HomeMy WebLinkAbout0113 OLD YARMOUTH ROAD - Health 113 Old Yarmouth Road
Hyannis P
A 344 050
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TOWN OF BARNSTABLE
LOCATION 'I (5 m gA,c9,= ec _ SEWAGE # ,9 a--3 Di-q
VILLAGE r� ASSESSOR'S MAP LOT3- I���'
_ 43� -
INSTALLER'S NAME Cz PHONE NO. �• ` mg,
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY:(type) 6-4-6 (size) �)L
NO. OF BEDROOMS PRIVATE WELL OR PUBLI WATER
BUILDER OR OWNER 841 j
DATE PERMIT ISSUED: '7 t
DATE .COUPLIANCE ISSUED: 11 .
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF INdJOHM OoAwO�a
Iiratiun for DWOuutti Works Tanstrurtion rrxutt#
Application is hereby made for a Permit to Construct ( ) or Repair .(04 an Individual Sewage Disposal
System at
..... _ .. .....•................................._....._...
�� :. .......-1 -. _._...._.__.
" cation-Address or Lot No.
.......�_._ ._._...__ .......................................... ... ..-•••••--••------------• -----.._.. ....... .................................
JA
Owner 1d ess
y . ..............
�J Installer Address
Type of Building Size Lot............................Sq. feet
..� Dwelling—No. of Bedrooms......... ___............................Expansion Attic ( ) Garbage Grinder ( )
ad Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
Other fixtures ._._..... ------------------- ------_.._.......
WW Design.Flow....................... ......_.gallons per person per day. Total dail flow-_____.__:__:......._.__._...S.3Q....gallons.
WSeptic Tank—Liquid capacity.Wb__gallons Length___ S..... Width...__-r�_____Diameter................ Depth_:___=_..._.-
x Disposal Trench—No. .................... Width_._ .:-__..__......Total Length.................... Total leaching area.__......__._.....sq. ft.
3 Seepage Pit No........I........... Diameter.____1.0..._._. Depth below inlet....... ........ Total leaching area...ro.............sq. ft.
Z Other Distribution box ( ) 'Dosing tank ( : )
Percolation Test Results Performed by.............................` .................... Date......................................a ..
aTest Pit No. i________________minutes per inch Depth of Test.Pit_.-........____.__.. Depth to ground water........................
Test Pit No. 2.................minutes per inch Depth of Test Pit____________________ Depth to ground water-.___.__.__.____....__..
x -----=-----------==----------------------------------------------------------•-----------•---••--.....--•-------•----.....--••--------•.
0 Description of Soil.........................•--------------•---------------•--------...........-----••-----•-••••-•-•--------•--•••-•----.•••.....---=•-•-..........------••••------_._..
W :.: :... ---------•- ...............................................................................•-•_..._
------------------------------------------------------=• - =--------------.....----------•-------------......•-=••--._.......... ._........_
Nature-of Repairs or Alterations—Answer whe --hca.ble---- -�-- ---�. ?� . ................
Agreement
The 'undersigned agrees to install .the aforedescribed Individual Sewage Disposal System in accordance with
the provisions,of iITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isjued by the board of health. p
Signed..... . .................
Date
Application Approved BY -. ....................... ---------•••�. ��1-.. a,..
Date
Application Disapproved for the following reasons-......-....................................................................................................
_.._
................................................. .........................................................................................................................................................
Date
Permit No......./..2_-_3.1 ...... Issued......................................................_
•
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
TOWN OF i A*. X[ZTH �.
, pplirttiion for Disposal Works Tonotturtion Vrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (ti) an Individual Sewage Disposal
system at:
�ocation-AddressNo....................................
I or Lot No.
...---- __.......»......... ............................................ ......... ....................................
....... -- ......_..._......................
Owner
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—'No. of Bedrooms......... ........... ...............:Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Buildii g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ------------------------------------------------------.............---------•------------------------•------........-------------...................--
WW Design Flow:............................ gallons per person per day. Total daily flow..._.........................130....gallons.
W Septic Tank—Liquid capacity.)AM..gallons Length...&�?_`._ Width..`�S'__ Diameter................ Depth_�'__`_r...
i
x Disposal Trench—No..................... Width------.............Total Length.................... Total leaching area....................sq. ft. .
