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HomeMy WebLinkAbout0068 ORR'S AVENUE - Health 68 Orr's Ave Hyannis A= 291.-198 . i ll Commonwealth of Massachusetts r Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner rlw or'c N7M".* k information is �� ��� S ZA I —I qb MA 02632 04/28/10 required for every page. City own' — State Zip Code Date of Inspection Inspection results must be submitted'.on this form:Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the O I 1 computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address ((� East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification 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 the inspection.The inspention was performed based on my training and experience in the proper function and liaintenance-of on sire sewage disposal systems..I am a DEP approved'system inspector pursuant to Section 15.?40 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Failsl, ❑' Needs Further Evaluation by the Local Approving Authority ,, r— I „n 04/29/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional,office of the DEP. The originals should-be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will:perform in the future under the same or different conditions of use. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 i every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes, no or not determined (Y, N,ND) in the ❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System:will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board'of Health. *A metal septic tank will pass inspection if it is structurally sounds not.leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: El Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 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 ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: El 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, safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 %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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification cont. D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform,bacteria indicates absent and the presence of ammonia nitrogen and`nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and:chain,of custody must be attached to this form.]' ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Z The system fails. t have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered.a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. . For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No El ❑, the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered:"yes"to any question in Section:E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected:for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and'location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of lnspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)):. Sump pump? ❑ Yes ® No Last date of occupancy: 02/10Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M y< 68 Orrs Ave. Property Address Ann Hagloff Owner Owners Name information is required for Centerville MA 02632 04/28/10 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 03/31/06 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3.2feet Maternal of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.7 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16' How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 Orrs Ave. Property Address Ann Hagloff .Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equals any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Cirrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number. ® leaching galleries nu mber: 3 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The system has three flow diffussors in a 12'x 25'field of stones. The diffussors were dry with no sign of ponding or failure. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M 68 Orrs Ave. Property Address Ann Ha loll Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool - Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. City/Town state Zip code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I _ i 3 F •• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Orrs Ave. Property Address Ann Hagloff Owner Owner's Name information is required for Centerville MA 02632 04/28/10 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record. If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet TOWN OF BARNSTABLE LOCATION �eiffrS �G�ra7 ��-�` SEWAGE VILLAGE ASSESSOR'S MAP & LOT - cS.INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 c1 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) /DqF ' NO. OF BEDROOMS PRIVATE WELL OR B�WAT BUILDER OR OWNER C'IJ2 ff, lrs DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: - �- VARIANCE GRANTED: Yes No V7 No.V.. .� ' Fas..... .. .... TkiE COMMONWEALTH OF MASSACHUSETTS y BOARD Q_E HEALTH .........................0 F.........;........................................................