HomeMy WebLinkAbout0035 ERIN LANE - Health .35 Erin lane
Hyannis P
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TOWN OF BARNSTABLE
t.LOCATION 35- SEWAGE # A 0/7
V.ti LAGE ASSESSOR'S MAP & LOTo7 -0f7'0oEr�
NAME&PHONE �.�� �` 77� 939g
SEPTIC TANK CAPACITY /Df� ��.�8� 1� ,/7e�t 3•OP�
LEACHING FACILITY: (ty ),_�C SJ Zle-, S�qQS (size)W13 14
1
NO.OF BEDROOMS
BUILDER OR OWNER
• PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Till
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='b TOWN OF BARNSTABLEV
LOCATION ?^ i l ca.-�-J SEWAGE ® l`-C> 7
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. _S C o 14
SEPTIC TANK CAPACITY X f�'� f000 L' .L
LEACHING FACILITY: (type) (-rLQ 4CL S'C , (size)77
NO OF-BEDROOMS (_!
`.-'BUrj.DER OR OWNER
-zpERMITDATE: 1 'I l l�C� f COMPLIANCE DATE:
;Separation Distance Between the: _
^. r
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility n� Feet
'-'Private Watei Supply'Well�and Leaching Facility (If any wells st'
on site or within 200 feet of leaching facility) Feet'� -
Edge of Wetland and Leaching Facility,(If any wetlands exist 1 A,
within 300feet of leaching facility) -l� Feet
1 Furnished by I
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-\ COMMONWEALTH.OF MASSACHUSETTS
EXECUTIVE OFFI%�P _FtNVl„ ONMENTAL AFFAIRS
JA
DEPARTMENT OF ENVIRONM- PVTAL PROTECTION
> 2005 MAY 18 AM 1? 34
• .�L�tu�S80tI r �el c,e,�. °1 �
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM
PART A
CERTIFICATION
Property Address:
Owner's Name: �
Owner's Address: ^ Ct./ZP. ie LP, 2li
Date of Inspection: k4lht ) ,
Name of Inspec please print)
>�+
Company.Nam
Mailing Address 7
Telephone Number: �;�)E2:7%
CERTIFICATION STATEMENT' '
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site:sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Vto Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F 'Is
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority_(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the repor to the appropriate regional office of the
DEP.The original should be sent to the'system owner and copies sent to the buyer, if applicable,and the approving
authority. /
Notes and Comments��
****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.
Title 5 Inspection Form 6/15/2000 page 1
tS
Page 2 of l I.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Proaertyj•A,ddress: &D, ..
Owner:
Date of Inspection:
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
15.3 03 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.
Answer yes,no or not determined(Y,NND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and.over20 years old* or the septic tank(whether metal ornot).•is structurally.
unsound, exhibits substantial infiltration.c 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:f it is structurally sound,not leaking and if a Certificate of Compliance
indicatinc,that the tank is less than 20 years old is available.
ND ex.plain:.
Observation of sewage backup or break out or high.static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will.pass inspection if(with.
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
disuibution box is leveled or replaced
ND explain:
The system required pumping.more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with.approval of the Board of Health):
broken pipe(s)are replaced
obstruction is.removed
ND explain:
2
Pace 3 of 1]
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continled)
Property Ad ress: t�
Owner: irpv iy�
Date of Inspection: Co
C. Further.Evaluation is/equired by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within;50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has aseptic tank and soil absorption.system (SAS)and the SAS is within.]00 feet of
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 aseptic 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 D---P certified laboratory, for coliforrrr
bacteria and volatile.organic compounds indicates that the well is free.from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other-
3
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Page 4 of I I
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property A dress: E�
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes N9
d/ Backup of sewage into facilit v or system component due to overloaded:or clogged SAS or cesspool Discharge or ponding.of effluent to the surface of the ground or surface waters due to an.overloaded or
clogged SAS or cesspool
Static liquid level in the distr''-bution 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 '/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ j 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and.the.presence of ammonia
nitrogen.and nitrate nitrogen is equal to or less than 5 ppm; provided that no other failure criteria
are.triggered. A copy of the analysis must be attached to this form.]
_' (Yes/No.)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15303,therefore the system fails. The system owner should contact the.Board of
Health-to determine what ME 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,:000t gpd to 15,000
gPd•
You must indicate either"yes" or"no"to each of the following:
(The following.criteria apply to large syst-zms.in addition to the criteria above)
yes . no
the system is:within 400 feet of a.surface drinking water supply
the system is within 200 feet.of a tributary to a surface,drinking water supply
— ! the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any ques;ibn 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.