3 Seepage Pit No........I........... Diameter......v....__..... Depth below inlet......4........... Total leaching area...rr.............sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~-' Percolation Test Results Performed by-••••-••••••••••.....................................................••.. Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------------------------------------------------------------------•----------...........................------..............------._......
0 Description of Soil................
U ---•----------------------------
-........
----•-----------------
------------------
-......
._... -------------------
---------------------------
••••--------
---•---.... -----------
.--.--------
W
................................................. ......................................................... •••• •.............-•-•--.......•---...._._........•..........---••-•--••-
U Nature of Repairs or Alterations—Answer when applicable.___ vtsN�e ._5 .Stnlsla e ...... R± l '^-�..... rr .'
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AAAAt
.A Agreement: r
The undersigned agrees to install the aforedescribed Individual Sewage'Disposal System in,accordance with
the provisions of 1IT1Z 5 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.
•
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Signed... - -dfA6-•---
Date
Application Approved By ) .. ..........................' =
�� . --
Date
Application Disapproved for the following reasons:................................................................................................................
........................•-------•----.......-•-----•----.............-------•----•-----..........-----^---------^------------•-•---------..........--•--•••.......--•...........-- •-----.....
Date _
.....,
Permit No...... y ....... Issued.................'Due:....--------..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of-YARMOUTH
C9rrtif irate of Tuamplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed. ( ) or Repaired ( )
by...................?�:........ `........:.. .............. ••• -•••-.............................------•----....._.....-•-•--........••--..---• --•--_....
' U Installer
at .......... ...........^........ ------------------------•----•----------.-------............ -------------------......_...--------------------- ...........
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 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 FUNCTION SATISFACTORY.
DATE........................'#............:............................................. Inspector...................................................................................
.
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
r� t TOWN of rK
No....:...:...:...........`r k FEE........................
Disposal Works Tonsfrur#ion Itrrmit
Permissionis hereby granted..................................!...----••-•••••-----•.............................................................................................. _..
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System .
atNo------------------------------------------------------------------------------------------------------------------------------------.--_-_-.----_-.-----.--....------ ......... .......
Street
as shown on the application for Disposal Works Construction Permit No...................:. Dated..........................
r .....--•---------------•---------.......-----------•-----------------------................._........
Board of Health ~
DATE......................... -----------------------------------------• . * ,
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs ilk
Department of � ���`� �
D Environmental Protection t AUG 1 3 19H
William F.Weld [fit i r tl= t
Governor } 1NDEF'�
Trudy Coxe C r
Secretary,EDEA
Davld B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
- CERTIF
Property Address:_ 91 0''"'`�-
Ad ress'of Owner:
i
Date of Inspection. �j a-i 196 ( different)IF d er
)
Name of Inspector: `
Company Name, Address d Telephone Number:
143'a_ S100 --169-- (49 A ;L
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 Evaluation By the Local Approving Authority
Fails
— _i
Inspector's Signature: , Date:
The System Inspector shall submit a copy of this inspection report V the Approving Authority within thirty(30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the,report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
t INSPECTION SUMMARY:
Check A, B, C, or D:
Al SYSTEM PASSES:
r
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
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B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
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, 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 conforming septic tank'as
approved by the Board of Health.
(revised 6/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
�J Printed on Recycled Paper
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IV,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM tf>;
PART A ,a+,
n n CERTIFICATION (continued)
Property Address:
Owner: 1K1Q.QQ,v�, WOY-QA;"
Date of Inspection: CA
61 SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
he
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval
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
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
<.,Yy
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.
e
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MA
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 APPROPRIATE) DETERMINES THAT ;
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soli absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. x'
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is .4
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm. ,
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board.of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged 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.
�9
2
< (revioed 9/15/05)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Q CERTIFICATION (continued)
Property Address: ` V&
Owner: ,
Date of Inspection:
D] SYSTEM FAILS (continued): O
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
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.
I r privy i within 100 feet of a surface water supply or tributary to a surface water su I .