_.............._........ Appliratwu for Disposal igoiks Tonstrurtiurt rrrmu Application is hereby made for a Permit to Construct (IX- ) or Repair ( ) an Individual Sewage Disposal ' . system at: ............_........... ....... -..............--. ..................._•----:...--_:....... /��, - oca ocn� A�dress or I/e�t o 1 7� n ....... �� _.................•__x •-=• -----------------------•------ .......... /4,/,,-,n2 9 _- / /. -/:v/Ir�c!b/'PoiY ...... er//� Address W. ...........4C� .Qq 11F•�1.... ............................' .....................a .................. Zcv...-...... . j Installer Address 2/ Type of Building Size Lot....../....................Sq. feet Dwelling—No. of Bedrooms........... .............................Expansion Attic' ( ) Garbage, Grinder (-'14) Other—Type of Building ....__ No. of persons............................ Showers —'Cafeteria Q, YP g ....... P ( ) ( ) W P P1� - --------- Q Other fixtures ..................................j�. � W DesignFlow............... -_----.---- Ions er e d Total dai� fw--------•------:.. .v......_.. al�onsj� WSeptic Tank—Liquid capacity:>j� gallons Length__ ..._._ Width.,. ©... Diameter................ Depth::.._-�...'_ .. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......... Diameter......l_ .... Depth below inlet.........`....... Total leaching area_. .3....sq. ft. Z - Other Distribution box (� Dosing tank ( a Percolation Test Results 2 Performed by........ :.. �� .. .......................: Date_.;�.O�Z��� 7 ,-� Test Pit No. 1................minutes per inch Depth of Test Pit.. _._-..V..... Depth to ground water...,?-................. Test Pit No.'2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ OG .................... - ----------- -------------- ..-...... O Descripti� of Soil�.--3 ..T.�_ s..... o f �� -`.3�---.c...- rP-�-... �4/a-L U8 S`.-....�`... c: Sa' ..;.. ..... .........•---•-------•-........_...---------•------------------------•-•-•-------------•---•--. --- W -•-•---•-------------------- ------------------•------------- --... • • ....... .. •= -- - ---- ----------- . ... .-----.. --------------.._..------------------------•----..................------------........ UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---•----•--------------------------------•-•--------........------------•-----------...........--------------------------•---------..............------•-•-----•------_-------•------------...._.....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.il'IlL 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. • i ed.... Sco Can hit, e a-----------.................................................. ---------------...... � Application Approved BY �._:... . . `'` ----- 16� �? Application Disapproved for the following reasons:----------------------------------------•---...-•--•---•-----•--.....---•-----............--•-----•------•••.. .................•---............------------•-•--•----•-•---......................------...............•..--------------....---------------------••-----_-------....---------------------.....--•-•------ te ' Permit No.� r �_ • --- .......................... Issued...............- --.....................a.._...__ Date No.V.... --C1- ' Fics........ 71 ....._ "THE COMMONWEALTH OF MASSACHUSETTS .'r. ' .POARD OF HEALTH ...................."... OF......... ...•�s7�3�C G� Appliration for Disposal Works Tonstrnrtion jrrmit Application"is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: — /e.S' �Loc�ay/t'r dress or Lyj fTo. ........C..Q f__......._G......:". ..A... ..........a/_........ :...... ....... CAA ner ............................................ Address Installer Address Type of Building 3 Size-Lot............................Sq. feet ..� Dwelling—No. of Bedrooms. Attic ( ) Garbage Grinder '4 Other—Type of Building No. of persons............................ Showers — Cafeteria fit yP g --------•------------ P ( ) ( ) 04 Other fixtures ---------------------------- :_..__..._. d // v-�� y....................................................... �-�,�---••-............._... WWDesign Flow..........................................gallons per person per day: Total dai,l3' flow..._.._.....__......_.._........___.._.___._gallons Septic Tank—Liquid capacity.`!gallons Length__�_G__ _ Width.............. Diameter________________ Depth_.!L}� Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage,Pit No......./............ Diameter..___1... :..... Depth below inlet.......... Total leaching ...sq. ft. Z Other Distribution box (x) Dosing tank ( ) a Percolation Test Results Performed by........r:E__ 6J�� '< d/Zo�� .............---•--•-•-•• •- Date.............. , a Test Pit No. 2.... per inch Depth of Test Pit-Z.�.0......... Depth to ground f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ n+ ---•------------------------------------•----------•---------•-•••-••........--•.........----------------------•-----•----•••--•----••-•---•-.:._...