HomeMy WebLinkAbout0073 FOURTH AVENUE (HYANNIS) - Health '�7r3 ]�ourth�A�en=ue'
Hyannis
A 246
I
i
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TOWN OF BARNSTABLE
LOCATION �>& SEWAGE#
VILLAGE /fXi-r,w:`otr-'OP*ICT ASSESSOR'S MAP&PARCEL X00'3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ;;M-e,0-CX" 0'e 500& (size)
NO.OF BEDROOMS
OWNER �'PrPf^' r
PERMIT DATE: ��'� 0 COMPLIANCE DATE: J ! 3
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
\ � � QO
V.
ONN
r
$►
\ c
U _ 13X o� 0
NO. FCC /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t✓
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Mi!6po5at �&p!gtem ConOtruction Permit
Application for a Permit to Construct.( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. U�_._ Owner's Name,Address,and Tel.No.
azi
Assessor's Map/Parcel , a4l .
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7 014
Type of Building: T
'Dwelling No.of Bedrooms � SLnot ize • sq. ft. Garbage Grinder ( )`
Other Type of Building I-e-?elp No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank flier!- /f row Type of S.A.S.7W eW'C-le 04X1'
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Raard of Health.
Signed Date
Application Approved by Date -/0
Application Disapproved by: Date
for the following reasons 7
Permit No. 2-U o^ (l Date Issued S "to
No. ^:Qlfl — 3�
Fee
THE COMMONWEALTH OF IVIArSSACHUSETTS Entered;yin computer. ✓ '`;?,
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4 gicatiDD� fOT.. i$ lOgaYr�p�tell� Con0truction Verm"it io
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) .Complete System ❑Individual Components
Location Address or Lot No.7oG ���T77 � Owner's����e�and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
��� G��vc�Gi� 77J' o�0 7 ��li/� 8/�1�4��✓ � f'� -.�
•%ra
j Type of Building: ,
{ Dwelling No.of Bedrooms Lot qize sq. ft. Garbage Grinder
Other Type of Building �Gtl' e No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
L Plan Date Number of sheets Revision Date
Title
Size of Septic Tank JiGtle- Type of S.A.S. 73ee�ti
.t
Description of Soil
Nature of Repairs or 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 Certificate of
Compliance has been issued by this B rd of Health.
Signed Date `
Application Approved by iVr. Date 0
Application Disapproved by: Date
for the following reasons
Permit.No. 9�U 0 — (> 2` Date Issued S'I; —(0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (fompliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( )by dr�/ W G ee�O�`r/�" '
at �-� �'o1-a !/L� has been constructed in accordance /
t with the provisions of Title 5 and the for Disposal System Construction Permit No. 1010 -( � dates-L —d o
Installer '�i�1�' �n��O�G 1 Designer
#bedrooms o� hCee r4j r°� t Approved design flow �U gpd
The issuance of this pe it shall not be construed as a guarantee that the system wi111�`u ctibft as desi ned.
Date S 1 /oInspector uW
-
No. Il/o—132, Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
=i5po.5al �&p5tem Con5truction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade) Abandon ( )
I
System located at
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: Cons ct•on must be completed within three years of the date of th pe
Date S o Approved by s�S�
tq Z&`droom �4r?. c o w•,/l k /SIoqr/ X_
Town of Barnstable'
y� . tip Regulatory Services
Thous F.Geiler,Director
" a Public Health Division
C7,,lFD � Thomas McKean,Director
200 Fain Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date:
Designer: �►gV Installer: J 1 i
Address: . Address: 1�
On was issued a permit to install a
(date) (installer)
septic system at 7� r ""���I based on a design drawn lay
(address)
l V I
17. datedOt
(designer)
1-certify that the septic system referenced above was installed substantially according'to
"'Elie design, which may include minor approved changes such as lateral.ielocatiort of the
di;strrbution box and/or septic tank. .
I certify ythat the septic system referenced above was installed with' najoz:changes (j.;e,
greater fliaA 10' lateral relocation of the SAS or-any vertical. eiooatioil of arty componaut
of the.septir system)but in accordance with State&IgcARegdiat ons. Plan revis ozk of
certified as-biii�designer to'follow. J."
Vr1
z 61AVID. .
