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HomeMy WebLinkAbout0040 MURRAY WAY - Health 40 Murray WaM:.A Hyannis F/R A = 307 007 Lam► . i No. 43501/3 RED Pen ` ' V� 10% 4 o N c s l� Ll I 3 5/,d y J y m � t dam. b. P 6 �.5 No� 5 Fee computer: THE COMMONWEALTH OF MASSACHUSETTS Entered in com P PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Disposal *pstrm Const>'Uttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A) ❑Complete System ❑Individual Components Location Address or Lot No. 40 p+(Ul PA4 La.)A-%( H y Owner's Name,Address,and Tel.No. D&Mc 4 i AL6p1C A-(ARrWC TR5 Assessor's Map/Parcel 3o,7 ®® ;t 5-"crA Vs( 7 c-YiVA,;F/t- of Installer's Name,Address,and Tel.No. 5®7r- 77- 71 Designer's Name,Address,and Tel.No. (2c&c'x lj 0 OA, Co Ad//l. tll S,. MAL Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) EX(Sr( dr- S GF-ft t 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 Boar f Healt e S' Date - V • Application Approved by. Date Application Disapproved by Date for the following reasons Permit No.C90C90 — 0 5 Date Issued ,: _"-+:F',�u,:•�-,�ws�'=M�'�3�7�'''�`•-�:�"� _,„,v_n.,�..,M�-,...�.. .�„ .•a. fi ^++^- -w.+ ,-.-, _ �. R .s p.+i�- as�'�'•A 1ST �,�i+" �++w.,, ..•r�+�a�r,.+a5^��•s.� n-•,.+,�,� s� NoC20 90 .s-6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i;� Yes PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Misposal 4pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(4) ❑Complete System ❑Individual Components Location Address or Lot No. 40 M,J&PAq t...)*4 H y Owner's Nam@,Address,and Tel.No. Assessor's Ma /Pazcel �r,. Cka"C 4 � ✓54`6AW I-WAr8&JC TICS• P 302 Io G 7 a S'astTN V;ftm il 4YA4W 6'cb Installer's Name,Address,and Tel.No. 5o9477•-92Ti Designer's Na/me,Address,and Tel.No. IZp4E� 8 C Oak ® !Vl/1 G iuMITEr PAWS. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil y Nature of Repairs or Alterations(Answer when applicable)_ _y� (jQ5_T(i>XC a_ Date last inspected: r 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 HealtlL S e LDate 2.. Q. U Application-Approved by Date Application Disapproved by. Date for the following reasons Permit No.C- Q Date Issued THE COMMONWEALTH OF.MASSACHUSETTS BARNSTABLE,4MASSA�'CIITSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-sit +Sewag"e` ispoal�sstem Gons ct , ,,nRepaired( ) Upgraded( ) Abandoned IV)by —T �.1 �•':IG'4j • � � ff, at /� ( 1 f has den.const`r`ctffin a 6bfdance with the provisions of Title 5 and the for Dispo.sht nst `cireP�er�r�nit !' . R datgd, Installer" QtA�Z od& __ D.es g er N #bedrooms Q1 i•may1(4plouved lde�i 'f ow ; gpd The issuance of this permits all not b ,oonns/true ed as;a guaranteep;tl at tl e sy� �n`wi ! as signed. Date l./"-' , ,_ Inspector - ' -- - - '- -'---- ---' — --!- --- No. " Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pStem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X System located at � �( _ Y �l� 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 m3ast be cofnpjleted within three years of the date of this permit. Date Approved by AsBuilt Page 1 of 1 Commonw alth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dlsposal System Form -Not for Voluntary Assessments LM Property Address f� oC/W✓ Owner Owner's Name information is �j required for c,vi /*'X od w/ 3,L?,0 every page. City/rows State Zip Code Dat of Inspecuon D. System Information {cone.} 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 p li water supply enters the building. Check one of the boxes below: 7hand-sk atch in the area below ❑ drawing attached separately � I • I C i I . 64 c i;l - ! ' s I ' I w Isms-osbe http://issgl2/intranet/propdata/prebuilt.aspx?mappar=307007&seq=1 5/29/2014 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �f- �Uvr� (,✓� Property Address- " (,4 r Owner Owner's Name information is AU Od 60/ required for State Zip Code Date of Insl5ection 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 314 forms on the V computer,use . �. Inspector:. only the tab key ^y/V/I► / //� ' to move your // ,G✓+( o C cursor-do not Name of Inspector use the return key. y►�m � Company Name Company Address )) Oa.6 a GS 7 a State Zip Code City/Town Z/ � o? ) 7�� 77 � (0 Y:� Telephone umber License Number B. Certification JP,o Tl[ 1 certify that I have personally inspected the sewage disposal system at this address and that t hrej information reported below is true, accurate and complete as of the time of the inspection `°The inspection �✓ was performed based on my training and experience in the proper function and maintenance of"fit site / sewage disposal systems. I am a DEP approved system inspector pursuantlto Section 15. 