HomeMy WebLinkAbout0066 MEGAN ROAD - Health 66 Megan Road, Hyannis
A=292 - 241
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Town of Barn Sta.br� P� �
Department of Regulatory Services
m►atasrnerrR i Public Health Division Date
MASS.
�p e439 , 200 Main Street,Hy nnis MA 02601
. AEU tAKI�
Date Scheduled_ �� v.0� Time Fee Pd.
Soil Suitability Asses_ sment for ew Ili ' s
Performed"By: � Witnessed By
LOCATION.t GENERAL INFORMATION
Location Address �g tv M e. " (� Owner's Name Gnu \,ACk6 r ,
n^t Address Co C\/l C:--)C,j\ a
Assessor's Map/Parcel: '/ �' / Engineer's Name
NEW CONSTRUCTION REPAIR
�` Telephone#
Land Use Slopes(%) Z_-u-- 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;dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
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Parent material(geologic) Uu"T� J Depth to Bedrock '2-06 4
Depth to Groundwater. Standing Water in Hole-: J461 )IE� Weeping lVom Pit,FAce
Estimated Seasonal High Groundwater
DETEMNATION FOR SEASONAL HIGH WATER TABLE .
Method Used: Y9k--
Depth Observed standing,in obs.hole: In, Depth to soli mottles: . In
Depth to weeping from side of obs.hole: in, around' ter Adjualment ft.
Index Well# Reading Date: Index Well level �e Adj.factor �. � AdJ.Groundwater Level
PERCOLATION TEST Date" t f / xttnti
Observation
Hole# L- Tine at 9"
Depth of Perc W Time at 6" i
Start Pre=soak Time @ ��� 'Time(9"_6"
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Pubic 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:NsEP lC\PERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# _L
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders.
Consistency,%Gravel)
ram!L L
ja
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon. Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.% yravell
Ja 3
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%O
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Flood Insurance Rate Map:
Above 560 year flood boundary No— Yes ._V _
Within 500 year boundary No Vr� Yes
Within 100 year flood boundary No. Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring perviqus material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on �y (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Protection and that the above analysis was performed by me consistent with
the required trainin , pertise and experience described in 10 CUR 15.017.
Signature Date
Q:\SEP-nC\PERCFORM.DOC
TOWN OF BARNSTA•BLE
LOCATION in e:Gi W� � � SEWAGE# Q
VILLAGE_ ASSESSOR'S MAP&PARCEL ,
INSTALLER'S NAME&PHONE NO. 5C5:
SEPTIC TANK CAPACITY e X\ Sk Cj ��
LEACHING FACILITY: (type)lam( L, G fAcrVbtfize) I� }CLJ
NO. OF BEDROOMS�n
OWNER CSC t c ,J r6,,,
PERMIT DATE: \:Z ( 1 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
0 .
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 �J
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No. .�� �q Fee
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppfiration. for Disposal .6pstpm Construrtion Vermit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components
Location Address or Lot No. � Owner's Name,Address,and Tel.No.Carr u uc,F�c,�,rr� � &0Meq�A
Assessor's Map/Parcel �- r,r,
Installer's Name Address,and Tel.No. D s ner's Name,Address,and Tel.No. .
Type of Building: SOg —.�4`/-DO 6
Dwelling No.of Bedrooms Lot Size \ a d sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 (� gpd Design flow provided 'o C„P'D gpd
Plan Date p ` 1 Number of sheets Revision Date
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Title
Size of Septic Tank (2- 7k\SN (b®�> Type of S.A.S. L C
Description of Soil y ��:� G��C �o�S G(�(jyln ��C�F C, S
Nature of Repairs or Alterations(Answer when applicable) Q(�cf� �� VS _L1_L C C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date � � ,ZL
Application Approved by �'�- Date �l-
Application Disapproved by Date
for the following reasons
Permit No. U y` 'L�� Date Issued r /�ILL
No. o I"I + ;�^ Fee V r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:J�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Nplication for -Misposal *pstem Construction Permit
�t.
Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Wo ML' Gil\ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel d—a q I lA ol r,A\s (
Installer's Name Address,and Tel.No. Des gner's Name,Address,and Tel.No.