(Installer's Signature) � - a• n
>. WSW 'rn
110::"66
�e�ST�A�
. . . �Sq�17Aa�P�•
(I3 er s Signature) (� X e: er''s,Staanp Here)
PLEASE RETURN TO BABNSTABLE''PUBLIC_Y EALTH.DIVISION , C RTIFIC TE
OF- C2WLIANCE WILLS`NO jiE SSUED_ =BOTH1-TJHS,,FORM
BU)<L.T CARD ARE RECEIVED BYiTIIE:RAR SLTABLL PUBLIC IEAL IaIV SIld_�
TANK YOU
Q:14ealth/Septic/Designer Certificafi -* 'Fora , 3.
TRANS.NO.:
CITY/TOWN:
APPLICANT:
ADDRESS: r-i5 Ua7W A 09-
DESIGN)FLOW: gpd
REVIEWED BY: DATE:
N/A OK NO
GENERAL
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street,Lot,tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)]
Locus Provided 310 CMR-15.2204 t
Plan proper scale?(1"=40' for plot plans, 1"=20'or fewer for /
components) 310 CMR 15.220(4)] ✓
Easements shown 310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- if not, a variance is required 310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas etc.)
310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR /
15.220(4)(c)]
Location and dimensions of system components and reserve /
areas. 310 CMR 15.220(4 e ✓
System Calculations 310 CMR 15.220 4
daily flow
septic tank capacity (required andprovided)
soil absorption system(required andprovided)
whether system designed for garbage grinder
North arrow 310 CMR 15.220 4
Existing and ro osed contours 310 CMR 15.220(4)(g)]
Location and log of deep observation holes(existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH'representative [310 CMR
15.220 4 h and i
Location and date of percolation tests(performed at proper
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 310 CMR 15.242
Certification statement by Soil Evaluator 310 CMR 15.220(4)0)]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3)'and 310 CMR
15.220(4)(n)]
Address 41�' ffi2o--q )ky& Sheet 1 of 7
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220(4)(k)]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. 310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220 4 m if water line cross see 310 CMR 15.211 1 1
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR 15.220(4)(o)]
Stamp of designer 310 CMR 15.220(1)and 310 CMR 15.220(2)
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate(two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2)or as
approved for an upgrade under LUA at 310 CMR 15.405 1 k
Test hole adequate to demonstrate four feet of suitable material? /
310 CMR 15.103(4)] ✓
Test Holes adequate to confirm adequate groundwater separation?
310 CMR 15.103(3)]
Benchmark within 50-75' of system [310 CMR 15.220(4)( ]
Materials specifications noted? [various sections of 310 CMR
15.000
System components not>36" deep(unless Local Upgrade
,Approval or LUA requested) 310 CMR 15.405(1(b)]
Address 7 ' "V ejq( iw& Sheet 2 of 7
N/A OK NO
SEPTIC TANK
Size OK? [310 CMR 15.223(1)
Inlet tee located ten inches below flow line 310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)]
Note regarding installation on stable compacted base [310 CMR /
15.228(l)] v
Separation between inlet and outlet tees(no less than liquid
depth) 310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater A
(except as described 310 CMR 15.227(5))or permitted for V/
upgrades under LUA [310 CMR 15.40 5 1 k ]
Minimum cover 9" (Tanks buried more than 9" must have risers /
on all openings and on the d-box) [310 CMR 15.2228(1)and 310 V/
CMR 15.232 3
Three access covers(inlet and outlet must be 20" or greater)-
middle access at least 8" (by 7/07) [310 CMR 15.228(2)] ow
Access to within 6 " of grade -one port for systems<1000gpd,
two fors stems >1000 gpd 310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)]
> 10 ft from building foundation 310 CMR 15.211 1
Buoyancy calculation Required/Done 310 CMR 15.221(8)]
H-20 Where appropriate? 310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
Multi-Compartment Tanks
Required when other than single-family dwelling or flow>1000
d 310 CMR 15.223 1 b
First compartment 200% daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2) and 3
"U" pipe through or over baffle,outlet of each compartment with
gas baffle or approved filter 310 CMR 15.224(4)]
Address" r yu� T l�"� Sheet 3 of 7
N/A OK NO
BUILDING SEWER AND OTHER PIPING
Located at least ten feet from any water line? [310 CMR
15.222(2)]