0 of �Q�CS Title 5 (310 CMR 15.000). The system: C Passes ❑ Conditionally Passes ❑ a`Fails ' M f day ❑- Needs Further Evaluation by the Local Approving Authority rn ✓ 0 /V TInspe tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner I 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. t5ins-09/08 Title S offidal inspection Form:Subsurface Sewage Q sposai System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 ,�iarrA C✓ Property Address . JLA k' - Owner Owner's Name information is 1 Al O required for. State Zip Code Date o Insp ction every page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) Syste asses: 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: j 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 l5ins-09/08 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7f (� 11�44 Property Address Owner Owner's Name )/ �j/ information is /�/! fs /a Gd 6C,/ required for City/Town State Zip Code Date f Inspection every page. B. Certification .(cont.) I 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 pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):, ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): more than 4 times a year due to broken or obstructed pipe(s). The Y The system required pumping ❑ Y 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): 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 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 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 t5ins-09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �U✓/r, �✓�vi Property Address 0 • o v �t.Y' Owner Owner's Name information is /� 0�2601 required for ��`� State Zip Code a e o Inspection every page. Cityrrown 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 presence of ammonia nitro bacteria indicates absent and the en and nitrate nitrogen is equal to or 9 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 LLJJ clogged SAS or cesspool ❑ 2r Discharge or ponding of effluent to the surface of the ground or surface waters L� 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 L than 1/2 day flow Tale 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 t5 ns•09/08 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 /�ti✓r� Property Address n ol/u e Owner Owner's Name 3 In°y information is / y GL 6 0 l ti f Inspection required for A✓�N Ci /Town � State Zip Code Date every page. b 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: ❑ [ Any portion of the SAS, cesspool or privy,is below high ground water elevation. Elr--,/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool'or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DER 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. The system fails. I have determined that one or more of the above failure � criteria exist as described in 31 0 CMR 15.303, therefore the syst em 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 y la rge e system m 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. . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t5ins•OW08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.• Not for Voluntary Assessments Property Address L4 v e Owner Owner's Name information is 3 A, I 0 -- required for �' State Zip Code Date of ifispection every page. Cityrrown 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? []� ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been n introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not �❑ available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ( ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ 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 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: ❑ Existing 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 C M R 15.302(5)] D. System Information. