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HomeMy WebLinkAbout0010 NEWSPAPER ROAD - Health 10 Newspaper load. Hyannis A=25. —012 - 003 a a I r h o 0 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR' AP&PARCEL ;�-6,3 -/tIZ-03 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY ' `� 1 ` LEACHING FACILITY:(type) 6'412� (size) 3 NO.OF BEDROOMS OWNER 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) Feet FURNISHED BY s nr ,_ No. .A106_�,571 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipphration for ]k9pont *pn;tem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade b'4—Abandon( ) - ❑ Complete System$4I.xidividual Components Location Address or Lot No. , /�ILI,�s�a Owner's Name,Address,and Tel.No. ti C, �1n Dom; p Assessor's Map/Parcel 7--- _p Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t5, Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3—30 gpd Design flow provided L/SO gpd Plan Date Cl „I ;;L D(o Number of sheets I Revision Date Title o�,e✓- D LD ✓ Size of Septic Tank d f7 d 5 Type of S.A.S. � c74� V�C ct S Description of Soil L.U A,VvX�f S 1/�/�.SZ Ci 0---R Nature of Repairs.or Alterations(Answer when applicable) f, Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainteriance 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 o h.'� 1 ^� Sigel o Date 6—d , " ,,-Application-Approved by, ate ,Application Disapproved;by: 'Date *� -''for the Following reasons 44 Permit No. Date Issued � �'}`-'Sf'+� �.;1„i,,.�=�,..j, -,,,y,,,..;�+c.i•:�..a.'.�._,:U+ -.. ,.rr -'^'..a^airy'�Y"'+^„j.�:..wr..+..y..-c't s:.+;..+;f_:d. -. _._ •r .w>.... r � ... -a- No. Fee Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Mizpo!gal �&p.5tem (Con.5truction Permit Application for a Permit to Construct( ). .Repair O Upgrade'.. Abandon O ❑ Complete System Individual Components Al Location Address or Lot No, "t��1.J5 PA�G✓ Owner's Name,Address,and Tel.No. 1 Assessor's Map/Pazcel ` —o 3 �-`ONn'-� Installer' me,Address,and Tel.No. Desigg�er's Name,Address an del.No. "�r (3 S�IS t� o a z� & �7 Type of Building: Dwelling No.of Bedrooms .3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures G Design Flow(min.required) 3 7d gpd Design flow provided L/SO gpd Plan Date Ct "'j p Number of sheets Revision Date Title 4 Size of Septic Tank I O(7 0 �z Type of S.A.S. CJZ� Cj C Description of Soil U A �4 `( S 14'-4Z yVe a Ci Nature of Repairs or Alterations(Answer when applicable) r 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 oMealt ) Sig n Date Application Approved by � � Date Application Disapproved for the following reasons Permit No Date Issued 7777 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS �w. (Certificate of (Compliance THIS IS TO CERTIFY hat the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Nell' 'i Abandoned( )by 6 \be'ivS � L-- ` at , KifWS 1 o WN(> 1` —j has been c nstrucJe din accordance with the provisionsXitle 5 and the for Disposal System Construction Permit No. dated Installer Z \0 ee --\, S Designer rJ f 7 k+�4 #bedrooms 7 Approved design flow gpd on as The issuance of this permit shall of be construed as a guarantee that the system will function esigned. Date �e� I.� C. Inspector No. ——��I/ Fee --. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS x1h5 pogal �&pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( Upgrade Abandon ( ) System located at 1 N-ev-5 A. Y' r 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: Construe on mus be co pleted within three years of the date of thf .�rmiit Date ( / § Approved by r7 L.- 6� Town of Barnstable �THE � Regulatory Services Thomas F. Geiler,Director = seaxsrABM M� � Public Health Division p'Eo �► Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: �P Designer: _Shgy Environmental Services, Inc. Installer: S Address: P.O. Box 627 Address: C S East Falmouth, MA 02536 J � . On a ( was issued a permit to install a (Mate)' (installer) septic system at 'based on a design drawn by ( ddress) Shay Environmental Services, Inc. . dated (designer) I 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. T 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. � �N OF MAssq CARMEN (Install er s S' ure o E. SHAY No. 1181 P o r FQ►3TECn VV Ia� . Sq I \PN N � (Designer's Signature) (Affix Des p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form e lugCommonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection One Winter Street, Boston MA 02108 (617)292-5500 TRUDY COXE ... ... Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 10 Newspaper Road, Centerville, MA Name of Owner: Rob Colin Address of Owner: Same Date of Inspection: March 29, 2000 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M.Ford Mailing Address: P.O. Box 49, Osterville,MA 02655-0049 Map: 253 Telephone Number: (508)862-9400 Parcel: 12 Lot: 3 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 sewage disposal systems. The system: ✓ Passes Conditionally Passes . Needs Further Evaluad By the Local Approving Authority ails Inspector's Signature: Date: March 31, 2000 The System Inspector shall subnU copy of this inspection report to the Approving Authority(Board of Health or DEP)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 original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS • `!�i G � ���i+ jf 11 EIVE0 TOWN OFBAfiNSTABLE r HEALTH CEPT. t v t revised 9/2/98 Page Iof11 Printed on Recycled Paper i s , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Newspaper Road, Centerville, MA Owner: Rob Colin Date of Inspection: March 29, 2000 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Newspaper Road, Centerville,MA Owner: Rob Colin s �j Date of Inspection: March 29, 2000 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: w The system has°a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or, s:tributary to a surfacewater supply.' .. ' ' a The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER k revised 9/2/98 Pap 3of11 ; v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Newspaper Road, Centerville, MA Owner: Rob Colin Date of Inspection: March 29, 2000 D. SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the 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'h day flow. 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. 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. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: 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 H of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Newspaper Road, Centerville, MA Owner: Rob Colin Date of Inspection: March 29, 2000 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 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. ✓ —t , 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,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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. For example,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)]• ✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. - revised 9/2/98 Page5of11 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Newspaper Road, Centerville,1V/A Owner: Rob Colin Date of Inspection: March 29, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms i actual): 3 Total DESIGN flow n/a Number of current residents: 4 Garbage grinder(yes or no): No Laundry(separate system)(yes or no): No; If yes,separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last two year's usage(gpd): 1999-142,500 gals.:1998-165,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: end(Based on 15.203) Basis of design flow 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: Pumped on June 1199-per Treatment Plant System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: July 7189-per as built card. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM v INFORMATION (continued) Property Address: 10 Newspaper Road, Centerville,MA "-1 Owner: Rob Colin Date of Inspection: March 29, 2000 BUILDING SEWER: _ "1` ,. ".v (Locate on site plan) A Depth below grade: Material of construction: _cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 28" Material of construction: ✓concrete _metal Fiberglass _Polyethylene other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 1000 Qal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle- 10" r How dimensions were determined: Measurin stick 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.) The baf)les'were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend installing risers. GREASE TRAP: None (locate on site plan) Depth below grade: , Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) revised 9%2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Newspaper Road, Centerville, MA Owner: Rob Colin Date of Inspection: March 29, 2000 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Designflow: gallons/day g Y Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level. There were no signs of solids or leakaiee. PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Newspaper Road, Centerville,MA Owner: Rob Colin Date of Inspection: March 29, 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,if possible;excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: I-6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Alterative system: y Name of Technology: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) wit was located, but not dug up. There were no signs of failure in the D-box. The bottom to grade was approx. 10'. CESSPOOLS: None (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 must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: None (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.) revised 9/2/98 . Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Newspaper Road, Centerville, AM Owner: Rob Colin Date of Inspection: March 29, 2000 +, , Map: 253 Parcel: 12 Lot: 3 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public%ater supply comes into house) Al- 19 i r3l, (0 Aa- a3 (w Ba- as A3- B3- Ay - 3a' revised 9/2/98 Page 10ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Newspaper Road, Centerville, MA Owner: Rob Colin Date of Inspection: March 29, 2000 ,. NRCS Report name'. e. Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar ' Shallow wells Estimated Depth to Groundwater SO+/- Feet Please indicate all the methods used to determine High Groundwater Elevation: — Obtained from Design Plans on record — Observed Site(Abutting property,observation hole,basement sump etc.) Determined from locafconditions . ✓ Checked with local-Board of Health Checked FEMA Maps — Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable topographic and water contours maps, the maps were showing approximately 50' +/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(AIW 247, Zone C, 2/00)was 7.1'. This report has,been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 4� R 4 � ECEIVEO �\ COMMONWEALTH OF MASSACHL:SETTS OCT 2 1997 ?: EXECUTIVE OFFICE OF E\, VIRO\\IE\TAL AFF. I S 10WNOFggR DEPARTMENT OF ENVIRONMENTAL PROTE � \ HFAL1HpENp�� •cc ,,, ONE ��INTER STREET. BO5T0N. At.A ,0_1 ,(S bl"•_9_, ..� g L WILL1Ax'F %ELD 2s"3 Pa,,_012, 00,3 TRUDY CO Govcmc• ` ARGEO PAUL CELLL'CCI D.AVID B STRUT Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission: PART A CERTIFICATION Property Address: ���" p���" E6 1 \*y4�)NLS Address of Owner: 'S�V,3 Date of Inspection: UOM Of different) Q.O. boy, \ZZy Name of Inspector. " I E,Cro •1�1� N1.i%S (A A I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) l O'Z(e U i Company Name: Eft /e'r•er-j.1 0" P.,.4--_1 Mailing Address: 12o Aenx e_3;% �j H1fS&025L H /`r © O-C, -51 Telephone Number: rSa4) /L,c Zo CERTIFICATION STATEMENT I cer,j� that I have personall% inspected the seAaee disposal system at this address and tha! the information reported beiov, is true. accura!e and comole!e as o;the time of rnspec,o-. The inspection was performed based on m\ training and experience to the proper fun:ion and maintenance of on-site seAage disposa systems The system: Passes _ Conc-ocnai:,. Passes Need Furtne• Eya'uaron B% the Local Approving Autnont\ Inspector's Signature: Date: �� The S\ste r Insoecto• sha" submit a cop\, of this inspection resort to the Approving Authorrm• within them- (301 days of completing this inspec:-on. It the sNsterr. is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner s�ia!i submu the resor to the aooropriate ree-or.al orice of the Department o-' Environmental Protection. The orig na! should be sent to the s%-ste n cane- and copes sent to.the buve•, if applicable. and the approving authonN INSPECTIO% SUMMARY: Check A, B, C, or D AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C-mR 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" section need to be replaced or repaired. The system, upe, . completion of the replacement or repair, as approved by the Board of Health, will pass. Indica!e yes, no, or not determined (Y, N. or ND, Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tanl failure 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. (rev;.sed 04/15!97) Day 1 of 10 f 1 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ' Owner. Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES tcontin,,&d Se%age backup or breakout or high static water level observed in the d tribation box is due to broken or obstructed pipes) or due to a broken, senled or uneven distribution box. The sys m wiF1 pass inspection if(with approval of the Board of Health;. Describe observations: 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 roken or obsilructed pipets). The system will pass inspection if(with approval of the Bcard of Health): broken pipeisi are replaced o�--,struction is removed C] FURTHER B'ALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board o Health in order to determine if the system is failing to protect the public health. safe- and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI ES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONME\T: Cesspool or prn, is v,ithin 50 feet of a surface ter Cesspool or prn-\ is ithin 50 feet of a borde!i vegetated wetland or a salt marsh. 2) SYSTEM KILL FAIL UNLESS THE BOARD O; HEALT (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER TH PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The sure- has a septic tank and soil abs tion system (SAS) and the SAS is within 100 ieet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil a orption system and the SAS is within a Zone I of a public water supa'v well. The syste has a septic tank and scil sorption system and the SAS is within St}feet of a private water supply well. The system has a septic tank and scil bsorption system and the SAS is less ttar: 100 feet but 50 feet or more from a private water supply well, unless a II water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from hat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to etermine distance (approximation not valid). 