5��� C"VC,(Mask• s r15 �- �t��.� S-G� 3�a
Type of Building: SD g ' d 9 y DO 4 p1(,61 -'
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage GrinderWo
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow,(min.required) _? 3 () gpd Design flow provided 3 ( Vo gpd
Plan Date Number of sheets Revision Date
;c. Title
` Size of Septic Tank (N\SN �b OC7 G(&. _ Type of S.A.S. q LC (1� C 4%(An VMJ_S 0_\tV\
Description of Soil , Q bk<1�5 C cosi11 J T&N
Nature of Repairs or Alterations(Answer when applicable)�2q c)No,c—e 20\ w 1.1 L C 6 C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
✓Signed Date
Application Approved by v 1 1 ` ` Date 'l
Application Disapproved by Date
for the following reasons p ;
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Permit No. D Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliante
THIS IS TO CERTIFY,that the On-site`Se/wage Disposal system Constructed( ) Repaired(" ) Upgraded( )
Abandoned( )by S c o 7n xoov C
at (4(,=� M C r4CA/%� (Z� (��G�n/\S has been constructed'n ac r
with the provisions of Title 5 and the for Disposal System Construction Permit No. y+/' dated
Installer 7 C—)A � Designer G,C'
#bedrooms Approved de'sigRflow nn gpd
The issuance of this pe t s 11 n t b co trued as a guarantee that the system itPfu f/n designed.
Date Inspector / �
\._.
- No. Fee �0 0 r _ t.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposar *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located at r,C, M ir, G �c/ 1.� n►`� '
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. J
Date 7/ W Approved by
J
No...... �i`'' F�s.,. J........"........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F KE,,�,LTH
�lD�� ...........OF....... 4........................
- 9
Appliratioft -for UWVviiat Marko Towitrurtion . erni t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
----------- _ = -F
Location dress or Lot No
. -— ••••--.. Address
1 rpF
er
Address .:_..
Installer Type of Buildi g Size Lot...qiV_;tSq. feet
H Dwelling No. of Bedrooms.--- ------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
W Other fixtures ------------•----------------- --
WDesign Flow--•--------- ---------------•------•--•---- ailons per person per day. Total daily flow-------___----_----____:_______•----•-------gallons.
WSeptic Tank—Liquid capacityc allons Length---------------- Width---------------- Diameter___.....------ Depth.-.--.----.--.--
x Disposal Trench— o_ ________________.___ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No e�_-- Diameter____________________ Depth below inlet--------- To ta leaching are i..._.______.___.sq. ft.
Z Other Distribu ton box ( ) Dosing tank
Percolation Test Results Performed by--------- ---------•-----------•-------•---------•-------•----------•---- Date---------------------------
�4 Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..-.: .____._.._..
Test Pit No. 2................minutes per inch Depth of "Test Pit.- ________- 1Depth to ground water-------.-__.---.--_-_----
::� - ---------- --
O Description of Soil--.-_---_-------------
---------- - -- - -. ••. --..--- ---------------------=------------------------------------
----------------------------------------------------
U -------•------•-------••-•---------------•-------------•------ •-•-------•-•---..._-----------•--------------•-•----••••--••-----•••...--•-•--•------
W •-----------------------------------------------------------------------------------------•-----•-------•--•---------------------------•-----------------•--------------------------
UNature 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 Article XI of the State Sanitary Code— The undersigned f n her agrees not to place the system in
operation until a Certificate of Compliance has bee is ed e board of th.
Sigd -----=----''j = r!�`�G ------------- -----------------------------=-
\ Dat
A lication. A roved B w ��"
PP PP Y `" ,> ----- -� 4ace�
Application Disapproved for the following reasons----------------------------------- ° - -
----------------------"--• -------------- ---------------
----------------
_ ------
---------------------------------------------------
.. ......
1� .....
Permit No.,------------------------------------------------------- Issued -
Date
r�
THE COMMONWEALTH OF-MASSACHUSETTS �..
BOARD OF HEALTH
," ............OF.... ..... .... `6�.:................
TT is TO& ha� rtif iratr of pomp—aure
T IS TO EIS. t e Individua Sewage Disposal System constructed' (k or Repaired ( )
ler
-- - --- ------------ described
t
.,
has been installed in accordance with"Clie provisions of Article of_ l)p ate Sanitary.C de as esc ibe in e
application for Disposal Works Construction Permit.No. .: .__° `____...._ dated__.- :�7/ZZ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM OL FUNCTION SATISFACTORY "DATE----- --- -•�---••------- - Inspector
THE COMMONWEALTH OF MASSACHUSETTS � �
BOARD pF HEA,, .H
�+q/C)e�
......O F..... .... r'
,/ - -
" FEE_. __
urti�e WrMit
e �� ---------------------------------------
.........