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ��y DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Title 5 official Inspection Form:Subsurface Sewage Disposal System•page 6 of 17 t5ins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address O` Owner Owner's Name information is �/ �/ G°'d 60/ required for Da every page. City/Town State Zip Code t of nspection D. System Information Description: r / moo I �, Number of current residents: Does residence have a garbage grinder? ❑ Yes L" No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Q--No Laundry system inspected? ❑ Yes N o Seasonal use? l ❑ Yes [ � Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ �9� 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 Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09r08 Title 5 Official 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 L1 d 14�&4&orl Property Address 9" P Owner Owners Name �(� L., /yY information is ;�A 04i1 /' 601 3 30 required for State Zip Code Date bf InslIection every page. City/Town D. system Information. (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ©/ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 t5ins•09/08 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Vol untary'Assessments i l D "1 Lt✓" y 1,14�2 Property Address D(L, Yr'J P Owner Owner's Name I information is /,L✓� I ��- Q blb /O required for `n State Zip Code Date o Insp ction every page. City/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of inf ormation: rvn Were sewage odors detected when arriving at the site? ❑ Yes I'R'0 Building Sewer (locate on site plan): Depth below grade: feet Material of-construction: cast iron 810 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 construction: oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•09M8 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners Name information is required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Septic Tank (cont.) /77 istance from to of sludge to bottom of outlet tee or baffle ------------- D �P i Scum thick ness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle J 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.): .� vtirGo ✓`l ytiee �� o ��. 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 Title 5 omcjai inspection Form:Subsurface Sewage Disposal system•Page 10 of 17 t5ins•09108 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address (4 r Owner owner s Name information is el 17.1 rf Ca b0/ required for state Zip Code Date o Inspection every page. City/Town 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): Dimensions: Capacity: gallons 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 Title 5 Official Inspection Form:Subsurface Sew2ge Disposal System•Page 11 of 17 . l5ins•09/U Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessmen s Property Address U✓ e�, Owner Owner's Name 800-information is a6o/? required for /To State Zip Code Date o Insection Ci every page. tyvm , 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.): /1v SQ/ W 57 //6 1�A Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: 1 ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: k Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 1 t5ins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Sewage Disposal System Form - Not for Voluntary Assessments Subsurface p 9 i Property Address Owner Owners Name information is /`// 0 2 6 0/ 3o p required for `' State Zip Code Date o Ins ction every page. City/Town D. System Information (cont.) 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.): r /"j/f/ G �tire , 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 [Sins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address �- all- Owner Owner shame / information is e;�4 ', /�� oJ ba required for State Zip Code Date of Ins ection 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.): Title s official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•09I08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments d i�u✓fG Property Address J� Owner Owner's Name ( information is �i`I 0.)60/ required for !G+ S 4 State Zip Code Dat of Inspection every page. Cityrrown 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 p lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately W 9 c � ii ` t 1 I I . r '4d- �a Q d -ad, 6Z7 - 3j, Cx-3 � Isms•09108 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 Property Address C14 ✓ Owner Owner's Name information.is AH�s / '�/ ( b/ 3 ��d required for State Zip Code Date Inspection every page. City/Town D. System Information (cont.) J Site Exam: ❑ Check Slope - ❑ Surface water ❑ Check cellar ❑ Shallow wells / ) %j/bL_ Estimated depth to high ground water: feet O� 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: pate ❑ 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 describ how you established the high ground water elevation: �fD Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09f08 Title 5.omciai Inspection Form:Subsurface Sewage Disposal System•Page A of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c J o 14�t4 Vt. Gy o- Property Address r ' Owner Owner's Name information is Qo-)60 required for G h 0IX State Zip Code Date of Inspection every page. City/Town E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked inspection Summary D (System Failure Criteria Applicable to All Systems) completed [---r-s—ystem Information- Estimated depth to high groundwater etch of Sewage Disposal System either drawn on page 15 or attached in separate file 1 t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f TOWN OF BARNSTABLE eC LOCATION SEWAGE # - q VILLAGE Pt lAllrls _ ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO.G A.'J)'S To b K4 1hr . A 6R--3 SEPTIC TANK CAPACITY L S�f''�ffO ®A l LEACHING FACILITY: (type) CAOS (size) NO.OF BEDROOMS a- BUILDER OR OWNER Pd V- PERMTTDATE: I COMPLIANCE.DATE: 0 �, Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 IS TrUCk/,1Q-&C V ad A co c3 aj 00 O O Get ,Z I n s Fn$......5P —..•L THE COMMONWEALTH OF MASSACHUSETTS �/_.,.{L BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnr#iun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..............feLl%lf:K .. � /1t'[ ...... ................../ c .t`---...-u ce'l.t....------......... cation Addres f�. .. A/1lI` Ownri Addre fi ... ....... a ..... .:.h _..__.11� / i�1 .:. ........ l J-� 1C ; �E,r� �21r i ..... 7�fM. ... staller Address UType of Building A Size Lot.................... ......Sq. feet a Dwelling—No. of Bedrooms...............C;'------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building �:dL.[p �°_ i� ri�_ No. of persons ............ Showers ( ) — Cafeteria ( ) P4Other fixtures -------------------------------------------- ---•-----•-----------------------......-----------------•------------. .... W Design Flow............. ......................gallons per person per day. Total daily flow...........&QQ ...I.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width........------.. Diameter------.......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------_------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ a Test Pit No. 1................minutes 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...............................................................................------------------------------------•-----------------------------------............---- x U --•-----------------------•-----••----------•---------------------.....------------•------------•-------••-----•-----------•---------•-----------------------•--•-••-••-•----------.....0.......-------- 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 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 is;lplbv he board of health. g Application Approved By ..... .: '.... .. ..... U ce Application Disapproved for the following reasons: .............. ......... ............................................... ........ ........................................... ----------------- --------- - -- ------------ --- -- Da e Permit No. ....2 u u.2--- .� Issued ..., ----------------------------------- Dace . .... ............ } THE COMMONWEALTH OF MASSACHUSETTS � k BOARD OF HEALTH TOWN OF BARNSTABLE AVVIirttfiom for Dispsal Works Tomifrnrtiun ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...........3 4 Q_1 1f`r2t .� !. cy�A11l21:�... ... /�� r4..�.�112...�f 1r< .t_ ��-. --- -Lcation-Address) / ) /, /or Lot No. ...................... UrCAU Own 7. !Addres§ - W ......... 'A _s.. l/.., ��1. s.:...