4
Paee 5 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a . PART B`
CHECKLIST
Property A ess:
Owner:\
Date of Inspection: (�
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
-Yes o
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 ba_k up
Was the site inspected for signs of break out ? y
_ Were all system components, excluding the SAS, located on site ?
_�_ Were the septic tank manholes uncovered,opened, and the ir__erior 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 owne-)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes/no
Existing information. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related tj Part C is at issue approximation of distance
is unacceptable) [310 CMR 15302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Ad� .ess:
Owner: G
Date of Inspection:
'Flow CONDITIONS
RESIDENTIAL
Number of bedrooms(.design): Number of bedrooms (actuaC/
l):
DESIGN flow based on 310 C .203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have,a garbage grinder(yes or no):�—/6
Is laundry on a separate sewage system(-es or no)A16 .[if yes separate inspection.required]
Laundry system inspected(.y 's.or no):IX!0
Seasonal use: (yes or no.): y
Water meter readings, if av U ble(last 2 years usage(gpd)):01—hG 7�7� 0 5` 11-�j PO
Sump pump(yes or no):/t�U v
Last date of occupancy:P y � �
COMMERCIAL/INDUSTRIAL,4a
Type of establishment:
Design flow(based on 310 CMR 15.2(l3� gpd
Basis of design flow(seats/persons/sgft,e=c.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Uitlr 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records.
Source of information:
Was system.pumped as part.of the in nwcion(yes or no)
r
If yes;volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYP OF SYSTEM
_Septic tank, distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system (yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy"of the DEP approval
—.Other(describe): `
fA1 roximate age of all gompo ents, d e insta �d(if known and source of information.
671
Were sewage odors;detected when arriving at the site(yes or n1
6
Pa°e 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM.INFORMATION(cor_tinued)
Property Ad-dress:
%l.
Owner: U
Date of Inspection: p
BUILDING SEWER(locate on site plan),
Depth below:grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,'etc.):
SEPTIC TANK: (locate on site plan,)
Depth below trrade:
Material of construction: concrete metal_fiberglass_ _polyeth;?'ene
other(explain) i
If tank is metal list age:_ Is age confirmed by a Certificate of Complic-ice(yes or no):_(attach a copy of
certificate)
Dimensions: ' k '
Sludge depth: h�'�� ` I/
Distance from top of sludge to bottom of outlet tee or baffle: {J
Scum thickness: 5
Distance from top of scum to top of outlet tee or baffle: 2,
Distance from bottom of scum to bottom of outlet tee oX baffle:
How were dimensions determined: ;��j,(eiDl 4d, agaa x- y-,Mrn�
Comments(on pumping recommenVKtions, i let and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert, evid e of eakage, etc.): •A �� ,�j
!�
GREASE TRA 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART-C_.
SYSTEM INFORMATION(continued)
Property Ad ress:
,4
Owner:�az)�
Date of Inspection: r.
TIGHT or HOLDING TANK: stank must be pumped at time of inspection)(locate on:.site plan)
Depth below grade:
Material of construction: concrete metal fiberglass Polyethylene J other(explain);.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present.(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: V
Comments (condition of alarm and float switches, etc.):
S' tIBUTION BOX: if resynt must be o ened loci e on site plan)
DL TI ( P P )( P )
Depth of liquid level above outlet inv�t�6G
Comments (note if box is level and.distribution to out�qual,any evidence of solids carryover,any evidence of
akage into oz out of box,a .).
e
PUMP CHAMBE (locate on site plan)
Pumps in working order(yes or no): r
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property ress:37 >
Owner
Date of Inspection: a(, 5: %
SOIL ABSORPTION SYSTEM (SAS):" (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
I aching chambers,number:
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 pon3ing, damp soil, condition of vegetation,
etc.):
E 1
6—
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CESSPOOL�,w(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 or no): n.,.
Comments(note condition-of soil,signs of hydraulic failure, level of porrding, condition of vegetation,etc.):
PRIV .(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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.A dr.ess:: Lam„
Owner- , d, A I
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM.
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benclunarks. Locate all wells within --0)feet.Locate where public water supply enters the building.
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Page 1 1 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property A.d ress: 1 �
P Y ,..
lfllw
Owner:
Date of Inspection: _ w O
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated.depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:.
Observed site(abutting property/observation hole within 150.feet-of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I
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. I1
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: �✓J� �✓d� G�j , C��7/�%S Lot No.
Owner. Address: �/ r
Contractor: O/ t�A/ Address:
Notes: ✓��/S���IS �/%��5
STEP.1 Measure depth to water table
to.nearest 1/10 ft.