Permission is,hereby.grtinte _-- "! -____--:--- -! ------ ---.�r g--.
to Construe) or Repair ) an Individual Ate Disposal/System `
-------------L------ _7 V
pp p a �"� -----------------
as
shown on the application for Disposal Works Construction P tf..No ted
Board of Health
DATE o-�
—:
FORM -1255 HOBBS .& WA REIN_,)NC.. PUBLISHERS -
Town of Barnstable
.t Regulatory Services
Richard V. Scali, Interim Director
• BAansrnac€,
9� 039.
MAM
Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: Sewage Permit# ssessor's Map\Parcel )
Designer: STm;)'--� A. Installer: SC
Address: 523 /2erv-7r= 6,4 Address:
V ,C
On SC0�1 M GrzM- was issued a permit to install a
(date)) (installer)
septic system at M CxA t �, �tyc.,nn�� based on a design drawn by
(address)
dated �A h o l i.4
(designer)
certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in compliance with the terms of
the IAA approval letters (if applicable)
tN Of
STEPHEN
(Ins 's Signature)
No.a I
fgAt '
(Designer's Signa e) (Affix Designer s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLLANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. `
THANK YOU.
Q'\Septic\Designer Certification Form Rev 8=14-13.doc
COMMONWEALTH OF MASSACHUSET"IS
- EXECUTIVE OFFICE OF ENVIRONMENTAL AI I AIRS
-- DEPARTMENT OF ENVIRONMENTAL Z 1E__- -��. '
ONE WINTER STREET. BOSTON. MA 02108 617 _�-550()
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11 LI-L1AIni F.11 ELD T 2 4 1997 . -1 RUDY COxL
Gocemor j0 'p Sccret�
ARGFO P:1Ll_CEI_Ll!CCI �NOEPT�IE AVID Lt STRL711S
Lt.Go�crnm SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC ORM 4 Commissioner
PART A
CERTIFICATION �S$Q L �ewlq,�
Merl' Raga ayl Lava ���ow�/i
Property Address: 66 MP an Rd hLyghh/S Address of Owner: t�'K
Date of Inspection: 14,1&1� 7 /J� (If different) e -�o7 6®/
Name of Inspector: �OS$� /°7 /�'/4�^�/A_f
I am a DEP ap roved system inspec or pursuant to Section 15.340 of Title 5 (310 CMR 15.000) ��-
Company Name: C C k s C�P
Mailing Address: 7 /Von- Sr�C/� ?��y, S . iq la 7)/9 02660
Telephone Number:
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewa e disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signal ur Date: lolo7
The System Inspe 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
(he report to the appropriate regional office of the Department of Environmental Protection. The original should t)e sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AJ SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" ect• n nTtf eed to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by th of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). nbe basis of determination in all instances. if "not determined", explain why not.
The septic tank is metal ss the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (all indicating that the tank was installed within twenty (20) years prior to the dale of the inspection; or
the septa whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
f is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: httparwww magnet.state ma usidep
CS Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6co 1;1-e✓
Owner: GQ/��S✓ C 5�7��
Date of Inspection: /% A 7
B) 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 cyst- will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box elled or replaced
The system required ping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if( approval of the Board of Health):
broken pipets) 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 SYSTE OT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENV MENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering ve ated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEA (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANN HAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surfac ater supply.
_ The system has septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system s a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The sy m has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
pr e water supply well, unless a well water analysis for coliform` bacteria and volatile organic compounds indicates that
e 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. Method used to determine distance (approximation not valid).
3 OTHER
(raviaad 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Me54n Rd . ) �iyapntn(,S m f-,
Owner: Cc,N I ns ESf-ot,te�
Date of Inspection:
D) SYSTEM FAILS:
You must indicate ei;, er "Yes" or "No" as to each of the following.
I have determined that the system violates one or more of the following failure criteria is defined in 310 CMR 15.3011 The haSis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded o .ogged SAS or cesspool.
Discharge or pondrng of effluent to the surface of the ground or s ce waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution boy above ou invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" b w invert or available volume is less than 1/2 day flow.
