HomeMy WebLinkAbout0058 HOMEPORT DRIVE - Health 58 Homeport Drive, Hyannis
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TOWN OF BARNSTABLE
LOCATION �c e �� ®�" SEWAGE'# ®cp
;.VILLAGE�r��"~�`� ASSESSOR'S MAP & LOT` "h-""Z.7
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS. 2
BUILDER OR OWNER .00eG
PERMIT DATE: 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) v� Feet
Furnished by a5, tP2 ���
► ,
�Ay
01% �`
No. Fee
S THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zppliration for 33igozal 6p5tem Corgi.5truction Permit
Application for a Permit to Construct( ) Repair(A.-<pgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. i_cP.1f61 t"oWT ,p aC. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel J4C'— , '.%,7
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
P/.D 4:9-.0*W 10 a 10 OP."2100W
Type of Building:
Dwelling No.of Bedrooms _7 Lot Size � i �� sq.ft. Garbage Grinder ( )
Other Type of Building ge& No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ff�� gpd Design flow provided �� gpd
Plan Date 6 jr o —40aP Number of sheets / Revision Date
Title
Size of Septic Tank -000 0 o. Type of S.A.S.
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 Boa of Health.
Signed Date
—7
Application Approved by r Date 1—t
Application Disapproved by: Date
for the following reasons o�
Permit No. d '-' 1 Date Issued —/q`o
———————————————————————————————————— ;J
• � �� v Z.r..n.-rr� .,,.},.�...,.*....,�.' .....�•;-.•�r �i.'.-.'.�.�;__.�,.- a..r..y.""lt-r-+.....uwr m< n.:� w .�-... .r,_�nr-. •a.
No. PO' 0 l Fee
r� �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
` PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Th6pogar 6potem Con0tructiom Permit
Application for a Permit to Construct( Repair(grade O Abandon(4) ❑.Complete System ❑individual Components
s
Location Address or Lot No. /�O/?9t�/ oGQ j ,d,GK. Owner's Name,Address,and Tel.No.
` •vy. : �G�T-c!,/cam 1�'
Assessor'sMap/Parcel ���'. J..,7
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
tv—d e�/,o t.9 i�,�s
Type of Building:
Dwelling No.of Bedrooms -� Lot Size Sv sq.ft: Garbage Grinder ( )
Other Type of Building Op ee P No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided C gpd
Plan Date 6— nr o - <2 d'a Number of sheets Revision Date
a
Title i
y Size of Septic Tank �'g c o . Type of S.A.S. /3JC_1
i <
aDescription of Soil
t
t
Nature of Repairs or Alterations(Answer when applicable)
t
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i
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
A Compliance has been issued by this Boar of Health.
Signed Date -�
Application Approved by. _ < Date / / q o
Application Disapproved by: ) Date
for the following reasons
Permit No. Date Issued 7` J "�
--------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (Upgraded ( )
Abandoned( )by
at 3 � � c3i/17� 400? T d OC �'/)/, has been constructed inf accordance
with the provisions of Title 55 and the for Disposal System Construction Permit No. ;LOQtI" �� 1 dated 7—��'a�•
Installer 0"' ,*-7,7 G cC-.60 it4 t" Designer d4 G/n -OF-
#bedrooms ,3 Approved design flow 3 p, .�/ „ gpd
The issuance of this permit sh l be con ru a guarantee that the system wP G I u ction as designed. ,
,pj) ' .�, I�
Date Inspector , f L/ j� f�'�C�
✓✓�J
——————--— ————— ————————————————————————— /—�,�—--——
No. aLoo ]
_ `I Fee +/0`�i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
W5po$al *p!5tem Cott.5trUction Permit
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 recognizes 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 th!` mit._
Date �{`d Approved by
k
Jul 18 08 10: 12a p. l
' 'own of Barnstable
Regulatory Services
N�a oT
m Thomas F.Geiler,Director
t1AIWSMISLE, +
. Public Health Division
ArEb!!�ia Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 4U� �� s
Desi ncr.- � 1 � "Y MbiAC4-% iaastallcr:- a l -
Address: ,address: I.A31�_
0.11 was issued a penrit to install a
(dat (instiller)
septic system at i-.- O� � _..-- based on a design drawn loy
(address) /
c�`t� C1 • ��Jt_J"� t dated
_ -1 certify that the septic system referenced above was installed substatlti^Ily according to
}Iie design, w1lich may include minor approved changes sr.Ich as late�1 relocatiarx of the
dystributioin box and/or septic tank.