_ Any portion of a cesspool o p y s s pp y ry pp y
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The followingcriteria apply to large systems in addition to the criteria above:
PP Y g Y
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
_ the system is 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)
The owner or operator of any such system'shall'bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 6/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
q6
Check if the following have been done:
/Pumping information was requested of the own r, occupant, and Board of Health.
VNone 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.
ZAs 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.
ZThe system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
ZAII system components, excluding the Soil Absorption System, have been located on the site.
ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
6hefacility owner Land occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
a
(revised 8/15/95) 4
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17
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 0
Owner: 1c1lZQQ/v., {}�nr1
Dale of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:H_gallons
Number of bedrooms: (�
Number of current residents:
Garbage grinder(yes or�
Laundry connected to system a or nd):_
Seasonal use (yes or(p: 1
Water meter rea ings, if available: 11V
Last dale of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last dale of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS a l source of information:
P System pumped as part of nspection: (yes o no
If yes, volume pumped. gallons
Reason lot pumping:
TYPE�PIF 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)
Othet(explain)
APPROXIMATE AGE of all components, bate installed (if known) and source of Information: %�'� �� It
Sewage odors detected when arriving at the site: (yes or ntR_
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: V�
ou
Owner. �,,,//��,,,,��
Dale of Inspection: 1
etlS
,
SEPTIC TANK:y/
(locate on site plan)
�I
Depth below grader
Material of construction: concrete _metal _FRP —other(explain)
Dimensions: ?< t-1
Sludge depth:_ /01
Distance from top of slule to bottom Of outlet tee or baffle: -?,'3
Scum thickness: y=3
Distance from lop of scum to top of outlet tee or baffler_
Distance from bottom of scum to bottom of outlet tee or baffle: 1
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
Integrity, evidence of leakage, etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to lop of outlet tee or baffle:
Distance from bottom of cr orn 1n bottom of outlet tee or baffle:
s
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.)
(revieed a/i5/9S) w=
. 'tax �«` }�++ � �` .� '�• .ss
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: e
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
E
DISTRIBUTION BOX: '✓
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
II
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: a1 16
SOIL ABSORPTION SYSTEM (SAS):V
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) .AJW AAA—)
904�(MPX�I�IAIM)
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: .1 13
Owner:
Date of Inspection: 1 a-) OiG
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
A- y DIGS
P- J
� �O
13, a �+
-3
DEPTH TO GROUNDWATER
Depth to groundwater: feet y
method of determination or approximation:
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(revised 8/15/95) 9 /��
No. �' FEE
COMMONWEALTH Of MASSACHUSETTS
' Board of Health, SCC� C.��e 1VIA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairxUpgrade( ) Abandon( ) - Complete System ❑Individual Components
Location ' ` Owner's Name
Map/Parcel# 344t Address
Lot# Telephone#
Installer's Name -L �! Designer's Name C
Address C `r lr?crm Address Qa F m
Telephone# (1A v A® Telephone# _ ® (sy5
Type of Building eQ,2�jC\ej �C�i-� Lot Size sq.ft.
Dwelling No.of Bedrooms 1 �\ Garbage grinder
Other-Type of Building No.of persons Showers (Vf Cafeteria (t!j
Other Fixtures K\ c1 1
Design Flow (min.requpired) 3`? gpd Calculated design flow % Design flow provided �J 3((gpd
Plan: Date cUo 1 Number of sheets Revision Date
i Title
Description of Soils)
R
Soil Evaluator Form No. Name of Soil Evaluator � o ate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSJs� \C��
The unde igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of'TITLE 5 and
further agr s n to place to ' o eration until a Certificate of Co pliance has been issued by the Board of Health.
Signe Date
Inspections
a"' "�' '"' 1�' --==a • °.,r ax,. .r:.c ,t k R +y`' 4`r.�j4%, s,1 ».. .,. ti' ,Y' ••a it,r,iw.`� y+� r c p•vv.�t4 J t�'�!it ti'r'• 3.