....................
.......... .......................... ................. .Date
r
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map IDcatein
site and determine:
OAppropriate index well...................................../T
BJ Water-level range _one ...........................................:.........
'i
STEP 3 Using monthly report 'Current
Water Resources..Cond tions
determine current depth to
water level for index »III ...........................
Mdnth/yea
STEP 4 Using Table of Water- Evel Adjustments r r
for index well (STEP 2A), current depth
to water level for index.well (STEP 3),
and water-level zone (STEP 2B)
determine water-level.adjustment ............:............:.
...................................................
STEP 5 Estimate depth to high water ;
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ...........................:........................................................... :
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Figufe 13.--Reproducible computation form. `
y fig x�`
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No. Z6e(F 0 l7 Fee
computer:
THE COMMONWEALTH OF MASSACHUSETTS Entered in com p
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[ppfication for Mi5po.5al *pZtem Congtruction Permit
Application for a Permit to Construct( )Repair(&/)Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No.�� \ ,� L( Owner's Name, ddress and Tel o.
LA t `\� Cich/O.
Assessor's Map/P cel �� �'� 5d—fir,. 2vA �° 1)V 1140
Installer's Name,Addre s,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
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 '6 v Type of S.A.S.
Description of Soil
uw
Nature of Repairs Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue. y this Bqaro of l
Signed Date I �►
Application Approved by Date 1Z11ZLj
Application Disapproved for the following reasons
Permit No. SOU 1 - 0 17 Date Issued17-117al
------------------------- ----------------
No. 7� G /
�
W C/ /— 0/7 Fee ✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE;.•MASSACHUSETTS Yes
:- ZippYication for Migpogar *pgtem Congtruction Permit
Application for a Permit to`Construct( )Repair( 4pgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 C 1 L Owner's Name,Address and Tel.. o. x
Assessor's Map/P I �� V'(�l—L+�'(v C(n,.? C- V
Installer's Name,Add re and Tel.No. 1V`C, S` Designer's Name,Address and Tel.No.
Sc v� M r VC, d '7 T
C.Vtll,t ^^C•
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
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 _ `1 /6,0 U Type of S.A.S.
Description of Soil
aA�-TJ Lk uv, W
i
Nature of Repairs oar Alterations(Answer when applicable) .J��C Z3 0 C I'D S{J1..4 13 F_-
NDate 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 of
Signed Date 116
Application Approvedby`+ Date / /i o
Application Disapproved for the following reasons
t
Permit No. s47) I - 0 7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of QConmpriance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( Vj Upgraded( )
Abandoned( )by Z l31 �k I rLe-SC
at L v., ,\ ( S has been constructed i accordance
with the provisions of Title 5 and the for D spgsal System Construction Permit No.-UV/- l/ 7 dated / /I ?.!v
Installer C �'^-tn/`V Designer
The issuance of this perc�tit/s hall not be construed as a guarantee that the s st " will e ' has desig. d.
Date / �� d Inspector
No. c/"�' �G�7 .--------------------------Fee
IZC11-017-06F THE COMMONWEALTH OF MASSACHUSETTS
.PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1=i5poga1 *pgtem Congtruction Vertu
Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( )
System located at A
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 in st be completed within three years of the date of this a it.
Date: Approved by
TOWN OF BARNSTABLE
LOCATION
l c.,r.•� =' 4 SEWAGE`#o�C'�'/-Ci 7
VII LAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE N C ��G
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) c j�Cy l �C� S �
(size) (o re C
NO. OF BEDROOMS_
BUILDER OR OWNER ><
PERMITDATE: 11 1 I. C G f COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility. (If any wells exist ,
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) �� Feet
Furnished by .
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1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, �` _A/\AL, hereby certify that the application for disposal works
construction permit signed by me dated 9�4 J d , concerning the
property located at C k �. �.yv..�', %L��14 meets all of the
following criteria:
This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
•/There are no wetlands within 100 feet of the proposed septic system
•There are no private wells within 150 feet of the proposed septic system
1Fhere is no increase in flow and/or change in use proposed
• There are no variances requested or needed.,
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) o _
B) G.W. Elevatioq—,A). +the MAX. High G.W. Adjustment J f
DIFFERENCE BETWEEN A and B
SIGNED : DATE: 1 o
[Please Sket6i proposed plan of system on back].
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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LO CATION SEWAGE PERMIT NO.