I certify.that the septic system referenced above was instaucd with"major changes (1'.e.
— greater thatt 10' lateral relocation of the SAS or any vertical'reocation of any component
of the sepbkc system)but in accordance with State&Local Regulations. Plzen revisxorx or
cez6fied as-biklt by designer to follow.
DAVID
�H OF Mqs�
{Installer', ignature)
MASON W
-No.1066
- SRNI TAM��
(D . er s Siglxature) (Affix e 8ncr' Stamp Here)
PLEASE RETURN TO 1a A)tZYSTA9L)r JUBT,XC lFIEAL,TH DIVIST(TN. C .RTIT+'IC;A"T':[:
OF C'OMCPLLANCE WiI,L, NQ ;BE .ISSUED-UNTIL BOTH .T WS•+FORM AND AS..
BUHT CAD ARE REC O VED BY-THE.BAR STABLE PUBLIC UZALTH DIVISION.
THANK YOU +-
Q:l Iculth/septic/Duipler C,'ertl0cation Fonn
Town of Barnstable P#
Department of Regulatory Services
OFIKE A Public Health Division Date
200 Main Street,Hyannis MA 02601
l�
BArMerE MA $
MA89.
Date Scheduled Time Fee Pd. D
�fD MAI
Soil Suitability Assessment for Sewage
Di/�sposal
Performed By: '` '� �. �t ' " d �# Witnessed BWr^f�( 't/i ADO�`�./1 ��
!..::..,•:.Ir:::!::,.::rr.:::::..:i:.�i:!:i:'::::ie::_v!i:,i:!:
ia�:.::.............!.,a.......r.....u...............ev.....lu..:.a............ .:.. ...: 1 _:: ..i.::e:::ld::i;i:. i! "�i;; 'i
T� ....:,..: is ....
r ..........,..r...:.
Location Address s, .0 �� ��oOt T Owner's Name A�411'TC1/eeae
�yd f✓��f' Address
Assessor's Map/Parcel: :2 orp 7 Engineer's Name
NEW CONSTRUCTION REPAIR j/ Telephone#
Land Use L iU�I v"�` ' Slopes(%) /17 Surface Stones
Distances from: Open Water Body �� ft-e"Possible Wet Area �^ ft Drinking Water Well ft
Drainage Way '* ft Property Line ! y ft Other ft
SKETCH:(Street name,dimensions of lot,a ct locations of test holes&perc tests,locate wetlands in proximity to holes)
t
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O
h l ce:
o
�- rn
Parent material(geologic) V ILL 't Depth to Bedrock Al"pth to Groundwater: Standing Water in Hole: / Weeping from Pit Face � `
`Estimated Seasonal High Groundwater
..:r.,-.,:--:.-:__„_.:..:.:-,::::.,:::,:.::::::,::..:::r .rr::::.,.,.::,.::.:_-., eiv!!!r:i!:!!!,:c!:.:::!,zn: ::-::..
..rr ....... .:,_:.:....e.r.i v..........._....J...............:1..:....ra__...........,...:.,...,......,...........:.r:....�v: ._.I.1...,....s...vr.:..a......i .
Method
... . I!i:�i _ r
.....:............ .. .. .. .. ....... .:.......�:...!: .. ._ .:: �. .i! ;:::iii!:c::+:....,.
.:...............r.....u.....:.::... .. :: .... ,.I. ........ ...... ... ....