No. Appni q J !' FEE
i
d o Boar Health'i f X-X''1CC C���t�2 �T , MAT
r APPLICATIONFOP DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT
Application for a Permit to Construct( .) RepairxUpgrade( ) Abandon( XComplete System ❑Individual Components
Location 1 1, CAAQ*novT4 r S Owner's Na me 5
Map/Parcel# ,� �� Addres�,/,5 '� Qc1 k. GS maM A M�
Lot# ol Tele�hone#
Installer's Name � � s Designer's Name
�i �� ►crm t�orti k Sv s
Address `,C�r(lc� �3T•, TCl.•,m. S__ ) Address �oo�• � (Yl _c,LQ_�,
Telephone# �y _ ���0 Telephone# g_ C) "7
Type of Building 1 Lot Size sq.ft.
T Dwelling-No.of Bedrooms 77kpp Garbage grinder (4/A
v Other-Type of Building ��X {t^a aQ_ _ `` No.of persons Showers (1r)!Cafeteria (Vf
Other Fixtures
Design Flow(min.required) J .. gpd Calculated design flow 4 �� Design flow provided �gpd
Plan: Date "1 BI 0-a) Number of sheets r'�'"''.� Revision Date
,Title ' c� zc 54L:W-4g�6 rD!S% Su
„ Description of Soil(s)
`_
Soil Evaluator Form No. "'�`�" Name of Soil Evaluator `�� _ h Date of Evaluation 3
DESCRIPTION OF REPAIRS OR ALTERATIONS QS Atr)
r •
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton t to place
/the sy tem W o eration until a Certificate of Compliance has been issued by the Board of Health.
Signe Date lf^- `-�
Inspections
No.t-VU3 qqG COMMONWEALTH OF MASSAC14USETTS FEE
4.
' �� fin._.
R /`, MA.
Board of Health,&J-
CERTIFICATE Of COMPLIANCE
Des}riptiori of Work: ❑Individual Component(s) VpComplete System
The u,nnd�ersigned herebbyy'ce tify that the Sewage Disposal System; Constructed (_),Repaired Upgraded ( ),Abandoned ( )
by
r r
has been installed in accordance with the provisions of 310 CMR 15.0' (Title 5) and the approved design plans/as-built plans relating to
application N,o..(/� 3' _ d/acted�}9-'9-0.3 Approved Design/Flow (gpd)
Installer
Designer: Inspector: Dater
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 400 3 ." !J FEE o
COMM®NWEALT14 ®F MASSAC14US ETTS f
Board of Health, / 9/ � L,.MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereb granted to; Construct41W/L.,
Reepair( Upgraade( ) Abandon( ) an individual sewage disposal system
at i ld �' /.(/5h7 12 46dl-w/'s as described in the application for
Disposal System Construction Permit No. M 3-- lltO,dated !. 0 '
Provided: Construction shall be completed within three years of the dateoof-this erm All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date L) Board of Health ._
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TOWN OF BARN TABLE
LOCATION SEWAGE #
VILLAGE wti'� ASS SOR'S MAP & LOT
I ,
INSTALLER'S NAME&c PHONE-NO� �-�— !��
SEPTIC TANK CAPACITY TOf dT `
LEACHING FACILITY: (type) �'' '� (size),
NO.OF BEDROOMS ,IWO
BUILDER OR OWNER
m
PERMrrDATE: 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 Feet
within 300 feet of leaching facility)
Furnished by
r
(A
ANON-
VJ
Sep - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 F' UL
s2sroi
:NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PEUCOLATIO:N TEST Al\M SOIL EVALUATION EXEMPTION
FORM
c4e-C.4S �N94`1 hereby cerTify that the engineered pian signet by me
u�tec 0 concerning the property located at
cr(h0.10 "R& $,tests all of the
fcl!owmg �:ntena.
• This failed system is connected to a residential dwelling only. There are no
:o=. , --rcial or business uses associated with the dwelling.
• T� soil is ciass:;:ed as CLASS l and the percolation rase is less than or equai to
-n:njtes -er inch. The applicant may use histoncal data to conclude th)s fsc: ur may
:onduc:t ?re!trnwary tests at the site without a health agent present
• Therc :s no incre:,se in flow and/or change in use proposed
here a:-e :to variances requested or needed.
