41 SEPTIC TANK
SIDE AREA: (29.5'+9.8')x 2 x 2=157 SF (0.74)=116 GAL/DAY
BOTTOM AREA: 29.5'x 9.8'=289 SF TEE SIZES: (TO BE CONFIRMED) 98.34 3-500 GALLON CHAMBERS WITH
LEACH AREA DETAIL (0.74)=214 GAL/DAY INLET*
UT ET:6 UP31 DOWN N ELEV. 2.5'OF AND 2 A TENDSD SIDES
CAPACITY=330 GAL/DAY GAS BAFFLE (29.5'x 9.8'x 2'EFF.DEPTH)
AT OUTLET TEE
TEST HOLE LOGS TH 1 ELEV. TH 2 ELEV.
O/A HORIZON 0!A HORIZON
DECK SUN ENGINEER: THOMAS McLELLAN,RE, LOAMY SAND LOAMY SAND
bh ROOM 8" 10YR 3/1 100.3 6" 10YR 3/1 100.5
WITNESS: DAVE STANTON,R.S, B HORIZON B HORIZON
BATH BATH spiral stairs DATE: 9-21-20 LOAMY SAND LOAMY SAND
BEDROOM DINING 18° 10YR 6/8 99.5 20" 10YR 6/8 9.3
to bedroom PERCOLATION RATE: <2 MIN/IN
BENCHMARK AT AREA k ti chen C HORIZON C HORIZON
RIGHT CORNER 101 P#:TBT 20-192 MEDIUM SAND MEDIUM SAND
OF BULKHEAD 2.5Y 7/4 PE, RC AT 48" 2.5Y 7!4
ELEVATION W 102.56-
LIVING 132" 90.0 120"1 91.0
ROOM
BED
ROOM I KITCHEN W NO GROUND WATER ENCOUNTERED
� S 42016'25"E
100.00, NOTE S
1 i Stockade Fence
I(n i 1.VERTICAL DATUM: ASSUMED
1i EXISTING FLOOR PLAN
2.MUNICAPAL WATER IS AVAILABLE.
r`�P\g ; 3.SCHEDULE 40-4"PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM.
4.ALL PRECAST UNIT:4 SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS.
36"oak ` ; i 5.PIPE PITCH= 1/4" PER FOOT(UNLESS NOTED OTHERWISE).
6.FIRST 2'OF PIPE OUT OF D-BOX TO BE SET LEVEL.
GAS \ 20 i`1
7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL.
th-2 I 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL
th-1
{ CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS.
bh ST ), ,\ 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION.
Q ca
a a 1101 10.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED T WITHOUT VARIANCE.
O existing
cg 10' 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH,MA.
(D
w DECK tank oow 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND
-40 �� IS SUBJECT TO CHANGE UNTIL SUCH TIME. THIS PLAN HAS BEEN PREPARED FOR THE SOLE
W woo PURPOSE OF CONSTRUCTION OF A NEW SEPTIC SYSTEM AND DOES NOT NECESSARILY
Z cWi,� ' EXISTING REPRESENT A FULL DETAILED PROPERTY SURVEY.
m
3 BEDROOM
DWELLING ro
13.EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED.
; / y �
J top fnd.=102.56
14.D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW.
W I 101 LL,
14, p`
t
deco. CL� N
L .. { I
PAVED �`�`� _......____.. _. - a 1 SHED i SITE PLAN
DRIVE �.O
100`
LOCATION:
-olStockade Fepc�_ .____ ___ __ _ _ ____ OF IlSSs\ 36 EIAINE RD.,HYANNIS,MA
N 42° 625"W' THOMAS J. PREPARED FOR:
McLELLAN
100 CIVIL -A! JOE MESSINA
I No.36471 DATE: 10-7-20
.o -g q JJ REVISED: 10-20-20(TH-2 LOCATION&P#) SCALE: 1"=20'
pX t\\STP�c *4`//
j BASS RIVER ENGINEERING
V�(/p
• V 0
THOMAS J. McLE AN, P.E. P.O.BOX 1163, EAST DENNIS,MA 02641
M20-56 508-364-9048