--------- O Description of Soil_ ...-36 7-0�j`q...S� so f�: 3 G `�C c is c s'�"tv ;?, C'r .......... . �5 --/�-' c-o ,�--2Sd' �A�✓-L�_-------------------------- •------- _...... __....... •--------------------------- ... ---------•-- U - ......---•------------------•--•---•----------------.. ...------------------------------•--"--•---•-•--•-------•-----•-------------•-----------•---.........._....--•----------•---.........-•---_••-•-- V 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 TIT1Z 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. i ed 5co7f CAS ncn p---• D Application Approved By...A -- ........................................ ........ � Date • Application Disapproved for the following reasons__________________________•_•________________._._........__________________________________._____._.....______._ ..............................................�...._......•-•--...--•••-•--•.............----------•••.._.......•----•--------.._...._....._._....._..-----._............---------Dat .......-•-•--. PermitNo� . m........................... Issued...........................................Dat•e.....:. Date THE COMMONWEALTH OF MASSACHUSETTS 7vu)d . BOARD OF H, ALTH� ..........................................OF.....�-UIVST/-- -•••-•-•--• •-•.................. T of iratr of Tontphaurr THIS IS TO CERTIFY, Tha e Individual Sewage Disposal System constructed (V or Repaired ( ) � 1V by..........� Q f`f...�a� �............................................Installer-•---•---------------------•-••---•----------•--- ..... Installer at•••...Ir.-01 . ......-I... l Z.........................•------- ----•-------.....--•----•-----•-----•---=--•-•----•-•--___---•-•----_____---------•-----___..... has been installed i accordance with the provisions of TIT 5 The State Sanitary Code asfdescribe in the application for Disposal Works Construction Permit No.-- '" ......... dated..... . . ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUAR 9/ ATTH THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE..... .. 1 .�'/.................. Inspector — �- —•-------------���--------_---,�-----�--_----- THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH .-- ........."TV..-.Vf�.!:.Y.........OF...... �. .�.L_�..L.J. ................. No... -•/-•• U FEE....._� ..•� Rio 1 Works T/1un,, )tr ' nrrnti Permission i hereby granted....., �.�. ....(,. ./u�^J . ............................................................. to Construct ( or Repair ( ) an Individual Sewage Disposal System - at No i Street �`_ _(,I11�_f�� as shown on the application for Disposal Works Construction Permit NoG?_ Dated___ _. ........ ---...-•--------------•-•--------_._....-------•---•••----•-•--••-•-------••--•-----_....._..-•-•-_--••- Board of Health DATE.....................-..............................................-•-•--•--•. TOWN OF BARNSTABLE f LOCATION 8(o (9-0-5 4i)Q , SEWAGE# a Ml-OrO - VILLAGE �A'JpNt�,J I1j ASSESSOR'S MAP&PARCEL cam(", m. INSTALLER'S NAME&PHONE NO. L1 ka r)74—BS(o—04 SEPTIC TANK CAPACITY t0 1000 CAL i.y 2�SrQrs N.c0 LEACHING FACILITY:(type) __t CD6L. C►...%6,LS (size) t N S'tZ�asG -` NO. OF BEDROOMS 3 OWNER �or�r� 1.R�n-t 4JC1l� PERMIT DATE: <Ja s' COMPLIANCE DATE: i Separation Distance Between the: ►JO W1ACC_4- e%7, Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1"40" ,9V,M b Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 1 l/ik Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) j� 1\1 A Feet FURNISHED BY - rCL, —^ t ' f� 7:' r6 Q d . po 9 TOWN OF BARNSTABLE LOCATION�6f L � `� SEWAGE # VILLAGE _ ASSESSOR'S MAP LOT wl�zll n":S INSTALLER'S'NAME & PHONE NO. A & B CANCO 775-6264 07 SEPTIC TANK CAPACITY Aj. LEACHING FACILITY:(type) ` f ✓� l (sue) ENO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: I h -1 Ss-- S 6 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No E� x �,,� � Iv) cy \ ` No...6.1 2::16% Fimic THE COMMONWEALTH,.OF MASSACHUSETTS BOARD OF HEALTH ...............................OF.............................................I............................................ APpliration for Disposal Works Tonstrurtion Frrutit Application is hereby made for a Permit to'Construct or Repair an Individual Sewage Disposal System at ............. 02j! ............................................ ..................... ............ lion tdtess . ) or Lot ;i�r -e- '0 ............................................... ........ ...................... owner Address .....................I.......... .......C144.11k,. .................................. ........7......................................................................................... 000999 Installer Address Type of Building Size Lot.ZZ___)1q1__)....Sq. feet U 117; , Dwelling—No. of Bedrooms........................................:...Expansion,Attic Garbage Grinder 1.4 04 Other—Type of Building ............................ No. of persons............................. Showers Cafeteria 04 Other fixtures ................................... -------------------------------------------------------- -----­------ 30 Design Flow. . ...................gallons per pTc77 Jay. Total da' flow-------------....... .............ga,11ons,,, Septic Tank Flow.....:...: gallons Length................. W' idth.J�... Diameter................ Depth_.-L)!�.. Disposal Trench—No..................... Width..........:......... Total Length.. Total leaching area...................sq. ft. Seepage Pit No........./.......... Diameter........L_e...... Depth below inlet_.....__... Total leaching area..�2....sq. f t. Z Other Distribution box Dosing tank Percolation Test Results " Performed by...... ..........................©yc.............r...................... Date... .7 Test Pit No. I............. inutes per inch Depth of Test Pit....Z2......... Depth to ground water.......Z2...... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............:-.......... 04 ...........r------------------ ............................................................ 7.a;.......... ..... 0 Descrip f Soil..'�2 77 -------- ... /..... tion o .. ................................................................ ........ ---- --------_--------- ------....................................................................................................................... ...............................................................................................................................................*--------------------*........***........***'*............. U Nature of Repairs or Alterations—Answer when applicable..............................................:................................................ ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed In'dividual Sewage Disposal System in accordance with the provisions of TL I T�LE 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. Signed.. . C, 7r C aq tL, 6, - 2 ................................................................................. .......................... Date Application Approved By..........1� ..... Ja.M Date Application Disapproved for the following reasons:.......................................7...................................................................... ..................................M...................................................................................................................................................................... Date PermitNo....... .................. Issued..................................................... Date No..."....K 7- ........ THE COMMONWEALTHiOF MASSACHUSETTS BOARD OF HEALTH ............ ............ ............ ....... OF...... . Appliration for Disposal -Works Tonstrurtion 11jamu Application is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal System at, ................. ------ ...... ........................................... ............... ........ ....... AAddress Lot N0, 7'/ 671��a P. / F................................... ............................. .............. —owner . .... ..........Address ........... .................... .........f.......C .................................. ............................................ Installer Address Type of Building Size Lot.. ................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures ................................... Y:5�......................... Design Flow........... .......................gallons per person er day. Total daily flow............................................gallons.,, Septic Tank—Liquid capacitye. gallons Length. Width...K'�v... Diameter................ Depth_.-S�._..'.�... Disposal Trench—No..................... Width.................... Total Length.......-_........... Total leaching area....................sq; ft. Seepage Pit No........./.......... Diameter........ Depth below inlet-................... Total leaching area..262....sq. ft. Z Other Distribution box Dosing tank( (6)/Z -7 0.4 2- --)l L-C CD -,7-- / Percolation Test Results Performed by.......... ............................... .7....................... Date................ 0.4 ....................... Test Pit Nd. I.....��:�inutes 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...._............_._... 04 ..................................................................................................... 7'�-: — 0 5e C: 0"'," !;;F... ........^...... 0 Description of Soil 7—V .......................................... ........................... si'/ —� ------<E­ .... ...... W /c .......................................................................................................................................................................... ........................................................................................................................................................................................................ 