Required pumping more than 4 1 es in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the S Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion 'a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any pion 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 ,,eater quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E1 LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The iollo.v ng criteria apply to large systems in addition to the criteria above
The system serves a facility with a design flow of 10,000 gpd o eater (Large System) and the system is a significant threat to
public health and safety and the environment because on more of the following conditions exist:
Yes No
the system is within 400 f of a surface drinking water supply
the system is %v in 200 feet of a tributary to a surface drinking water supply
the em is located in a nitrogen sensitive area (interim Wellhead Protection Area • IWPA) or a mapped Zone 11 of a
ublic water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater trea(ment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �(o IIM e of,, je. 1 47 / q ym 1 S NA
A
Owner: COt Il/)S �Stl
Date of Inspection:
to I (, I q7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks I
f am7mtes d+FiRg-tkiat—period. Large volumes of water have not been introduced into the system recently or
/ as part of this inspection.
)VIA _ 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.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, mrrril have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, 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:
The facility o\,%,ner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)J
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properi} Address: (0(�' me ctyl �� .� 14 y G nn fs M fr
0%%ner:
Date of Inspection:
1016197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms: 2-
lumber of current residents:
Garbage grinder (yes or no): 0
Laundry connected to system (yes or no):-�5
Seasonal use (yes or no). NO
eater meter readings, if available (last tv,'o (2) year usage (gpd): I�g6�I�4 �, �a10001 . ��95'�Ci96 ? Z8,�S0
Sump Pump (yes or no):Ji—C,
Last date of occupancy:^�2—117
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Nun-sanitary waste discharged to the Title tem. (yes or no)_
Water meter readings, if available
I ast date of occupan
OTHER: scribe) —
Las to of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and sours of information.
hum oaf d q 111 j q 2 4e:t� Tret,�M l!"1f P/O F17—
System pumped as part of inspection: (yes or no)�O
If yes, volume pumped: gallons
Reason for pumping _
TYPE OF SYSTEM NO D,BOX
_"_ Septic tan iI absorption system
Single cesspool
Overflow cesspool
Pri"y
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: z y YPG rS . �IOuSe �'lf�r
►�i 7 3 �e r ��ScSS�n�6 �i'e 1 c� C A'2D
SrHage odors detected when arriving at the site: (yes or no) /v C)
(zevieed 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (06. Me5q✓L h�q,/)AIS
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade.
2�
matenal of construction: cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction line SD eom
Diameter //
Comments: (condition of joints, venting, evidence of leakage, etc.)
n�C .uo E��/DE7tJCC �F �e��4,5�
SEPTIC TANK: l�
floc.+te on site plan)
Depth below grade.
'.material of construction: A"concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: T /O X �,C� S ,7 p/`7� D•�
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: -20
Scum thickness:_ y/D S/(�Fo9tE
Distance from top of scum to top of outlet tee or baffle: /D
Distance from bottom of scum to bottom of outlet tee or baffle:_" X.eo,-i L/L) v/9
How dimensions were determined: .sT7C/( Q,49
Comments:
(recommendation for pumping, condrtio of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) /' Pin /ecaml* n e f` ovf/
e 1,-e Va ve o
a T •, a P i / D✓n
GO S. i'Ovi 44 i 19
GREASE TRAP:
(locate on site plan)
Depth below grade:
material of construction: _concrete _metal _Fiberglass _Polyethylene _ot plain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet or baffle:
Date of last pumping:
Comments:
trecommendation for purr g, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, strucural
mtegnty, evidence of . 'age, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: K0
Owner. tJ�5
Date of Inspection: /
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Pol ene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/da
Alarm level: Alar working order — Yes; _ No
Date of previous pumpin
Comments.
(condition o�intee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_ NO TS.
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump cha condition of pumps and appurtenances, etc.)
(revised 04/25/97) Pago 7 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 66 /9;7a6,? Rql
Owner: &Q7`q/ .e
Date of Inspection:
i %/97
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non•inirmive methods)
If not determined to be present, explain:
Type: S7"V 4,f
leaching pits, number: � ���
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length: 3. 0 !
leaching fields, number, dimensions:
overflow cesspool, number: Q /�
Alternative system:
Name of Technology: =
7, 0
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, tc.)