3) OTHER (ravzaad 04:75/97) sag. 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following - I have determined that the system violates one or more of the following fail re criteria as defined in 310 CMR 15.303 The bans for this determination is identified below. The Board of Health should be ontacted to determine what will be necessary to correct the failure. Yes No Backup of wage into facility or system component due to a overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the groun or surface waters due to an overloaded or clogged SAS or cesspool. d S;a:ic-hao;:d lever in the distribition boa above outlet in n due to an overloaded or clogged S45 or cesspoo;. Licu+d depth it cesspoo!. is less than 6" below invert or available volume is less than 1/2 day flov. Recuirec' pumping more than, 4 times in the last year OT due to clogged or obstructeo pipes . Numrw o- times pumped _. An, pon:on o;the Sol: Aosorption System, cesspo or privy is below the high groundwater eievatior. An% port:or o*a cesspool or prny is within. 100 t of a surface water supply or tributa,% to a surface Wate• supply. And po^,ion of a cesspoo' or privy is wdhir a ne I of a public we!l. An-. pc-:c- c;a cesspoo' o• pn,.ti• is within 5 feet of a private water supply well Am po-�.or. o-a cesspool or privy is less th n 100 feet but greater than 50 feet from a private hater supply well with no acceo;able Ovate, qualm analysis. If the w• II has been analyzed to be acceotabie, anach copy of well water analysis for cohiorm. bacer,a .ola:,le organic compo ds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate ei:ne• -Yes' o, "No" as to each of the ollo.ving. The fo.;o":rg c ate ,a aor. to large systems in addition to the criteria above: The syste•n sen•es a facilin w rih a design flo of 10,000 gpd or greater (large System: and the system is a significant threat to public hea`;h and saie-� and the en.uonme because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet f a tributary to a surface drinking water supph the system is located in a ni ogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a public water supply we The owner or operator of any such system s all bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. lease consult the local regional office of the Department for further information. (revised 04135/9') page 3 of 10 Y � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address; Owner:-fW\W i Date of Inspection: Check if the following have been done: You must Indicate either "Yes' or 'No"as to each of the following: Ye NoNo Pumping information was provided by the owner, occupant, or Board of Health. I _ 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 pan of this inspection rnin Note if the• are not available with N/A. .I; tans have been oo:a:ned and exa. ec ) — A_ bull,. p �( The facdm or d%%elirng %%as inspected fo, signs o;sewage back-up. 1-'r The sstem does not receive non-sanitary or industrial waste flow. The site \+as inspected for signs r)f breakout — All sNste-r components. excluding the So,. Aosorptron System, have been located on the site ` The sep;.c tank rnanhoies mere unco.ered. opened. and the interior of the septic tank was inspected for condition of X —t bariies or tees, materra� o�con s;ruction. dimensions,s, oepto of liquid, depth of sludge, depth th of scum. —The size and loca;,on of the Sol' Absorption SN-stern on the site has been determined based on The iac,im ovine ano occupants. d drneren; from owner, were provided with information on the grope, maintenance o` Sub-Suriace Disposal Svsterr.. _ Existing mio'mation. Ea Plan at B O H — De-,ermined in the frelo :c am of the failure criteria related to Part C is at issue, approximation of distance is unaccex;aD.e (>3.302.3�b! (T.,%sad 04 ".515-: tags 4 or 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..-1 PART C SYSTEM INFORMATION Propert% Address: Owner: 3 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow '7,10 ¢p.d./bedroorr. for S.q-S Number of becrooms o Number o:current residents Garbage g,. der (yes or nog, tJ Laundry CO-•^ected to system (,yes or no' Seasonal use ryes or no-. x— Water meter readings. if available (last two i1 year usage tgpdi. _ymCl Sump Pump Ives or nor�0 Las date o'occupancy 1 CONIMERCIAL'INDL:STRIAL• Type of establfshmen: Design flo%% ea.lions-oa% Crease trap present wes or no_ Industna! 1%aste Hoid:ng Tani; oresen; ves or no Non-san,ta-, %2ste d,scna•gec to the T!t,e 5 system ;vet or no_ %%ater meter reac:ng; if mailable Las Fa:e o: c, OTHER: .De:cr;be Last sate of occ.:ca-;. GENERAL INFORMATION 'UMPING RECORDS and source of fnforrna:to^ S%stem pumpec as par, of inspection: ;yes Or no A10 If ves, volume pumped ¢allons Reason for pumping TYPE OF SYSTE.