------•--...-------•--------- .� �1A��1�c1f/ 2rl....Z- ,62S ..... > staller J Address Type of Building Size Lot............................Sq. feet t-, Dwelling—No. of Bedrooms---------------------------------_----------Expansion Attic ( ) - Garbage Grinder ( ) aOther—Type of Building So-gle... !?A_-L. No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures W Design Flow..............IV......................gallons per person per day. Total daily flow..........�SC0.t_.'?................gallons. W. Septic Tank—Liquid capacity............gallons Length................ Width..-----.......-- Diameter---------------- Depth................ xDisposal 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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-..---------------.- Depth to ground water........................ f=, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water..-.-:-..------•.------. P+ .•••----------•-•••••--•-•--••••--•--••-•-•-•-•••••---••---•---•-••--••...•--•---------------------- --------------------------•-••-- ------------- ••••- O Description of Soil--------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------------------------------------------- ------------------------------------------------------------------------------------------------------- --------------------------------------------- -•- --------------------------------------------------------------------------•------------------------------•------------------------•-------------------------------...------------------................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------•---........................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued issuad by the board of health. Sigrled .. --- ----------r� -`'�----------- —' XApplication Approved By ------- . --------�`P--�� ----- -------� ................................ TDate ........ Application Disapproved for the following reasons: - ------------------------------ - -------------------------------------------- --------------------------------------- Date Permit No. Issued I Date U O d « THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tr r#tfirak of (foutliffit ue THIS IS TO CERTIFY, That the Individual Sege Disposal System constructed ( ) or Repaired ( ) by ------------------------------- - �'A.� --`-5 �cQ.1a. ZZ 1"n ----- ----------------- Installer at ----------------------------------------------------'� ��(J`r -�- _ QrJ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- ------------------------------------------------ dated --------------..------. -------_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. DATE (/' ! i 9 2--------------------------------------------------------- Inspector - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OFBARNSTABLE No... U `2; FaE........................ ........... '-Dislinsal Works Tnntrudion Prrmit Permission is-hereby granted. S SU !Ct. Z14`C= .. to Construct or air ✓an_Individual ewa a Dis_oral Sistem atNo-----------------•---- v------t✓� /4_r...(mil/(�:_-_--/7_ id 4/_�- .-Street._ _•-------------•---------......-- �.......................... l � as shown on the application for Disposal Works Construction Permit No. o) _.a - Dated-----•-S -------------- � f ......................"---•-^= --- =----t� =-=-�''=--•_----•------------------- DATE •--•— 1/U? Board of Health ------------•---•------------------------------------- FORM 36508 HOBBS R WARREN.INC..PUBLISHERS .�`C� c 0 5/25/01 t.: NOTICE: This Form Is To & Used For the Repair Of Failed Septic Systems Only. 114 a r PERCOLATION TEST AND SOIL EVALUATION EXEMPTION • . r 4 FORM • Tif�ED�o��' A. .c�. t�r„ s .