• The- bottom of the proposed leaching facility will not be located less than fourteen
l fee: aonve the maximum adjusted groundwater table elevation. f Adiusc the
nundwater cable using the Frimptor method when applicable)
Please complete the following:
"f,:)p Df Cround Surface Elevation (using GIS information) _ �es
t�.W E;evat:on ad;uscmen( for highG.W. 0?'•J•. =
FF REt�t.F.. BETWEEN and B air a
S.G.VED DATE: �Lq 0
NOTICE
31asec j-ori ire move r.for-mation, a ceoair permit wil! be issued For )edr^oms
^.z . MUM `;^ :dditional bedrooms are authorized to the future without en,incerec
"ep_: s_�scem plans. _
�c:nn:r,:au �ciccam9
i
Permit Number: Date:
t
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: �_ Lot No. �� d
Owner: �RNC7c � � Address:
Contractor: �Zy�R��c � Address:-
Notes: 'T,k��
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date
coon h/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OA Appropriate index well....................................................
OWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... D�J as
mo h/year
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 26)
determine water level adjustment
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ..................................................:..........................................................
1;
Figure 13.—Reproducible computation form.
15
i
CABMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536
September 29, 2003
RE: Certification of Title V Septic System Installation:
Residential Property 113 Old Yarmouth Road, Hyannis,MA
Dear Sir or Madam:
On September 25, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at
113 Old Yarmouth Road, Hyannis, MA, based on a design drawn by Shay Environmental Services on
September 8, 2003.
y I I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow.
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions,please do not hesitate to call the undersigned at(508)-548-0796.
Sincerely,
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
Of t.,14
o CARPIEN GN 1
O
Carmen E. Shay, R.S., S.E. No. 1181
President
TOWN OF BARNSTABLE
LOCATION � O( - SEWAGE # 17�,,j�
VILLAGE i-I�f ASS SOR'S MAP & LOT, �l "
INSTALLER'S NAME&PHONE NOS G.✓r Dc
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)� SCrc {
-NO. OF BEDROOMS
BUILDER OR OWNER r ��
�PERMITDATE: �.a COMPLIANCE DATE: 1 ZI/Q
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
NO ! �
0
l
3-24' DIAM. ACCESS MANHOLES
_ LOCUS MAP ,
4 ��. �._,� :. �0� I T E
0
*NOTE; ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE (O Leost 24 inches tall)
�- 10' min. from-1 Schedule 40 PVIC w/Charcoal Odor Filter
Existing Foundation house to septic tank I sttIN
TOF ELEV 40.D0 Septic tank covers must be LEACH TRENCHES CROSS-SECTION (1 TOTAL) NLET / l / OUTI T l
` I within 6 In. of finished grade 'I THE ACCESS COVERS FOR THE SEPTIC TANK,
TOP of LIn� El- 34.00 y �: DISTRIBUTION BOX AND LEACHING COMPONENT O Sty
! -Gran. ow Septic 'an„ - 38 00 %Grad• ow D-Bo. - 38.00 '',f..tt.-r-;T�"?'�•�T�' Ty"'�•. �:.�. t,:• FINISHED GRADE. QAjA �P
n„I.h crone - o« x.00 4'-0' wld. SHALL BE RAISED TO WITHIN 6. OF
2' of 1/s•-+/2' 1 STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EQUALS Etch
0.02 } HOLE H-20
40 MIL Rubber Liner
t D'ST Box r w co.. woerro stun. PLAN VIEW ON ALL OUTLET TEE ENDS
p 52 NEW 5=0,0 or Grsdter 0.0,0' PM foot 5�.005
4• P.forat I P.W.C. -1/B•-1/2' Washed Stone N�
EXIST PIPE 1�: 1,500 GAL. TER ` Ma.. � 3-24' REMOVABLE COVERS
i FROM rOUNDATIDN , h SEPTIC TANK n 5 /- ! 1' = 2000" +/-
' of IaMc 2• m 3/4-tit Walled Sfona 6 4 Invert EI•.-s4.50
I' H-20 to Bottom of uooh Facility EIw•32.00 ,.' •"• :•..