Disposal piping at least 18" below water line(when water and
sewer cross, see 310 CMR 15.211 1 1
Cleanouts required/provided? 310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9)and 310 CMR 15.252(2)(c)]
Siphonproblem/ leachfield below pump chamber
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310
CMR 15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed
DISTRIBUTION BOX
Stable compacted base [310 CMR 15.221(2)and 310 CMR
15.232(2)(a)]
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)]
Riser if deeper than 9" [310 CMR 15.232(3)(f)]
Inside minimum dimension 12" 310 CMR 15.232(2)(b)
Minimum sum 6" 310 CMR15.232 3 e
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 1-5.232(3)(d)]
PUMP CHAIMBERS
Capacity (emergency storage above working=design flow)? [310
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE 310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible
Alarm floats- alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. 310 CMR 15.231(6)and 8
Stable Compacted Base 310 CMR 15.221(2)]
Buoyancy calculations needded� ?1Provided? 310 CMR 15.221(8)]
Address 1 ) �V�—�'rl +�� Sheet 4 of 7
r
N/A OK NO
SOIL ABSORPTION SYSTEMS (SAS)GENERAL
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240 1
Required separation to groundwater? [310 CMR 15.212)]
Aggregatespecified as double washed [310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) 310 CMR 15.241
Inspection ports specified and within 3"final grade? [310 CMR
15.240 13
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
GALLERIES,PITS,CHAMBERS 310 CMR 15.253
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. 310 CMR 15.253(6)] V
Each structure with one inspection manhole(if>2000 gpd must
be tograde) 310 CMR 15.253(2)]
Aggregate 1'minimum-4'maximum. 310 CMR 15.253 1 b
2'sidewall credit maximum 310 CMR 15.253 1 a
In bed configuration, inlet every 40 s . ft. 310 CMR 15.253(6)]
TRENCHES 310 CMR 15.251
Width 2' minimum 3'maximum 310 CMR 15.251(1)(b)]
100 feet-maximum length 310 CMR 15.251 1 a
Minimum separation 2x effective depth or width whichever
greater 3x if reserve between trenches 310 CMR 251(1)(d)]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? 310 CMR 15.211(1) 4 and Guidance Document]
BED SAS(Maximum size of bed or field 5000 d)
minimum 2 distribution lines 310 CMR 15.252(2)(a)]
Maximum separation between lines 6' 310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. [310 CMR 15.252(2)(g)]
Separation between beds 10'minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only 310 CMR 15.252 2 i
U�
Address �� � � P l�� Sheet 5 of 7
N/A OK NO
DID THE PLAIN Ili TVOLVE
Pressure Dosed System ? Provided pump and piping
calculations as required 310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2)and I/A /
Remedial Use Approvals]
J/
If used in gravelless system-make sure jet is directed as not to
scour soil interface Guidance Document
Inspections once per year(systems<2000 gpd)or quarterly
>2000 dgood to note on plan 310 CMR 15.254(2)(d)]
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255 3 ?
Impervious barrier and/or reta ining wall? Guidance Document
Impervious barrier installation must be supervised by
designer 310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer[310 CMR 15.255 2)(a)]
Side slope not exceed 3:1 ? [310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2)and
Guidance Document
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 2 e
Gravelless System[FA Approval Letters]
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
Alternative Septic System[FA Approval Letters]
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual? '
Has applicant submitted a copy of a maintenance
Variances
Are the variances listed on the plan? [310 CMR 15.220
4
RLS Stamp necessary on plan if a component is within five
feet of property line 310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414
Address l f�U�' r t�/�/ Sheet 6 of 7
N/A OK NO
Nitrogen Sensitive Areas
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 -also refer to Policy�regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well?
310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CMR
15.216 1
Miscellaneous
Pumping to septic tank? 310 CMR 15.229
Shared System 310 CMR 15.290] EE E
Address✓ �� Sheet 7 of 7
t .