GIC
GJ OJ oe&rX 4 &2< /
/ i ah
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 groundwater:
inflow (cesspool e pumped as part of inspection)
Com Is:
in to Is
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, s of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
INFORMATION (continued)
Property Address: lgesan /�{/4nl11S
Owner:
Date of Inspection: �s
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Town
t;L0
I REA e D F 6 G
C O
D
A
BD
4E 3I
(revised 04/25/97) Page 9 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 66 Me5A D,, Rd ttVamnl1
Owner: Ca 11trt S EC';fA+6
Date of Inspection:
io It, 197
Depth to Groundwater^' Feet G/2orn Pt 7— eo7"Tvrv& 7-0 ES4r'maj•P' l�1$�` GrovnstW�fP�,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
/Check local excavators, installers
(/ Use USGS Data J �ai�s6��. C
FS7`7��-�0"� c�� /Tt5'�• (Ira✓n�wt��f✓ / �9Z .
Describe in your own words how you estahlished the High Groundwater Elevation. (Must be completed)
/. l.{• S �.S E/evgf A) . SO L SO
02. C loses 7' wa'le` -4 6/t
,c>levar7'r 01' ) .1v/7-e / 99aZ (6era5h ty t-M�!/�-��
a
3. 19/w o?3 0 c2--o/Vig 4/17 -n-en
3 / f- 6•S y /d _
(revised 04/25/97) Page 10 of 10
No....... .......... Fug.... ..................
THECA® C HEALTH ALTHOF MAS� TS
BOARD
Appliration -for llsp sal Works Cn> ustrurti n Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at•
5
Location dress or Lot No.
/� Address
------•---�---�y'G�'��r'•�•-\-' -- :l6��r -----r°�-•�` ---•---•--• -------------------------------------------------••---------•-------------®--------•-•-------•--
Installer Address1.1
dType of Buildi g Size Lot..- -.Sq. feet_._
U Dwelling No. of Bedrooms------- -----------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons-------------..-_-----_____- Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------- ------------------
W Design Flow........................................... allons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity -------- allons Length---------------- Width_.............. Diameter--------------- Depth----------------
x Disposal Trench— o---------------_--_ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No 1r_.?____ Diameter-------------------- Depth below inlet........ Tota leaching area- --------------sq. ft.
z Other Distribution box ( ) Dosing tank
~4 Percolation Test Results Performed b ------ -------------------------- _-_. ate____._________.._-._._---.-______
Test Pit No. 1................minutes per inch Depth of Test Pit-.._._.____________- Depth to ground water...._-------___-
fi Test Pit No. 2................minutes per inch Depth of Test Pit....................1Depth to ground water.-.--._---_-_---_-_--___
tx -- -- - --- - - ------- - -- --------------•------------------------------------------
0 Description of Soil-----------------------------------
x
W ---------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- ---------------------
VNature 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 Article NI of the State Sanitary Code—The undersigned f her agrees not to place the system in
operation until a Certificate of Compliance has bee is ed e board of
Sig d . -• ------- •-.. =.. .
— at
Application,.Approved BY----- ... �=-- - .: �..�
ate
Application Disapproved for the following reasons----------- ------------------------- ---- .............--------------------------------------------------------
-----------------------------------------------------------------------------------------------------------•--••-------------------------•------••-•---------_........... ---_-----------------
PermitNo........................................................ Issued.......GP-------- dl ------------------
't Date
x.'t'�•,. '..'iv'N.' �.'g-�.,� _,..._ ..� .; . -. t, :'."y- z�;...s h.�, ,y,.. ,..,,t�r,� .' ... -'\
No....... .s----•-•• Fps. ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF KEALTH
L�.JZ
Appliration for Uiipoiittl Workii Tutuarurtion Vrrui t
Application is hereby made for a Permit to. Construct.'( ) or Repair, ( ) an Individual Sewage Disposal
System at
-----------------
Location dress or Lot No.
er Address
W ---------•- :'. >a. ...... - ' ------•-- -- ------•--•---------------------•-----
Installer Address
QType of Building , Size Lot_._ __ _ Sq. feet
U
-1 Dwelling—No. of Bedrooms-__._ _______________________Expansion Attic ( ) Garbage rinder ( )
aOther—Type of Building ---------------------------- No. of persons---_------------------------ Showers ( ) — Cafeteria ( )
04 Other fixtures -----------------------------------------------------
W Design Flow......--------------------------------------gallons per person per day. Total daily flow.........................._------.._.-----_-gallons.