/:�o T 83 -.977
VjILLACE
I N S T A LEIt's NAME i ADDRESS
® UILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 171�
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
®5?'�...................OF.... �G ..................................
zz Appliratilan for Dispas al Works Tomitrnrtion ramit
J5 Application is hereby made for a Permit to Construct ( "-�or Repair ( ) an Individual Sewage Disposal
System at:
.----- S................. .....•------....----------.............-•-�---•--...........................
�/n Location-Add res or Lot No. , .
LiJCI .. rs jr-.................. �'GMyS ...... ........: CC...... ...+r�C_.......- J!•�K ii f.a�........._......
Ow Address
................. ...... .A ... � :..... --- tom: ,-K.. :.----- _ I...................
y�Installer Address
Type of Building Size Lot-.!,R.RV...._......Sq. feet
U Dwelling—No. of Bedrooms.................Z :.....................Expansion Attic F- ) Garbage Grinder
Other—T e of Building ........ No. of persons...........:................ Showers — Cafeteria
Q' Other fixtures ............................
W Design Flow..............h --------.------------gallons per person per day. Total daily flow............���:..............._..gallons.
WSeptic Tank—Liquid capacity./tow w..gallons Length................ Width................ Diameter...-..--.--_._-- Depth................
x Disposal Trench—No. .................... Width...........--------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit....--.............. Depth to ground water........................
GTq Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water--------................
P+ •-•-----•-----------•-------•--•--•---------••-------•---------------------------•••-.........--••-....._......---•---..._....------------..._...•-----------
ODescription of Soil........................•---------..............--------------------------------------------------------------------•---------------------------•-------...........----
V --------•------•------------••-----•--.....---•------------------------------------------•------•--•----------•--------------•-------•--•-------•----.........-•---•-----•-----•------•-------•----•----
-------------------- ---------------------------------------------------------------------------------•-------------------------------------------------------------...-----•--•----•...---•----•....I
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in.
operation until a Certificate of Compliance has en is by t e bo d of health.
Sine ... . .. ..... -------------- �`�
Application Approved BY ---------------•-----......_...... /0-.-'..-----�-•----------.
Date
Application Disapproved for the f ollo ing asons----------------------------••--------------------••------•--------------------------.........------•-----------.
•--•---••-•...........................•----------••--•••-----------------••------....._..--•--------•--•-'-----•---------•---•-•-----------•--------•--•--------••-•--•---•-----....- ----•-------
Date
PermitNo......................................................... Issued.......................................................
Date
T
No...... J Fss...61jo.............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..��_ .��...............OF.-... �^�f
Appliratiou for Uiip:as al Works Tomitrurtiuu rmuff
Application is hereby made for a Permit to Construct ( 4-15r Repair ( ) an Individual Sewage Disposal
System at:
......^�..... L......•��.... ��_�Mef:�..-�E�� - -------•--.......�-------------------•--...------................---•
Location r�ess� / •.w o L�•oott No.
!r 1.....1 KZ S._...---- Ea....® ;t, .... ..... _._.. _ ._.....
U a wner
Address
! ...e.t...
•................� ..--- ---...---•••......---•••--• � ��?�
Installer Address
dType of Building Size Lot....JL.V.le........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (--) Garbage Grinder ( )
Other—T, e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures ..................................
W Design Flow...............11A......................gallons per person per day. Total daily flow........X.!- 0....................__gallons.
WSeptic Tank—Liquid'capacity-��-gallons Length................ Width................ Diameter................ ......gallons.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.............................................................•.......•..... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes_per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------••------------------....-------•----------------------------........------..........._....---••----......--------...-----------.....-----
0 Description of Soil.............................................................................................................................-..........................................
x
-----------------•------------------------------•--------------------------------------........--------------------------------------------------------------------------------•--....---•--...--.•-----
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
---------------------------•--------------------•-•-----------•-------------------•---•---------•-----••--•-----------------------------------------------------------------•-••--•----......----.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of IT:S,i�. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issu e-d by t1ke bo• d of health.
Signed. • •• ..... . .. ..-- ---.....--•-- ... ..._....
Application Approved By......................... - j-�
= .............-•-----------•---••-----......--------------------- =- - J-------------
Date
Application Disapproved for the foll ing asons-................................................................................................................
....•-----------------------------------------•-....----........-••----•-•-----•-•----•--------•------....__...-••-----------------•-•-------------------------------•--••---•---•----------•--..........
Date
PermitNo......................................................... Issued_..................- te.------...----•---------•--••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD+— OF�.HEALTH
.......j..?'':?.?:-t-...................OF:: ^g-` 'r. ......................................
dw
Tntifiratr of f ompliFaurr
THIS IS TO CER��...........