&A X _ Seotic tank.`carfb;a+on box:'sotl abscrptfon system Singe cesspool Overflow cesspool Pn.) 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: IJ a Sewage odors detecie when arriving at the site. (yes or not (revised 04/25;9': Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: iO NQws�Pe�. Owner: Tp, A'C• % Date of Inspection: y loa-ok�1 BUILDING SEWER: (locate on site plant �D Depth below grade. Material of construction. _cast iron _40 P`'C _other (explain! Distance from private water supply well or suction Ii Diameter Comments: (condition of joints, venting. evidence of leakage, etc.) SEPTIC TANK:*S (locate on site plan Depth below grade 4 material o+ constructio. Aconcre:e _me:a _Floe•glass _Polyethvlene _othertexpla n If tani is me:ai. Iis: are _ Is age con:.irmec o% Ce-t:f,ca:e of Compuance _(1es%o Dimensiors t lwl06 Sludge depth 6 if %I Disiance from top o: s:ucee to bonorn o'ou:ie: lee o• ba�.e A_ Scum thickness t _ u Distance from top o: scurr. to top o' outle: tee or ba-",e t I (j Distance from bottom o' scjT. to bo-o�-- o�outiv. tee e• bar-e _ How dimensions were dete•minec ( O.A11JtX . Comments trecommendation for pumping condition o� inlet and outlet tees or baffles. depth of liquid leve! in reiauon to outlet invert, structural integrity, evidence of leakage. e:c.i k _ t k �- GREASE TRAP:�� (locate on site plan: Depth below grade Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tea or baffle Date of last pumping Comments: (recommendation for pumping, condition of i!ilet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc., .,q _ ,. •mac a-• Pace 6 of 1C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIO% (continued) Propert% Address: (0 Owner: ^�►�tCtC 1 Date of Inspection: I�a01�1 TIGHT OR HOLDING TANK: 00 'Tank must be pumped prior to, or at time. of inspection: (locate on site plan, Depth below grade Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions. Capacir% gallons Design floes galiorsda• Alarm level A;a•m it "ork:ne order_ Yes. _ No Date of previous pu-p-ng Comments (condition of inlet tee. cond,tion o• a!a,rr. and float switches. etc.) DISTRIBUTION BOX43 locate on size p 27 Dept^ o` licuid Ie%e' aoo•.e o;,t;e: in�e' yay�` I ��►�TTNJL� Comments note r� level and da e_: er s e^u2 ev-c.e-ce oi solids carryover, e\idence of leakage into or out of box, etc i SUS oe tir Q e�Q �G PUMP CHAMBER: NC) (locate on site plan Pumps in working order. (Yes or No, Alarms in working order (Yes or No Comments. (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART C SYSTEM INFORMATION (continued) Property Address: (6 Natispr OL Owner. 1�:V14 PI(X-1 Date of Inspection:Q(*� SOIL ABSORPTION SYSTEM (SAS): (locate on site.pIan if possible. axca a"t n not required. but inay be approximated by non-intrusive methods, If not determined to be present, explain. Type: leaching pits. number.1l.k�• leaching chambers, number:_ leaching galleries, number. leaching trenches. number,length: leaching fieids, number, ci,-nensio^s overflow cesspool, number Alternative wstern Name of Tecnr.oiop Comments in pie condition of soli. s!g^s of hydraulic failure, level of pondin condi n vegetation, ecc.' 1 off- jw&, jNJ �ls aC L�FQc—n �JC - ltin— CESSPOOLS: Ilocate on site piar Number and coniig:;ra'-o-. Depth-cop of liquid to inlet m%•er, Depth of solids lave- Depth of scum layer Dimensions of cesspoo: Materials of constructior Indication of ground%ate- inflow icesspool must oe pumpeC as part of inspection. Comments: (note condition of soil, signs of hydraulic failure, leve! of ponding, condition of vegetation, etc.) PRIVY: I n i l (locate o 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., (revzoee o.;zsis-) Page I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued Propert% Address: 10 FCC"Ph 'Ce" ' Owner: F014cc % Date of Inspection: 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) i a z �1 - S(b gc I L1' Q y a \,bu A3� �y �3- 31 frw.ae'_ 04':5J9'i Page 9 0! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properri Address: lr,�WS JlAfk . Owner: ;, Date of Inspection: � ',26�q� • Depth to Groundwater 3JlFee-, Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abuning property. observattor, hole, basement sump etc.) Determine it from local conditions CnecK %%ith Iota' SGard o• -)ea'1•' Chec:. FEMA macs Check pumping records Check Iotal exca-ato•s irstaHe•s A— L se GCS Da:z r• Des cFibe in %oi, o%N-. %••o,c. rc., %e_ es:ao�-s^ec the 6nie` Cround�Aater Elevation. (Must be completed At. 52 trwz,9*d C4'25'9'. Page 1C of 10 l TOWN OnF—B►ARNSTABLE LOCATION !0 news Cr K-C-' SEWAGE # �9' 4;�Ga VILLAGE ► �'�!''