WSeptic Tank—Liquid capacit _ _ _ `_�'�allons Length---------------- Width................ Diameter......---------- Depth................
x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area-._-.--._- .___--_sq. ft.
Seepag�Pit No �' _.. Diameter____________________ Depth below inlet_--_.___-______ Tota leaching area. ..----------sq. ft.„
Z Other Distribu ton box ( ) Dosing tank ( ) fq .
aPercolation Test Results• Performed by.......................................................................... l-.---.
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.--- ........:.
(3 Test Pit No. 2----------- ___minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------- ---------- --
Description of Soil------------------------------------
x
W = -----------------------------------------
x
UNature 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 Article XI of the State Sanitary Code— The undersigned f her agrees not to place the system in
operation until.a Certificate of Compliance. has
b 'f fis uye'd- e board'of e h.
S ci n" t
D
Application Approved By----
------------------ ---
sN ` ----
ate .�.
'Application Disapproved for the following reasons------------------•----•••--- .......................................................................
...•---•-•--•-----------•---•--------•••-•-•---••-•--•--••--•-•-•-•----------------------------------------------------------------------------------- ........ ------------ ._. ....---------------
Date
Permit No......................................... ---
--------------- Issued------- --- --..�- -- ------�=-==-- -�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH y
..... ,............OF........_.... w......... .......
,Q1 rtifiratr of Tontphattrr
T IS TO ER. That e Individua Sewage Disposal System construct d ( ) or Repaired( )
bY '
--------
- ez f I Iler �' ,.
> •a.• `�a��,. 9, ------•------------ -- ------------------
i
- --
has been installed in accordance with e provisions of Article X of The ;t7ate Sanitary C. de as described in the
application for Disposal Works Construction Permit No_____________ _ ........ '-___-- dated...... n..17 ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME
SYSTEM WI L FU CTION`SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .,OF HEA„ H y '
No......................... FEE... .........
• �i��o� ork,� �ott,� "urti�t��rrmit
is ereby grante -'- --- '`"' ------ „ -------
Permission ""°'` ..��'
to Constr ) or Repair ` ) an Individual w'ge Dispos System
--------------
at N o... &V ........... .. ---
Stre t .---
as shown on the application for Disposal Works Construction P if Noh- ated--------- "�
�2�� � d
Y
Board of Health
DATE :/S .
I.
•......:....--------•-:
FORM 1255 HOA/R��._.JNC.. PUBLISHERS -
ACCESS COVERS MUST BE WITHIN 9- MINIMUM. INVERT ELEVATIONS : DESIGN CRITERIA : GENERAL NO TES :
6" OF FINISH GRADE 3' MAXIMUM COVER
FIRST 2' TO INVERT OUT SEPTIC TANK: 99.2 . DESIGN FLOW:
FI
FI LEVEL MI N 2" OF PEA 5TONE INVERT IN D I ST. BOX: 98.87 3 BEDROOMS AT l l0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
OR F l L TER FABR 1 C IN T OUT D I S T. BOX: 98.7 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE D l SPOSAL SYSTEM ONLY.
4" DIAM PIPE INVERT IN LEACH CHAMBER: 98.6`
/
° DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: 97.6 NO GARBAGE GRINDER V 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
99.2 98.7 � l 2' �°
v BAFFLE 98.87 98.6 � 97.6 ADJUSTED GROUND WATER: N/A SET. SEE SITE PLAN.
SEPTIC TANK REQUIRED:
3 OUTLET 4 LC-6 LEACHING CHAMBERS OBSERVED GROUND WATER: N/A 330 G.P.D. X 200% - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND
EXISTING D-BOX W/4' STONE SIDES. 2' ENDS. ll 'N x 33'l x 12"d ✓ 'BOTTOM OF TEST HOLE #/: 92.0 MAINTENANCE OF THE SEPTIC SYSTEM SHALL
SEPTIC TANK PROVIDED: 1000 GAL.EXISTING
1000 GAL H-20
SEPTIC TANK 6" CRUSHED STONE OR CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
COMPACTED BASE -�
\ DES J GN PERC RATE < 5 M 1 N/l NCH
SOIL TEXTURAL CLASS - l 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
PROFILE : NOT TO SCALE . � jv
EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
Z 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' 1N DEPTH SHALL BE CAPABLE OF WITH-
STANDING H-20 WHEEL LOADS.