Town of Barnstable -P#
Departmenf of Regulatory Services
wttvareet e \ a( D
Public Health, Hate
r6sq �e� 200 Main Street,Hyannis MA 02601 0
Date Scheduled aba Time Eee Pd.- o d
Soil Suitability Asses ent for Sewage isposal
Performed By-r �r "`� t��� p
Witnessed By: d n
IV
I:O:CATI6N & GENERAL.IN C RW ' O:1N
Location.Address 73 /I 4e- Owner's Name 01A,6,
�hh�7f
Address
Assessor's Map/Parcel: n�� ,� Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,din ensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Parent material(geologic) Depth to Bedrock 100
Depth to Groundwater: Standing Water in Hole: V Weeping from Pit Paco V-4 14
Estimated Seasonal High Groundwater
DETERM NATION OR SEASONAL RICH�WAT.��TA���::
Method Used:
Depth Observed standing in obs.hole: in. Depth to Boll mottles: In,
Depth to weeping from side of obs.hole: In. Groundwater Adjustment ft•
Index Well# Reading Date: Index Well level Adj.factor Adj,Croundwater Level
iC ,Ar ;aN: cTtij e
Observation
• Hole# Time at 9"
Depth of Peic Time at 6"
Start Pre-soak Time @ Z/�� Time(9"6")
- End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\SEPTIC\PERCFORM.DQC
DEEP OBSERVATION HOLER LOG
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) Soil Other
(USDA) (Mansell) Mottling (Structure,Stones,Boulders.
AD Q3 '7 Consistency,%Gravel
(�
G
AL
o
DEEP�OROJ VATTON II3'OLE':L'OG 1. FTo1e# "
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) Soil Other_
(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
i
onsistenc %Gravel
ZH
l i
0EEP`,00SERVAT1rON HOLK.L OG'
Depth from Soil Horizon• Soil Texture Soil Color Soil Other
Surface(in.) (USDA)
(Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
' � t
I ,
DEEP'O$SERVATION HOLE:LOG :Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.)
(USDA.) (Munsell) Mottling (Structure,Stones,Boulders.
onsiste Gravel)
Flood Insurance Rate Mal):
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes._
Within 100 year flood boundary No-Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? � �•
If not,what is the depth of natur lly occurring per 'ous materia17-.M'Z:"'
Certification
I certify that on I2 (date)I have passed the soil evaluator examination approved by the
Department of Envir6nmental Protection and that the above.analysis was performed by me consistent with
the required training,ex ertise an xperierice described in 310 CMR 15.017.
,t 7
Sign J Date ��G��d
Q:\SEPTIC\PERCFORM.DOC
I
°F1KE r�
Town of Barnstable Barnstable
0ftti
Regulatory Services Department 1�111
ficaCitv
BA.BNS[•ABLE. `
MASS.9. Public Health Division
'Tfv MP+n 200 Main Street, Hyannis .MA 02601 2007
Office: 508-862-4.644 "fhomas F.Geder,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205009328
4/27/2010
Martha Chapin
55 Indian Meadow Road
Middleboro, MA 02346
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 73 Fourth Avenue, Hyannis MA was last inspected on
March 29, 2010, by Mark Polselli, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE B ARD OF HEALTH
o as c ean, R.S., CHO
Agent of the Board of Health
t
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address// �/J�✓' ��� l.��tG �
Owner Owner's Name n
information is N h �j4 oc�6 0/ T ` /0
required for �f State Zip Code Date of Inspection
every page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your
cursor-do not Name of Inspector
use the return
key.
Company Name
OIL
Company Address —
(���amj♦/�� �Gs ��� � i� Oo16�l
� City/Town State Zip Code
72 s— 2� y� a
Telephone N er License Number
i
B. Certification
W I certify that I have personally inspected the sewage disposal system at this address and that the
cc r-a inforritation reported below is true, accurate and complete as of the time of the inspection. The inspection
o- - was performed based on my training and experience in the proper function and maintenance of on site
y' sewage disposal systems. I am a DEP approved system.!nspector pursuant to Section 15.340 of
Title�5(310 CMR 15.000). The system:
� CI-4
o Q..,. ❑aPasses ❑ Conditionally Passes Fails
o 0'Needs Further Evaluation by the Local Approving Authority
Inspec is Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to-the appropriate regional office of the DEP. The original should be sent to the system owner
a
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
. � 1 17
15ins•09/08 Title 5 Official Inspection Form:Subsurface4—goisSystem•1.teOof
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
73 F Gf r441 �y
Property Address �j
Owner Owners Name
information is pqh If Od 601 3—0? W
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
i
Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 17
l5ins-09/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�J Fo W
Property Address
Owner Owner's Name
information is /,�
required for ,
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below):
I
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
Required b
C) Further Evaluation is y the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
I
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is a N h,f / Od CIO I
required for State Zip Code Date of In
every page. City/Town
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes /No
,�/ ❑ Backup of sewage into facility or system component due to overloaded or
uuu clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
❑ /. or clogged SAS or cesspool
❑ �,/ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Yz day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name /q-
information is �!%/ 60
A?
required for N 6S
every page. City/Town state Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Q/ 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.