� ASSESSOR'S MAP&,LOT1S3 /2- INSTALLER'S NAME&PHONE NO. 10`f 3 SEPTIC TANK CAPACITY (liTb LEACHING FACIUN: (type) P►T (size) �X G NO.OF BEDROOMS BUILDER OR OWNER- Il PERMTTDATE: --COMPLIANCE DATE: 7 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 o w' feet of leaching facility) Feet n site or within 200 g ty) Edge of Wetland and Leaching FaciIIty(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by c � T ci . 6' TOWN OF BARNS`TABt L0.'., ATION 1 ✓� > '� §EWAGR #: ., '._ VILLAGE1 ` ASSESSOR'S MAP A LOT INSTAL,y!J R'S NAME & PHONE NO. 4 ' SFI'TICT NK CAPACITYNr Ll'i-SCHI;NG FACILITY:(type) / (size) NO. OF BEDROOMS j PRIVATE WELL OR PUBLIC WATER .}a BUILDER OR OWNER pia t H"y rs. DATE:'P�I'RMIT ISSUE.G: , i)ATE -,Z-,,OtIPLIAIVCE ISSUED;_ lo� � VARIANCE GR� NTED: Yes Nrs _ �. � � -. ., �� .. � -�.., ' - I �, _ J No...... Fmc Z.5........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tvwr.....................OF......6AZ.6... --------------------_----_----- 0 Appliration for Bispvaal Works Prrinit Application is hereby made for a Permit to Construct (x) or Repair an Individual Sewage Disposal Syst at: ....... ................................. ..................................... Location-Address or Lot No. ..................................... .............................­---------------------*------------------------"-----------I------- Owner Address .. .......... ............ ............................................................................0...................... 1� Address Installer Type of Building Size Lot..__ .....Sq. feet U oms...... .....OnC...............Expa nision' Attic ( )Dwelling—No. of Bedro, Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ............................................................................................................................0........................ Design Flow......1.1.0--_-_--------------_----gallons per person r dV. Total daily Pow---------0.112......................gallons. 1:4 Septic Tank—Liquid capacity)jqTq.gallo h..V'7.k�.. Width.-I.. Diameter................ Depth-1---!f..... Disposal Trench—No..................... Width..... Total Length___..........._..... Total leaching area--------------------sq. f t. Seepage Pit No.........I---------- Diameter........./P....... Depth below inlet......1_0....... Total leaching area....1.4-07...sq. ft. Z Other Distribution box (� Dosing tank ( ) Percolation Test Results Performed by.......D.awn........C.a. P..c..... Date_._. C9 I------------------* ......I-----------0-------- Test Pit No. I_..._..._.-.minutes per inch Depth of Test Pit--___- " Depth to ground waten. 7T--- fv e- I � Test Pit No. 2........a.minutes per inch Depth of Test Pit----1y!....... Depth to ground ............... 0 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'TTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the bDoar(dlof health. Signed.--------- ........................................... Date Application Approved By............. .. ........0....................... ........ vU Date Application Disapproved for the following reasons:..............................................0................................................................ ......................................................................................................................................................................................................... Date --- N\ Permit No.......49 ?- -- -- ----�re---e.?-.7...0......... Issued-------------------------------------------------------- Dat- No...... ....7. ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ............. ...............OF.............................. ............... Appliration for Bispos al Works Ton6trurtion Prrulit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst ' at: -k �U ...................•- Location-Address or Lot No. ......................_.......................................................................... .....-•-•-.•....•..----------------•...._....._._..._.......-----•_....._-•---•--__...__.....---• Owner / .................•-••.•.••-••••Addres Installer f C/ Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.............................. ._...Ex Expansion Attic � g— -•------- p ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers YP g --------•--------------•---- P ( ) — Cafeteria ( ) 04 Other fixtures -----•-------------------------------•----•---------...-------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-__----._____-__:__-___. rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-------------I........ P4 -------------------------------------------------------- •----------- -------------------------------- ------- •------------------------------ .•••---------••---- 0 Description of Soil........................................................................................................................................................................ x w -------------------------------------------------------------------------------------------•---------------------------------------------------...