I:..._..:.r .r i..r... ..r......... ....r r.. .: ..... ::. r..... ...... .. .. ... ,: .r.. ...
.r.......1.........:.....rr:.r..:........ .....:.. ... :.. a::... .. ..... ... ... :..... ............ ...il '.. .................. e.. ... .. ....:.:: :: .:::::
is:.
.r. ........r.,......r.:,r.:..:. r.r.1. ...... .......... ... ...y].�.;may!,: ...,!, .... yI'y1;� TM
,::.I:i.::::!r�:l:!:::
:. : .i .L...�.. .y�K�.. .. �..1 ..� � ,.! JJ:13i"!IJl��ir. ..:1.........r........N._..,....._..:..,
: :: ������.�:r. ...�Wl}i �� ... .: :. .�...L,...�..:.._......�.:T.—..'.:._........:....:r..�......,...............I. .. .v.... r..,......r..
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
,r......._r....r......,....i.. :..........__................,. ,,.. ,.. .. ,..a .... .....
:...r._.._�...,...r,.:,..._......1..._..:...............-----_ ......_
....-_...�.rv:::.!.,,.....I:............r.............:.......: ... ..:-1:r,.._........._.r...r:..:.._........ ....._.............._................_..............
�;[!:u;;-=:�:::::.:::.!;,,,•;r rr,...rr.:r:r,•r:d.:,::,::_.!:�::._:,::::::�:.r::.:::r::�ir......._..:....."._,. ...........::�.:......._..........._..............._............ .
Observation
Hole# Time at 9"
t Depth of Perc 2✓ Time at 6"
Start Pre-soak Time @ Time ff'-6")
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/l)
a
Original: Public Health Division Observation Hole Data To Be Completed on Back----,—
Q:HEALTH/WP/PERCFORM
Depth frXX
om:.:::: .;:.::.: u;:;.::•:.....
..
p . Soil Horizon Soil Texture Soil Color , Soil I h e r
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Houlderes.
%
lot love Zt
VqK1 "
: A....1...:1i.:..... .) ........................I .ole..#...........
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Houlderes..
%
00
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
r Consistency,n
Gravel) -
... . ..........
.. .N.H. .. ......
. . ,E. ,OG... ...............I�tale.#.......................................
.........:....:...
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boui.deres.
Gravel)Consistency,%
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No ; Yes
Within 100 year flood boundary No P.- Yes
Depth of Naturally Occurring Pervious Material
Does at least foul feet of naturally occurring pervious in terial exist in all areas observed throughout the
area proposed for the soil absorption system? i
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection-and that the above analysis was performed by me consistent with
the required training,expertise and ex erie descr'b d in 310 CMR 15.U17.
Signature
Date G Zvv
t rta 'R V
Commonwealth`of Massachusetts
Executive Office of Environmental Affairs
REGEIVEO
Department of MAY 16 1997
Environmental Protection o a
TOWN OF 8M%TABLE
HEALTH DEPT.
William F.Weld
Governor e
Trudy Coxe
Sec,e,a'%EA Q e
David B. Struhs CT V
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION `
Property Address: 4�z�i;1T C�v�`3�2_ 1,���,,��t, Address of Owner: q
Date of Inspection: —(3 ri7 (If different)
Name of InspectoP:��� ".�-emu ` j
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system-
(XPasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
- Inspector's Signature: 4 }�� '_ _.:"`""— • �,-' Date:
The System Inspector shall 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 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 Department of Environmental Protection.
The origina! should oe sen: it ine system owner and copies sent to the buyer, if applicable and the appro�'ing au;hori;�.
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.
B] SYSTEM CONDITIONALLY PASSES:
One ormore system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
liuficak yes, no, or not determined (Y, N, or ND). Describe hasis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsuund, shows substantial in(iltrauun ut exfilttatwn, ur tank failure is
imminent. The system wilJ<.pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 6/15/951 1 ;
c.