❑ [Er""— Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 0/ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ L Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
/ 10,000gpd.
[t—]'/❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered 'yes" to any question in Section E the system is considered a significant threat,
or answered "yes In Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address '
Owner Owner's Name _
information is A�
�N�fl /%� �Z�� � �9 ��
required for State Zip Code Date of Inspection
every page. Cityfrown
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ � Pumping information was provided by the owner, occupant, or Board of Health
❑ []� Were any of the system components pumped out in the previous two weeks?
L�J ❑ 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
U this inspection?
❑ ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
0/❑ Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
�0 Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
,--, Was the facility owner(and occupants if different from owner)provided with
Ly' t J 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:
❑ �xisting information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
33v
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is �� 6o
required for State Zip Code Date of Inspection
every page. CityfTown 4�
D. System Information
Description: 1000 C-1 //0 41c--
x
Number of current residents: �,�
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes [Z� o
Laundry system inspected? ❑ Yes ❑ilk
Seasonal use? ❑ Yes
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes I� rvo
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No ` l
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner %Ownef's Name
information is
required for h
every page. /Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
t
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of Sy
Septic tank, d'
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
} ❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
i
15ins•OV08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4
73 F 4 C
Property Address C44
Owner Owner's Name information is /�/ Q
a �'f ' / n�� as . 9
required for
every page. City To`nm State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date i stalled (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes 0,440
Building Sewer(locate on site plan):
/O
Depth below grade: feet
Material of construction:
ast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan): J
Depth below grade: feet
Material of fiction:
oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
I
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: X
L/
Sludge depth:
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
6
l/lG 1
Owner owner's Name 11
information is ��N �f t 9 ' �a
required for State " Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Septic Tank (cont.) 31
Distance from top of sludge to bottom of outlet tee or baffle /
Scum thickness
el
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
h V4'7/7.?91- 4 �.T �f V-7
o 4 . S
�Q1'9 /e rg Gc
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form
/-Not for Voluntary Assessments
/J 0
Property Address
Owner Owner's Name
information is G OP GO Z.
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
I
Dimensions:
Capacity: gallons
i
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
c4a
Owner Owner's Name f I - 1 Q
information is -J a N N �j u- 4 ( 6 o/ 3 C)required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
s 93
i OUY7
Property Address
Owner !Owner's Name
information is a, �L_
required for te Sta Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
I
Type:
❑ leaching pits number:
❑ leaching 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 ponding, damp soil, condition of
vegetation, etc.):
�i
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of.liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
FOC4 V-
Property Address I
Owner Owner's Name
information is11L�C4 14 ki tS Od L o
required for
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form Not for Voluntary Assessments
3 Fo y r A
Property Address //--
Owner Owners Name
information is �Co
required for h f r �—�—
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where ublic water supply enters the building. Check one of the boxes below:
I
hand-sketch in the area below
❑ drawing attached separately
3
C01
6d- Lt
l5ins-04r0e Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Ile
Property Address
C-1" -1y 1 P7
Owner Owner's Name
information is o/ —7 o?.9—A?
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
I
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ 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 descr how you eAtablished the high ground water elevation:
//
o � "51
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9,3 FoL,11-1 �
Property Address
Owner Owner's Name � / _
information is !/ ,g S /' "� 0� �
required for
State Zip Code Date of Inspection
every page. Cityrrown
E. Report Completeness Checklist
inspection Summary: A, B, C, D, or E checked
inspection Summary D (System Failure Criteria Applicable to All Systems)completed
[System Information— Estimated depth to high groundwater
ZK/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
15ins•09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ek 24537 P:u289 a22558
05-10-21DIO Q 09 = 13u
DEED RESTRICTION
Be it known that The State Environmental Code Title V 310 CMR 15.000
Minimum Requirement for the Subsurface Disposal of Sanitary Sewage and
the Town of Barnstable Board of Health deems the following:
Due to septic design restrictions it is allowed that the system be designed to
accommodate the existing two (2) bedrooms (as defined by Title V) in the
house at the property, but notice to all that the number of bedrooms shall
never exceed two (2)bedrooms since the septic system is not designed to
accommodate greater than two bedrooms.