-----------------------------'•-••••-•••-'•-••••'--'•- 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 T'jE of the State Sanitary 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....................................................................................... Date Application Approved By............. *�-..... ......... ...... Date Application Disapproved for the following reasons--------------------------------•-------•----•----------------•---------------•-•-----------------------_.__..--- ------•------•................•••...-'••-•----••••-•-•----•-•----••-"-••••---•--•••••-••--•--......----•--••-••••---••--•----•--•-••-•--•-••--•-•--•-•-•-----•-•--•••--•------•--•••-•--••••------•-•- Date Permit No....... �--------�LL--`-2-`--_----•---------_ Issued--------------------------------------'--•'-'---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Gct-�,..............O F...............1 ..(.............................. Trrtifirate of ToutpliFatta THIS IS T CE TIFY, That the Individual Sewage Disposal System constructed �) or Repaired ( } qq� Installer al has been installed in accordance with thVprw sions of iIT E 5 of The St y Code as described in the application for Disposal Works Construction Permit No.... -._ -.r��,_____________ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... ........................................................... Inspector.......... , ..................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... e'1".1.................OF..: I.......� cc••'-N" 1y.................. FEE. , BisposFal Vorkii T. mitrudion a. i# Permission is hereby granted-- /-l• ------ rf �- to Construct orRe air an Individual Sewage Disposal System atNo --------•--•---• - ------ _="----------------------•-----•------...-•----•---•-----•-•--.....-•----.....-----•--•----••--••.........•-"•.......... Street as shown on the application for Disposal Works Construction Permit No.�'=�_�_ Dated.......................................... ---------------------------------------•------- ...................................................... Board of Health DATE............................................................................... FORM 1255 HOSES & WARREN, INC., PUBLISHERS w r k K m z ,, - - a .., "'may'� . ;a - : -rr. .� s`T'.:' ,+-.+•,' Y� Y`r a_ i a G NGE MGZtL 4- pP4 -- f14, 307G,o Goa?<y c2'lkilk ANC oiof \ J 1 4� I (do.S I s�•tc ,c� I, r2,N r'Jtrt SL 'uCIND TAY-E1•! Flo ov^-fd- v _ ' 1 4, ✓ �'•f�i� (l�ca,ti2(> N ?2ecAs-r- L +.,417s o � ' tv ' x. _ �,� Ca. �'v ST2 UG C tort DF.Tta.t tS To •� t� A.r-zo��n.�:� 'rStT';� --y v m a Maw,. E�� ;Rp+.t!�s✓c�Tef. U�t�E l"r!,E �' 1 i _ �jl C, ToP o�Foua'�•vaTidS ' , v 2 T� LF _ - ,- - — � FtesT 4 a F PF-E I 7 F ouTU TTEZ. Z&' cog, +4- '1?e toy: Ll vEL- . ! ..EEC 1 ;K. IOcy Ln#,A Te►.1i- , N ;-`. Pia - �_ ' --— -- --- �oevn ' a 10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. ALL OUTLET PIPES you THE y Existing Foundation hove to septic tank CHAMBER ACCESS cover mutt I» S'ECTIDN A -A asnneunoN sox SHALL BE t2• - r ka TOP OF FOUNDATION ELEV. 100.00 (Assumed) Septic took coven mutt be D-BOX cover mutt be w(th(n 0" of fM1eMd grade SIT LEVEL FOR AT LEAST 2 FT. CONCRM cam Y '^ wlthln a" of finished grade �-.: wlthln a In. of finlehed grade PROFILE VIER OF LEACHING SYSTEM - Grade over Sptb Tank - 99.00 �9550 /-moat over SAS- ELEV. 90.a0 3_ a• T v .�•, ,�.,, ¢� {! KNOCKOUTS •.' � �•r rp•fte"d°rrwe ftm •er rid•- I/t•aa@t ftWIM,@ _ 5.5' 12' INUET S OUTtEf ;lO News o er Dr 0.02 3 TOLE H 10 Top of SAS-Elev.•95.63 ;• e• '' P P 10' NEW s�0.01 a Gnoter S- 0.010' pr foot f :,. 47 T. EXIST. PIPE 'R in 1,500 GAL. '''• FROM EXIST. FOUNDATION N SEPTIC TANK g 75' 1aa• 4' - SCH. 40 T �•m• N 20 DepthEffoothe PLAN SECTION CROSS-SECTION '� E " H-10 ew @Mr °' a ,� a o 0 0 0 0 �'w•` \ CONCRETE FULL FOUNDA u > p, u II II A 3.5y . 5� 3.5 3 • ♦ one n t weCNI • 29.3' _ f ( r' ' SYSTEM PROFILE a "•°'3/4"'1 1/2• Ch 29.5' 2.75 3 HOLE H-1DISTRIBUTION compacted @tone $ 0 12 II 2.75 0 BOX f , Not to Scale £ c Effective oath NOT TO SCALE ' it.i. t iR4ar _ c c $ Efftctive,Length _ :a�slJfgg�,IN•i ,.`•"r . t f �� s ln.of 3/4"-1 1/2" o SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES compacted stone m NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 8" BELOW GRADE Bottom of Test oIe 2 0-. 8a7.50 500 - C H-30 LEACHING UNITS / WIGGINS PRECAST 1. Contractor is responsible for Digaofe notification, VERIFICATION ♦Obs. Groundwater - T Hole . NONE OBSERVED Not to Scale and protection of all underground utilities and pipes. ni 2. The septic tank all distri¢u$ion box shall be set level on 6 of 3/4 -1 1�2 stone. 