.... M /.-, „�.,Stan. , . . : . _ GENERAL NOTES
a nj n X 56' aamoeetee.ton. 3 min cisaronoe
CONCRETE CRAWL SPACE FOUNDATION— I� `I s _ 1J• �T i
Note: All each inn tto be capped at end• r/PVC =ap.. 4' °for.t.o °vC e�min_T_12__mk+. MNet eo outkx 6•,�,n. 1. Contractor Is responsible for Digsafe notification
5I PRCIADEO °� INLET
l' 3/4*-1
O >I li O '�DT "0 SCALE Bottom of Linn Elef.- 32.00 INLE •� °t' TT and rotection of all under round utilities and i es.
SYSTEM PRO'' s In or 3/4 -1 1/2' u „! • e , Bo�tam of Teet Ha. , O«-27.00 ,o mn. T� r J,,) I P 9 P P
compacted ,tone vI v LEACH TRENCHES - : �
�- s s _r a J5 _r 2. The septic tank anq distribution box shall be set
Not to Scale c ;I C I $ } 4'-0* min. 1 I level on 6" of 3/4 -1 1/2" stone.
�s am eft L a aoa 3. Backfill should be clean sand or gravel with no
I i=
° I i stones over 3" in size.
6 in.o' 3/4'-1 1/2'
cornpocted stone I , t f •f 4. This system Is subject to inspection during Installation
�t 7' , by Carmen E. Shay - Environmental Services, Inc.
•" +0'-0' J s' -e' S. The contractor shall install this system in accordance
*ith ,Itle V of the Massachusetts stete code, the approved pion
NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHN 6" BELOW GRADE ` BOSS SEC_
. and Locc Reguiot;ons.
I
I
( .r,r•y nStallation the Contractor encounters any
-^- - soil conditions or site conditions that are different
�� - from those shown on the soil log or in our design i
NOT TO SCALE r•stollotior must halt & rrmediate notification be j
rroae to Carmen E. Shay - Environmente! Services, lrc.
(H-20 LOADING) 7 No vehicle or Heavy machinery shall dr .e over the
\ FOUNDATION `V SEPTIC TANK D-BOX --Z'--s LEACHING FACILITY Sept C system unless noted as H-20 Septic components.
8 -sta.! Tuf-Tite gas baffies cr equals on oil outlet tee ends
9. Ai' Distribution Lines shall be 4" diameter Sch. 40 NSF PVC p pes.
10. All solid piping, tees do fitt rgs shall be 4' diameter
PERCOLATION TEST Schedule 40 NSF PVC pipes of th water tight joints.
1. SITE and Surrounding Properties are Connected
i to Municipal Water. {
Date of Percolation Test: SEPTEMER 3, 2003 I
Test Performed By CARMEN E. SHAY, R.S., C.S.E.
Results Witnessed By WAIVER( Per Barnstable B.O.H.) NOTE:
EXCAVATOR: ROBERTS SEPTIC SERVICE, INC. THE PROPERTY LINES ARE APPROXIMATE AND
4V Percolation Rate: Less Than 2 MPI m 27" Below Land Surface COMPILED FROM THE SURVEY PLAN GENERATED BY
YANKEE SURVEY CONSULTANTS OF MARSTON MILLS, MA, DATED 7/16/03
O Test Hole ENTITLED " PLAN OF 113 OLD YARMOUTH ROAD, HYANNIS, MA"
�8 No. 1 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
h 1 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
\\��a CB D.H. DEPTH SO4LS ELEV., THE SEPTIC SYSTEM INSTALLATION.
0 38 00,
FIND Loamy
Sand
1 � � ,o rR 4/3 138.25
NO WETLANDS ARE LOCATED WITHIN A 200' RADIUS OF THE SITE.
A,
Lj
Loam y
0 L^ �• Sand
10 YR 5/6 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
O
N/F Fredrick L. J ne 1 27' B. 35.75, I
6,888 +�- SC1. ft. 5' Soo FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED
` / 8 Coarse OF AS PER BOARD OF HEALTH SPECIFICATIONS. I
4 Sand
G / S 60 27"- 132 10 �� T/e 27,00 EXISTING SEPTIC TANK & LEACH PIT TO BE PUMPED DRY REMOVED
13 \ 5 Ofls, TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION.
Oo., CB D.H.