for the property located at 73 Fourth Ave, Hyannis Mass as shown on Town
of Barnstable MagR 246, Parcel 113 with said property being referenced in
the Barnstable County Registry of Deeds under Book 23977 and Page 339.
Whereas,_JAdkft A as the owner of said lot has
agreed with the Town of Barnstable Board of Health to a restriction as to the
number of bedroom's as a pre-condition to obtaining a Disposal Works
Construction Permit in compliance with the State Environmental Code Title
V.
Executed as a sealed instrument on the cPO day of
l 20 Id
Owners Signature;_ ,
Maw-N A Cyl!j� r)
Commonwealth of Massachusetts
,ss
.2010
Then personally appeared the above-named known
to me to be the person who executed the foregoing instrument and acknowledged the
same to be free act and deed,before me.
Notary Public
My Commission Expires:
BARNSTABLE REGISTRY OF DEEDS
ASSESSORS MAP : 7�"23-!!' _..__ _._ _...._. .,_._v�........._ ..__._.. _.._ ;, _-._..: TEST HOLE LOGS NOTES:
PARCEL:
SOIL EVALUATOR:
I
FLOOD ZONE: /�:d'11.�%� /� _ __ ..__.,._ v_. W i TNESS : IPSI� 1) The installation shall comply with Title V and Town of Barnstable Board of
Health Regulations.
REFERENCE: DATE:�- �
PERCOLATION RAT : �- , 1�`i l 2) The installer shall verify the location of utilities, sewer inverts and septic
• components prior to installation and setting base elevations.
hll�t('�g,o� ._ . 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.The first
TH- 1 TH-2 two feet out of the d-box to the leaching shall be level.
L( 1 ,0 64AW 4) This plan is not to be utilized for property line determination nor any other ll purpose other than the proposed system installation.
3 5 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
7) The property is bounded by property corners and property lines.
LOCATION MAP 8) The property owner shall review design considerations to approve of total
design flow and number of bedrooms to be considered for design. Receipt
l / I of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
tp per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
Title V specs.
10)System components to be 10 feet from waterline. Sewer lines crossing the
water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
1 w q-......7 ' `r �- --- applicable. The proposed SAS is being installed below the water service
SEPTIC SYSTEM DESIGN line. The line is to be sleeved as aforementioned and maintained in place.
1 l) If a garbage grinder exists it is to be removed and is the responsibility of the
FLOW` ESTIMATE owner to ensure such.
12)The installer is to take caution in excavation around the gas line if such
2 BEDROOMS AT GAL/DAY/BEDROOM •�Z7�GAL/DAY exists.
13)The installer shall verify the location, quantity and elevation of the sewer
�--- - -"` SEPTIC TANK lines exiting the dwelling prior:to the installation. Sewer line is to be re-
plumbed to front of the dwelling.
ZAL/DAY x 2 DAYS - GAL
�..�� _...__ .
IL
USE 1tv GALLON SEPT I C TANK
- IL ABSORPT 1ONfL-7—
�SYSTEM �..
I t l
x ti o
SIDE AREA: Z 1 12� x` ` orre �
BOTTOM AREA: ram✓' 12 X b+ DAV�S6
hla SON
to 1066al
�
TIC SYSTEM SECT I 'ON
0 Log or raxjwnj
� ` r
1
�t �
GALS "?
SEPTIC TANK
IW5 A/210
SITE AND SEWAGE PLAN
._---� LOCATION : A,W tom, 1l
PREPARED FOR : j I' �1�' �G
. ....�... v ....__. . __._ t
.. w�. �.. SCALE.
l
W DAV I D B . MASON `R& DATE: Z010
Z DBC ENVIRONMENTAL DESIGNS
W DATE HEALTH AGENT
EAST SANDWICH . MA
3 ( 508 ) 833-2177
Z