One WinterStreet • Boston;Massachusetts 02108 • FAX(617) 556-1049 • Telephone (617)292-5500
_, __. `a Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
-CERTIFICATION (continued)
Property Address: 'j 1116iW c'y0b'T 0-1 t� ��<c
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
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(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
/ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
' WHICLI WILL PROTECT 1H[ PUBLIC HEALTH AND SAF,rTY 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 (ANC) PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ 1 he system na,, a septic tanx anu soil ausurpoun system anu is within 103 fbct tir u su laCc "atc: suNN") or tributar t to a
surface water supply.
_ The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system Lras a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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•
DJ SYSTEM.FAILS:
�I I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
` Backup of sewage into facility or system component due to an overloaded or clogged rSAS.or:cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded ur clogged SAS or
cesspool.
F
2
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property
P Y Address:
Owner: V-W AV 6�%"✓
Date of Inspection:
D] SYSTEM FAILS (continued):
L� 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 1/2 day flow.
L+ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($).
"Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
LI Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
LEI Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
` r The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is %A ithin 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 suppiy well!
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.
(revisedY8/15/95)' 3 ~
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
t
Property Address: 5 ej P6,.L
Owner:'- ATS(}L-�-) .
Date of Inspection:
Check if the following have been done:
'Pumping information was requested of.the owner, occupant, and 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 facility or dwelling was inspected for signs of sewage back-up.
:-T e system does not receive non-sanitary or industrial waste flow
-,The site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on the site.
Z1 Ile septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
/tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
�The size and location of the Soil Absorption System on the•,site has been determined based on existing information or
approximated by nun-intrusive methods.
hE facili;, v.%; i.- ; .,! occ.jPa";:, i`d:1fere^., f101-, ov,ner;vv!ere provided with information on the proper maintenance of Sub-
Surface Disposal System.
,2
(revised`e/15/95} 4 Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ,`) SAC-V e_po-
Owner:
Date of Inspection:
FLOW-.CONDITIONS
RESIDENTIAL:
Design flow: -,6,3C- allo s
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):,
Laundry connected to system (yes or no):
Seasonal use (yes or no):
Water meter readings, if available: J✓�iJ4-
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial.Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pornped gallons
Reason for pumping:
__.._T,PE O 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: r,�
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �� ( `A,�,.,O z,•r�- t e�_.
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
t( ,
Depth below grade:
Material of construction: concrete metal _FRP —other(explain)
Dimensions: _74 �
Sludge depth: 79t'
Distance from top of sludge to bottom of outlet tee or baffle:
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:
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.)
GREASE TRAP:,'
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thicknes>:
Distance from top of scum to top of outlet tee or baffle:
Distance from hottnm ro crinh M nntiom of o1wipr tee or battle' .
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.)
s
(revised 8/:5/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _
SYSTEM INFORMATION (continued)
Property Address: k Ottic<_�A-w K'
Owner: UT�e vJ 1
Date of Inspection:
TIGHT OR HOLDING TANK:/
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP —other(explain)
F
Dimensions:
Capacity: _ gallons
Design flow: _ gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V
(locate on site plan
Depth of liquid level above outlet invert: J"t
Comments:
mote 4 ievei and distribut-w, > t•yua:, e,.dcfiCe of evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 6/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:V)Aq `rCV0
Date of Inspection;,
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, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
(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 ground�Natc:.
inflow (cesspool must be pumped as part of inspection)
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 Hof ponding, condition of vegetation, etc.)
t
(revised 8/15/95) B
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Dale of Inspection:
-_.--SKETCH OF SEWAGE.DISPOSALj3YSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
U
DEPTH TO GROUNDWATER
y..o
Depth to groundwater:_Lc feet -
method of determination or approximation: .+`f i J� �+
(;1Ltz lr� �._�9 i;c'• il\1��.�-�.i- t v'Y+c' ."� j - .