`,hereby certify that the engineered plan signed by me dated ¢�4'IdZ ,.concerning the property located at meets all of the following criteria: •_ 4"' This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil.is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed There are no variances requested or needed. • 'The:-bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W.'Elevation, 3•45 +adjustment for high G.W. 2• _ DIFFERENCE BETWEEN A and B z 3 ¢ SIGNED : ao� .S _ DATE: NOTICE Based upon the above information, a repair permit will be issued for 3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. y:health folder:percexmp TOWN OF BARNSTABLE �G LOCATION ' M UrrA 1 Wt,. SEWAGE VILLAGE 14t lAnn 15 ASSESSOR'S MAP & LOT #' Oo INSTALLER'S-NAME&PHONE NO.C MSA'S T'r,K 1l 1P,4 TK-r . .SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ,'t�' Ft i CA6S (size) NO.OF BEDROOMS �. A BUILDER OR OWNER PERMIT DATE:_ / COMPLIANCE.DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 facili?rucky Feet Furnished by A ' 'a &C . - C o A-b 1A o C--E4 B-€40 B ' F 3p a © J c I � o '843i inn tic SOIL TEST TOP OF FOUNDATION 20 FT, MINIMUM FROM CELLAR i DATE OF SOIL TEST ELEV. _ 100 0_ \ . - 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE ---~ SOIL TEST DONE BY 'r (ASSUMED) �— CLEAN SAD WITNESSED BY CONCRETE OBSERVATION HOLE 1 ELEV.=_ COVERS CAM AND SEED Ar INCHES 4" SCHEDULE 40 PVC PIPE PERCOLATION RATE __:S- .__ MIN./INCH AT N_ _ MIN. PITCH 1/8" PER FT. 2" LAYER OF DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 1/8" TO 1/2" \ " MAX. \� \ WASHED STONE VENT 4 CAST IRON PIPE MIN. NOT REQUIRED (OR EQUAL) MINIMUM y 1� PITCH 1/4- PER FT. ` 1 ONCRETOF U o1 FLOW LINE -- r o, ANCHOR 10" , � ELEV. - 97.0 _ 10" rr _'MIN. ¢�. 0„ 0 0 00 0 - .._.� (� CI 1'Ds�h fr .�40k ��+� LEV. - s _ LVEL o 0 0 - o 00 0 10-, g (/ 6" SUMP o _ o 0o ELEV. - ELEV. - _� GAS ELEV. _ -1 ELEV. _ BAFFLE DISTRIBUTION V- C LIQUID OUTLET ELEV. - q _ HIGH CAPACGTY INFILTRATORS WITH a� 1149 '�' 6 Q BOX ___�_ STJNE IN AN 4 FEET 14 INCHES DEPTH TF-E (TO BE PLACED ON FIW BASE) TO BE WATER TESTED ' V 6 FEET 24 INCHES 1500 GALLON IF MORE THAN ONE OUTLET I I X 36' TRENCH FORMATION � `: 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) SOIL ABSORPTION � WELL N A NO WATER ENCOUNTERED AT ______ ELEV. _ ,� � e FEET 34 INCHES SEPTIC TANK CLEAN c C ZONE A,v � • NDEX DOUBLED WASHED STONE J SYSTEN (SAS) ADJUST FREE OF FINES & SILT DESIGN CALCULATIONS WATER 74B�E ELEV. NUMBER OF BEDROOMS 2 *SI SIGN GN 3 SEWAGE DISPOSAL SYSTEM PROFILE USGS PROBABLE WATER TABLE ELEV. - GARBAGE DISPOSAL UNIT N___ vBSERVED ( / / ) � __.,____ TOTAL ESTIMATED FLOW NOT TO SCALE BCTTCM OF TEST HOLE ELEV. - ____� ( 110 GAL/SR./DAY X 3 BR-) 330_ GAL./DAY REQUIRED SEPTIC TANK ' APACITY GAL. Ji°i1Z�tj3lAlAbLSu/`��Vw4-" �. +4 ACTUAL SIZE OF SEPTIC TANK Q_ GAL. SOIL CLASSIFICATION DESIGN PERCOLATION RATE <_ �__ MIN./IN. lirdot iz-4 Q_. EFFLUENT LOADING RATE GAL./DAY/S.F LEACHING AREA 4y3 SD. FT. 11X36 * 47X2X JO / 12 350.9 0 LEACHING CAPACITY AREA X RATE) _____ GAL./DAY 350.9 RESERVE LEACHING CAPACITY _____ GAL./DAY NOTES: 1. ALL WORKMANSHiG AND MATERIAL S SHAD CONFORM TO D E P TITLE 5 AND THE TOWN OF BARNSTABLE_____ RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. ' 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE. LOT 6 rpp40' 3. ALL COMPONENTS OF THE SANITARY SYSTEM St1AL. BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN AREA=9,440t S F. 10 FT OF DRIVES OR PARKING AREAS, H-20 LOADING SHALL BE \ USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL LEGEND: BE MORTARED IN PLACE. ' I ` EXISTING SPOT ELEVATION 00,0 5, NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH EXISTING CONTOUR ----00---- DEEDED OR ZONING REGULATIONS OWNER / APPLICANT IS TO 0 I FINAL SPOT ELEVATION 1 OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. • FINAL CONTOUR �— 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR SOIL TEST LOCATION IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS ��•.,� UTILITY POLE -o- PRIOR TO COMMENCING WORK ON SITE. TOWN WATER 7 CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS N - _ --- — I QE'e/( GASCLINEASIN `�®j SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION i t / CLEAN OUT U �' IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER 98)` ,U CESSPOOL C.P. O 8. PARCEL IS IN FLOOD ZONE C__ c _ 307. w�. � 9. LOT IS SHOWN ON ASSE��JRS MAP _ AS PARCEL 007 __ EXISr1NG DWGL .r `'" • 99 4 vi"OF G ! o� TANYA ti DAIGNEAULT fn APPROVED: BOARD OF HEALTH ,q No. 1095 a+�tkeacl qAl �( D4 TE AGENT !pp pp, _ _ r�,� x PROPOSED SEPTIC DESIGN HELEN SL_ADE i / 40 MURRAY WAY yYANNIS { TA CD 0 ENVIRONMENTAL CONSULTANTS 26 COMPASS LANE, DENNIS, MA 02638 t (508) 385-2425 V1 DATE SCALE _ 2 Q N1v REVISED JOB N0. I I LOCATION MAP - i REVISED BEET 1 OF 1 OL y © T.A. DUMAS j