1 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation "A 04 by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance PERCOLATION TEST , C with Title V of the Massachusetts state code, the approved plan 114.48 l and Local Regulations. f M O l 6. If, during installation the contractor encounters any Dote of Percolation Test: AUGUST 28, 2006 co o, soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. LOT-E �r�''r'?Tr I from those shown on the soil log or in our design Results Witnessed By. DONALD DESMARAIS ( BARNSTABLE B.O.H.) I TEST HOLE #1 �;Y 'i li I installation must halt & immediate notification be Excavator: SHAY ENVIRONMENTAL SRVCS., INC. QQ fy,688 Square Foot +/- ,;r 4 Percolation Rate: Less Than 2MPI O 48" 1 ELEV.- 99.00 ►''' tf� made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. Failed D-Boxt •'• ;.'�IS .-. 8. Install Tuf-Tate gas baffles or equals on all outlet tee ends. Leach Pit t ,�,1 I Q 9. All Distribution Lines shall be 4 diameter Schedule 40 NSF PVC pipes. Test Hole Test Hole �+ ;; ..-$9 j 3 10. All solid piping, tees & fittings shall be 4" diameter No. 1 2 L� Schedule 40 NSF PVC pipes with water tight joints. DEPTH SOILS ELEV. DEPTH SOILS ELEV. ► tir CO t 0 11. Municipal Water is Connected to The Residence and Abutting EXIST. l = Properties Within 150 Feet. o a9.00 0 9sso Loamy an Loamy 1000 GALLON ��. 4ii ' I W SEPTIC TANK 0 I THE PROPERTY LINES ARE APPROXIMATE AND 10 Y 3/2 10 Y 3/2 -�' TEST HOLE #2 H COMPILED FROM THE SURVEY PLAN GENERATED BY 0"-5• A 98.50 0"-e" A 98.00 00 0:1 _ _ 0 DOWN CAPE ENGINEERING of YARMOUTH MA Sandy Loom Sandy Loa N - .4, O0 f"CERTIFIED PLOT PLAN OF LOT "C" NEWSPAPER ROAD, HYANNIS, MA" I . ., h� o FATED MAY, 16, 1989 10 YR 5/e 10 rR 3/e LOT-C ���' DECK " j v & THE DEED DESCRIPTION, BOOK 13222, PAGE 350 8"- 30" Bw 95.50 8"- 38" 9w 95.50 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Slit Loom Stlt Loom ��' ,_.•-+ I THE SEPTIC SYSTEM INSTALLATION. 2.5 Y 0/0 2.5 Y 5/5 30"-48" G 95.00 38"-48" G 94.50 j EXISTING LEACH PIT TO BE PUMPED OUT AND 99 I FILLED IN PLACE Sad sod i I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE HALT 2.5 Y 7/4 2.5 Y 7/4 DR VEWAY 1 I FROM THE EXISTING LEACH PIT TO BE DISPOSED •_ __ _ _ Ji' 4TIN l.. ...__ _ . __._ 48 132 88.0 48 132 ..._. Q 87-50 _-,__ __ __. _ r, <._ _ _ IF' G 1 _ -� - _ -BOARD-OF-HEALTH--SPECIFICATIONS _..._ .. _ I - OF�4S PER . + 9 EXISTING GARAGE 11 i NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY 9 9EDROOdif O i ASSESSORS MAP 253, PARCEL 12-03 HOUSE -� a � I #10 II II LEGEND Depth to Perc: 48" to 66" \�� J� O 104X1 DENOTES PROPOSED Perc Rots- Less Than 2 MPI Groundwater Not Observed \\ DECK i I SPOT GRADE No Observed ESHWT \ 1� 1 PROJECT BENCH MARK 1 i TOP OF FOUNDATION x 104.46 DENOTES EXISTING ADJUSTED H2O Elev. = None f I SPOT GRADE ELEV. = 100.00 (Assumed) � 1 PL PROPERTY LINE \\ -'`g4.• �r $6 96P PROPOSED CONTOUR GRAVEL 1 gyp• ; - - - - - -97 EXISTING CONTOUR � 1 DRIVEWAY ��� - 1----------r y i 1 ° 89.53' DEEP TEST HOLE & A AdPERCOLATION TEST LOCATION 2-1e• IXAM. ACCESS MANHOLES 98�� ..._.-. 6 FOOT STOCKADE FENCE ,'�., •., t �,t..r• •b`.r•« f• ------------------------------------------- THE � , 1�• ''''/�/ •F •.. ••'y,1Li•Krt•i.rL�•J.111�_.+ , NE W,S'PA PER R OA_D �^ 1�^ •� � ACCESS COVERS FOR THE SEPTIC TANK, P LOT P LAN WET \ ou °SET DEEPER THAN6 INCHES BELOW s141SHEEDT (40 FOOT RIGHT OF WAY) '� GRADE SHALL BE RAISED TO WITHIN 0 OF �j hti FINISHED GRADE. OF PROPOSED SEPTIC SYSTEM UPGRADE •1 � INSTALL TUF-TITS GAS BAFFLES OR EQUALS - -----------------------------------'"--""------------------------------------�` PREPARED FOR STEEL REINFORCED PRECAST CONCRETE �\ PLAN VIEW \\ RICHARD MOSER & DELANE 0 CONNOR 3-2e REMOVABLE COVERS \\\ AT NOTE: SITE IS WITH A ZONE II \ # �O NEWSPAPER ROAD 3 BEDROOM PERMIT REQUESTED. OVERSIZED SAS DESIGNED AT OWNERS REQUEST. \ •min. w:o.aoc. •,r HYANNIS MA INLET s m� 2• min. Inlet to outlet t.mh. Design Calculations `\ ' '4. 10•min. �'�Te�-a• •j OUTLET 1;• � :` \ ' Number of Bedrooms: 3 Equivalent to 330 Gal./Day �ZH SS PREPARED BY: 4'uid min. Garbage Grinder: No CARM�'N E. ,SH�4 Y b� o.w�r «, '• uyuw dwu+ Leaching Capacity Proposed: 440 Gal./Day (AT OWNERS .REQUEST) M N Septic Tank - 2 x 440 Gal./Day = 880 USE EXIST. 1,000 GAL. Septic Tank. Z := . " •• SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch o S A �' NVIRONMENTAL SERVICES, INC. Bottom Area: 0.74 gal/sq. ft. x 420 sq. ft. 311 gallons 0. 4' -'o• Sidewall Area: 0.74 gal./sq. ft. x 188 sq. ft. 139 gallons �a P.O. BOX 627 CROSS SECTION END-SECTION Providing: = 450 gallons G1ST5_� EAST FALMOUTH, MA 02536 Use: (3) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, �NiTAR\P- TEL FAX : 508-539-7966 USE EXISTING 1000 GALLON H- 10 SEPTIC TANK TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND SCALE: 1"=20' DRAWN BY: CES DATE: SEPT. 12, 2006 2.75 OF WASHED STONE ON THE ENDS. NOT TO SCALE UNITS TO BE SEPARATELY PIPED AND TO BE SEPARATED 2' APART. PROJECT#SD964 FILENAME: SD964PP.DWG SHEET 1 OF 1