--(rev'ised,8/15/951: 9
TOWN OF BARNSTABLE
LOCATION' �� /�jgA/Q J- o, SEWAGE # 71
VILLAGE 4 ASSESSOR'S MAP & LOT 4� /..17
INSTALLER'S NAME & PHONE NO. �Ay& B Qk= 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) -j
NO. OF BEDROOMS ` ' PRIVATE WELL OR PUBLIC WATER
BUILDER OR'OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: /a?- " 1?— 9
114
VARIANCE GRANTED: Yes No
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MAP - Q68
No... ........s.... Fics..........................._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripoonl Workii Towitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (V5 an Individual Sewage Disposal
System at
............................... ........___1' , ��� rs f-----------..:.. ..........---
ocaUo„-Address r Lot o. v
0'4A.)C o'ner Address
VType of Building IvstalIer Size rLot.._`'..........: .......Sq. feet
., Dwelling—No. of Bedrooms.___.._ ......................._._.-..L�pansion Attic ( ) (garbage Grinder ( )
0-1 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a -----------------------------------------------------------.......-----------•-•-----------•••--------•........---•--•---
•--_..gallons.
W Design Flow............................................gallons per person per day. Total daily flow............................................gal
Other fixtures .----•---------- ----- --- - �
f.4 Septic Tank—Liquid capacity............gallons Length---------------- Width---.._-_-___---- Diameter................ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................._. Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by....... ....................................................... .......... Date........................................
1
Test pi o.NImnutes per inch Depth of Test Pit-----------------_ Depth to ground water........................
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
9 •---••-----•----------------------•-----------•.................--••----------••--•-------•--........................................
-........
................
ODescription of Soil........................................................................................................................................................................
W
U Nature of Repai5 _41teration Answer when applicable._..L-11 "fA_1 .......L.'.....�DO /C'ir�J- -• � !.
iv � .
Agreement: ij'iO" �
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys m 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 //' v . 9F
L .... �. ............ .
ApplicationApproved By ..........f .................................... f.................................... ..............^'......... ..............
M1e Application Disapproved for the following reasons- ------------------------- ............--------------------------------*--------------*---.... ---.--*........
.................................................. ...... . ..................................................--.. ........................................
9141
Permit No. � ............ Issued ........d..* ..................
Da'e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of C ampliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by A.v<
... ....................................................................
Q �� / Insrallcr
at ... t/..- h`D/jlCf?.rir /�<.. -1 ............ ,�f7rriSdr ........................
has been installed in accordance with the provisions of TITI.P 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .. -- .._— dated r.. ... .�1_G�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CO RUED RUED AS A GUARA TEE THAT TFIE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ....... .e.�...-'.... ".'....- _....._ Inspector:.- � � ,../....i� is✓.�f ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Disposal Morks Tonotrudion rnmit
Permission is hereby granted------------------------------------- - Alla._.__-__
to Construct ( ) or Repair ( 4' an Individual Sewage Disposal Syst
as shown on the application for Disposal Works Construction Pets `No U __ Dated---/ '---4-7�j................
��—J` Board of ficalth
DATE..--/ "� .
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
.- ..r -.�.. •..�1+.��•M-,.:.....w._.:7F4.�-:r.1..33�.r..w•-�'"'�.y_.•9'.z�•,....-...:.-+':....�-.-o:a•r�..-_�-.e.-..y,,,,.�.J-�4'a'-r,�.. „ :;+...%�.,j,,,,..h,4
' f
No.. .L:_.'.1! �a t' d 7 Fas...._.3 .. ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
,ppliration for Di'ipit ial lVilr1w (nomitriartion Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal
System at
..•!� hon-Address �or Lot ricic .ocs e«�
-__ ------------------------------- rr���,�0,�
00—er Address
Installer Address
Type of Building Size Lot............................Sq. feet
,.., Dwelling— No. of Bedrooms-______ ___-_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ .No. of persons---------------------------- Showers ( ) — Cafeteria- ( )
A' Other fixtures _____________________
w Design Flow................... per person per day. Total daily flow.- _____.__.._______________.__.__.___._gallons.
C4 Septic Tank—Liquid capacity------------gallons Length---------------- Width________________ Diameter_............. Depth................ .