, hat thy, Individ al Sewage Disposal System constructed ( — r Repaired ( )
by-------------------•------.-..... ......• .......................................................................................................
.---------------------......----------•----...----•--------------•--.....-•-•---•-•-•--•------•-----.....--...
Installer
at . ...............................
has been installed in accordance with the provisions of 'IT , LE 5 of The State Sanitary Code escribed in the
application for Disposal Works Construction Permit No.. .3_"_ . ............. dated__ ... ._ -----:__--__-._-_-.-----.
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® S A GUA ANTEE THAT THE
SYSTEM WILL U TION SATISFACTORY.
DATE............. - �................................................... Inspector.........-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEAL H
`p-ua OF.. �.'�
..........................
No....4 °........ FEE...-•.. ............
�i��rrr�ttl/�' rk� �uu��r Uaac rrutit
Permission is hereby granted..........l�'-!-G.-------- ---••-- ... �K 4e�<' ..-•.......................................................
to Construct ( t),-or`Repair ( ) an Individual SUage Disposal System
atNo........................................................................................................................................... -- . .-----_- ......
Street
as shown on the application for Disposal Works Construction Permit No..___. -" .:�' ated_;� __ ._ :............
...........................•� ------. . ..........................................................
oard f oard of Health
/
DATE---.......�:..1. ......................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
SOIL LOG
N0. 1 0 NO. 2
R. --
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* i+4 rs l ANC
SITE PLAN
2 F
I—
',r a' L1Atg�
TOP OF FOUNDATION El.: -lao 'hs�uN
6 -
• JA1C Cc7Yt K r� DIP, v[Jh�r 5�dr`CE
e
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g
IN.EL. q7 '� z:a r _ �5S 10
e , a e , ,. ..
% IN.EI �� lN.EI _._ E1. 97 2' COVER 3 8 WASHED - 11
,•
r ...
ee -
- r--= .- -_ a' • •ti. - - 1/8 SHED STONE �'„r
12
D/B W/ 6 SUMP IN E L 96,L �e�c; ,� �• " -= 3/4 1 1/2 WASHED STONE — 13
• 4 ll UID LEVEL • °
Q � a, • ^ , 14
o I �
6"EfF. DEPTHi'w .� � a "
• �� c � ��' •`� I 1 PERC TEST RESULTS
PRECAST SEPTIC TANK WITH PRECAST LEACHING PITS P E R C RATE : __x- .rV,l„�_ ,=� _._—__
I CAST IN PLACE INLET AND °� °o
�. ° NO.: _1 _ SIZE : _ '_rtA WHITNESSED BY: � ______._
-- °"
EL. '
' OUTLET T 'S PER TITLE Y , - BOARD OF HEALTH
SIZE : a ZG '16 I xs '8' HV>>; DIA . DATE : _ ----
` 1�vb G��u 1 t•�S ..
E .ln
L rt
PROFILE OF PROPOSED SEWAGE SYSTEM ' `�`` , iz'
SYSTEM DESIGNED BY THE TOWN Of _ _ ��. _�°= _ __- — REGULATIONS AND
SYS M _ _ _
STATE TITLE Y FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4"= 1 ' 0 " % -° L=%;►K ` '
i
N . B .
1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE
2. ALL PIPES SHALL BE SLOPED 1/4 " PER FOOT EXCEPT FOR
THE FIRST 2 FEET OUT OF THE O / B WHICH SHALL BE LEVEL� C HAL
3. DESIGN FLOW _2.— BEDROOMS AT 110 GALDAY PER BR . GAL/DAY
SEPTIC TANK SIZE -z-a� X '.s = ?? GAL.
USE i000 GAL. W/ou- GARBAGE DISPOSAL
LEACHING SYSTEM: USE E F P bFF 71H
.-• , � -� -, ti� ��r.. Jain, '�"�F��c..r,.'A.�.. � t,-,`T�......w_. _ . ._.._.........�.,..�....-..__._ _ _...._._ .._ .
EFFECTIVE AREA : SIDE ,- x Sx �.� 3 �V's -' "-- c �- - ► a _ FL �-
E BOTTOM k1,L) r
TOTAL FLOW __-___
TOTAL REQ'D FLOW X GARBAGE DISPOSAL
RESERVE FLOW ___ _._=__I44 GAL/DAY _
REFERENCE PLANS : _ c ��.,�-, _, � ---------- _----
APPROVED B
BOARD OF HEALTH
DATE :PROPERTY OWNER : _ __ _ _ ______ SITE AND SEWAGE PLAN
FOR - .21N 57 RA) i
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