PROVIDED: 4 'LC-6 LEACHING CHAMBERS
W/4' STONE SIDES.2' ENDS. A-451 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
451 S.F. x 0.74 - 333 G.P.D. APPROVED EQUAL.
ti
Aft 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SOIL TEST PIT DA TA S 'J ��- PRECAST CONCRETE OR APPROVED POLYETHYLENE.
INDICATES �_ INDICATES
BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER
PERCOLATION = OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE
TEST _ GROUNDWATER OUTLET.
TP #l P#14561 TP #2
7. BEFORE CONSTRUCTION CALL "DIG-SAFE".
HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-888--DIG-SAFE AND THE LOCAL WATER DEPT.
0" 102,0 0" 102.0 FOR LOCATION OF UNDERGROUND UTILITIES.
FILL FILL
8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
l5" - - - - - - - - - - - - - - - - - - - - 100.8 12 - - - - - - - - - - - - - - - - - - - - IDI.D DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
LOAMY IOYR LOAMY IOYR
-_ - A A OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
l' SAND 3/3 SAND 3/3
/0/.3 CONSTRUCTION 1 NSPECT 1 ONS.
------------- I8" - - - - - - - - - - - - - - - - - - - - 100.5 18- - - - - - - - - - - - - - - - - - - - J00.5
_- \ p LOAMY IOYR p LOAMY IOYR
\ C7 L7
\ } 100 / SAND 5/6 SAND 5/6 9. EXISTING L EACH P 1 T TO BE PUMPED DRY AND\
\ 28" - - - - - - - - - - - - - - - - - - - - 99. 7 24' - - - - - - - - - - - - - - - - - - - - 100.0 BACKFJLLED.
4' / MED-COARSE 10YR r C/ MED-COARSE IOYR
CATCH BASIN ._------- 159-20' SAND AND 7/4 SAND AND 7/4
42" GRA VEL GRA VEL
( c
�� ` 20'TREE
L O /-T. I I EX 3-TREE
•I l 2. 277+ S/ F DWELL ING SEP TIC
. .. K�
/! P I T�\ •,•. 4 LC-6 CHAMBERS I = NO WATER NO WATER
120 92.0 120 92.0
Oq 1 .:::::. ', .....,Q W/4. STONE SIDES. 2• ENDS
TP+/ �r - ' DATE: NOVEMBER 19. 2014
ar` "'::. : \' ;GARDEN, TEST BY: STEPHEN HAAS
Ij BM. CORNER BN BOX ' WITNESSED BY: DONNA M10RANDI
} WOOD EL-102.8 ! ` - +101.9 PERC RATE: l 1 MIN/INCH
TP•2 n�
DES
j
} 1 102.3
} , GARAGE
I 1 PAYED DR�VE*Ae
� } � � \ /2"OAK SHED 2 C.{ 01,
TREE CLUSTER 4 TREE
\`ter
1"_�----- " l P�
o4 y d
UP 5
\\ '07Z,d/`1
SEPTIC SYSTEM DES / GN
66 MAOAN ROAD . MAP 292 , PARCEL 24 /
\ BAFRNSTABLE . ( HYANN / S ) MA .
PREPARED FOR :
Route 2B LEGEND C A O R U 10A H,A / B ,A R ,A
AL µD "�s� 0 CB CONCRETE BOUND
-W WATER LINE SCAT E l 20 " DECEMBER / O . 2014
LOCUS 0 HYDRANT
Q
GAS LINE
HEAD WIRES
L
OHW- O STEPHEN A . HAAS
� -
-0 LIGHT POST _ ENG I NEER I NG , INC
--E- UNDERGROUND ELECTRIC LINE / IP . O . Box 1 6
-T- UNDERGROUND TELEPHONE L 1 NE / �.��� �� Sou t h Den n i s MA 02660
-CT V- UNDERGROUND CABL EV I S I ON LINE L.Gc,�, 1 `� ( 5 O 8 ) 3 6 2-8 1 3 2
+40.4 SPOT ELEVATION
40-.-- EXISTING CONTOUR
LOCUS MAP 0 /0 20 40 R 071 PROPOSED CONTOUR JOB NO: 14-084
-T