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........................................
a
Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
+ ----------------------------------------•----------------•----------••-••-••••-----•..........------.........................................................
0 Description of Soil........................................................................................................................................................................
w
-------•..............•-
U Nature of Repairs or Alterations—Answer when applicable_ � _. .............
.._.
. __ P.-S-�4_41___.. -'__-_�U�v__.__;__! _f:____.
-
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 -----------------------------
Application Approved By --..........f .r1•li�kily. .- ------------ ---....../ -
Dace
Application Disapproved for the following reasons- ----------- ------ -----------------1-...............-...-......... . -. .-.............. --....................
.......................................................... ... . .......... ...............-....... ........-...... -.... --------. ------ ........................................
Permit No. 1 '......................... Issued ........ ...._-��
Dare
1
ASSESSORS MAP :
_
.. ._ __._. ..___. _ TEST HOLE LOGS
PARCEL: � /Z� NOTES:
_...,.�.. .......... . ..„ �. _ ..__ -.__ ___...... _....----.....,. �......�. _. SOIL EVALUATOR:
V t4AL
`! V FLOOD ZONE:
REFERENCE: , W) TNESS . - 1 1) The installation shall comply with Title V and Town of Barnstable Board
_ . 9.., _ of Health
DATE. U>� Regulations.
. . .
PERCOLATION RATE:
"Z ! 2) The installer verifyhall the location of utilities, sewer inverts and septic
components prior to installation and settingbase elevations.
� �� TH- I TH-2 3 All ravit septic piping „gravity pt p p g to be 4 inch Sch 40 PVC at 1/8 per foot. The
pG 414a first two feet out of the d-box to the leaching shall be level.
1044) This plan is not to be utilized for property line determination nor any other
LwMir 6W0LMA 5 purpose other than the proposed system installation.
�✓�� 1Ul� M� k 5 5) All septic components must meet Title V specifications.
23� 6) Parking shall not be constructed over H10 septic components.
LOCATION MAP CT�� 0V 7) The property is bounded by property corners and property lines.
t a-( 8) The property owner shall review design considerations to approve of total
2 1 21 7� design flow and number of bedrooms to be considered for design. Receipt
/4
1 of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
%J ( 9) The existing leaching or cesspools shall be pumped and filled with
material per Title V abandonment procedures. Those within the proposed
SAS shall be removed along with contaminated soil and replaced with
i
�# �- � 0 � yv t{I�t�n� t����L �.to t���. ��° g p
_T�.... P._ k. _ _ , _...__,....___ clean sand per Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing
SEPT IC SYSTEM DESIGN the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted
if applicable.
l 1) If a garbage grinder exists it is to be removed and is the responsibility of
o f FLOW EST I MATE the owner to ensure such.
PQ � 12)The installer is to take caution in excavation around the gas line.
BEDROOMS AT �V GAL/DAY/BEDROOM -33�a GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
0 lines exiting the dwelling prior to the installation.
SEPT I t,, TANK
(`AL/DAY x 2 DAYS - 6 GAL
USE GALLON SEPTIC TANK (9YJt7nW�D_
6'�RZt A 0 wad ac AXA ON SYSTEM „� ...
awl ltx���l ¢
'SIDE AREA: Z-�C �-I- Ilb ?( �.. ,1 -- /�! - i.� 'y., , f!IS t
-� Z3 `
—_._I✓XI 3 _.'J �l BOTTOM AREA: 2, � ,��� �� �„ !` �, f
AID
2 TIC SYSTEM SECTION
V _
004
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D-SOX
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TAN f a
EPT1C K fv I.EN 21� ,
S 3 �
10
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SITE AND SEWAGE PLAN
1:E
i.
:r LOCATION :
PREPARED F 0 R
P
M
SCALE: ^Z
a
DAV I D B . MASON RS DATE: t-: 30 &Z DBC ENVIRONMENTAL DESIGNS
w DATE HEALTH AGENT
EAST SANDWICH . MA
W ( S08 ) 833- 2177
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