�j✓ 4j EXISTING 2 \25' E' FND Perc y
/ Perc Rate- Less Tho 2 MP ASSESSORS MAP - 344 PARCEL 050
to
h BEDROOM � Depth to erc: 48' to 60" 1,
RANCH i Co Co ZONING - RESIDENTIAL
' }-�' 6.5' M AM NOcj(o I Groundwater Not Observed
9 CRAWL SPACE 8 / P AOPO�ED 3 / MMN No Observed ESHWT FLOOD ZONE
•O FOUNDATION / /
y ADJUSTED H2O Elegy. None
SLAB * 38.50
0 each Pit
to. If
/,�, PROJECT
, ` ALL OBUTIO PIPES FROM THE t2. - �EGEND
ALL OUT ET IPE SHALL THNSET LEVEL FOR Al LEAST 2 rr. Ica+caETe COVER
d �C\ , 3 _ 5• pUr.F' p Qto `��. _ NEW 1500 gal. N / / / // / I '•,`t KNocKouTs188XO DENOTES PROPOSED
BENCH MARK o f 24.2 �, \ / to' Septic Tank / / ' \ - - 55 ouTtET - SPOT GRADE
NAIL SE' I / / / / / / 6• i -
V. = 37.00 (NGVD) I o / // / / / ' ~ x 04.46 DENOTES EXISTING
` / -i5.5 - - -� SPOT GRADE
I T HOLD1 `n / / / / PLAN SECTION CROSS-SECTION !
I
ELEV. 48.00 � ^ / / / / I PL PROPERTY LINE
/ ( i
I o' T i PROPOSED CONTOUR
> 3 HOLE DISTRIBU !ION BOX - H-20 LOAD NG 971--
e� NOT TO SCALE
LOT 4 D-Box ll l l l l Il l 97- - - - - -97 EXISTING CCN-OuR
I I
DEEP TEST HOLE &
Desion Calculations PERCOLATION TEST LOCATION
PROJECT BENCH MARK Number of Bedrooms: 3 Equivalent to 330 Gal./Day
TOP OF FOUNDATION / Garbage Grinder: No FENCE
ELEV. = 39.00 (NGVD)) / �/ / / II / Leaching Capacity Required: 330 Gal./Day Minimum per Title V.
ca / / Septic Tank - 2 x 330 Gal./Day = 660 USE 1,500 GAL. Septic Tank.
�l/l SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch PRIVATE DRINKING WATER WELL
I
40 MIL Rubber LinerREVISIONS
\ /�� CIO �/ � Proposed Leaching Trench Dimensions: 4' Wide by 56' Long by 2' Depth. I R E V i S I 0 N S
FROM ELEV. 34.0 To Elev. 32.0 & 10 Feet Bottom Area: 0.74 goi/sq. ft. x 224 sq. ft. = 165.76 gallons
Beyond Each End Of SAS N Sidewall Area: 0.74 gal./sq. ft. x 240 sq. ft. = 177.66 gallons
Providing: 343.36 gallons NO. DATE: DEFINITION
Use: 1 TRENCH - 561 by 44 x 2'D
#113 OLD YARMOUTH ROAD
Floor Plan P C z' C SEE D
I NOT TO SCALE
� � 4RRU F OR
R .
Utility Area ! SUBSURFACE SEWAGE DISPOSAL SYSTEM
1
�ytN°f'�s,� 0 F I
ROGER ROBERTS �� QUXR # 1 13 ODD YARMOUTH ROAD
Bathroom T.li �
Kitch L7 m
Bedroom Dining Room en x
# 5 T R E N T O N STREET P �� H Y,A N N I S , MA
I � U
YARMOUTH , MA ,t . PREPARED BY:
i w
- aI. CARH17Y E. SHA Y
j ENVIRONMENTAL SERVICES, INC.
( 508 ) - 648 - 5310 Living Room �` �� 34 THATCHERS LANE
EAST FALMOUTH, MA 02536
Bedroom � _"
TEL/FAX : 508-548-0796
EXIT SCALE: 1 "=20' DRAWN BY: CES DATE: SEPT. 81 20U3
iPROJECT# Roberts FILENAME: roberts.DWG SHEET 1 OF 1