31 U Nature of Repairs or Alterations—Answer when applicable............................................................................................... at ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I A'1E 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. Signed......5 c, C a ................................................................................ .......................... Date Application Approved By............ ls� ...................................... Q Date Application Disapproved for the following reasons:..................................A ..............:............................................................ ......................................................................................................................................................................................................... Date PermitNo...... ..................... IssuedL.................. ............................... Daft ———————————THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ..............OF,-... ......................................... Trrfifirtttr of TontIfflaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V) or Repaired by...............A...... ....................................................................................................................................... at.......... Installer .................................................................................................................................. 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....................� — I , 5� Y) �A\............................................................. Inspector-_____......._........ ................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ....OF............. .. ........._......................... No.. .......... FEE. ....................... Disposal Works Tonstrurtion "pamit Permission is hereby granted.........A. ........................................................................................ to Construct (�) or Repair an Individual Sewage Disposal System' atNo......... ......Z.4--............ ........ ................Z ..................................................................... C,treet as shown on the application for Disposal Works Construction Permit Dated.......................................... ................................. .............................................................. DATE_.... Board of Health --------------*---------- 20 FT. MIN. F-[ EL. FOUND. SOIL TEST 10 FT. MIN. DATE OF SOIL TEST CONCRETE 4 WITNESSED BY T D,,%,^" SCH. 40 PyC PIPE GLEAN SAND PERCOLATION RATE /- z. MIN INCH covERs MIN. PITCH 1/8' PER FT. OBSERVATION HOLE I OBSERVATION HOLE 2 CONCRETE 2" LAYER OF ELEV. = 9s ELEV._ 4" CAST IR N PIPE 12 COVERS (OR EQUAL,j MIN. I/8"- I/2" WASHED PITCH 1/4 PER FT STONE -r-OP4# f4'= FLOW LINE t t �,,�,�✓t / 10, N wy MIN. EL= 2d' S EL = yr ( y EL- LEVEL Sb EL. = 90 7 DIST EL = e a o w WATER AT ��� EL.= �Z ? WATER AT EL.= BOX G > - 3/4"- 1 112" c •o° G u 1000 GALLON WASHED STONE 40 4 °a ° ' w G • o t 0 °° DESIGN CALCULATIONS SEPTIC TANK w v�' � EL.=e PRECAST LEACHING NUMBER OF BEDROOMS BASIN OR EQUIV. GARBAGE DISPOSAL UNIT .t/y 6 DIAM. TOTAL ESTIMATED FLOW 30 SEWAGE DISPOSAL SYSTEM PROFILE t � GAL,/BR /oAY x 7 BR.) GAL, DAY 0. REQUIRED SEPTIC TANK CAPACITY 9 r GAL. NOT TO SCALE ACTUAL SIZE OF SEPTIC TANK !0 GAL. BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL.s gZ =- LEACHING AREA REWREMENTS OBSERVED WATER TABLE ( / / ) EL.-- SIDEWALL AREA 4AL./S.F BOTTOM AREA ' GAL./S.F LEACHING CAPACITY ( BOTTOM♦ SIDEWALL) ' ' GAL _ LEGEND . <� RESERVE LEACHING CAPACITY GAL, EXISTING SPOT ELEVATION 00,0 I l O(o �` EX(STING CONTOUR — — — - 00— 0> --— FINAL SPOT ELEVATION ® NOTES ' FINAL CONTOUR ----- I 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO DE Q.E SOIL TEST LOCATION TITLE 5 AND THE TOWN OF f RULES AND ---- - UTILITY POLE � REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE , - TOWN WATER W ===W 2 ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO CATCH BASIN ® ) WITHIN 12 OF FINISHED GRADE . I EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H- 10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT OF DRIVES OR PARKING AREAS. H-20 LOADING MIN, FRONT SETBACK SHALL 8E USED UNDER OR WITHIN 10 FT OF DRIVES OR PARKING. Qa, I MIN. REAR SETBACK 5. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE P. MIN. SIDE SETBACK SHALL BE MORTARED IN PLACE. / {`D fN / 6. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH "1 DEEDED OR ZONING REGULATIONS. OWNER /APPLICANT IS TO v,fp►iK !I, 2y TE �� j OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 11�jI 9 APPROVED : BOARD OF HEALTH QI 3s r I ' DATE AGENT `-_ =f I r j PROJECT LOCATIONt I APPLICANT. 15 0* l# I y ROB/N W. WILCOX PROFESSIONAL LAND SURVEYOR 203 SE T UCK E T ROAD # ��3 ' _ - J � � 385-6478 SOUTH DFNNt5 MASS 02660 SCALE, _ fQA /' Z t REV. REV LOCATION MAP J0e 000._1;113 2 - GO -z SHEET i OF 7-573 20 FT. MIN. F77 OFFOUND. �'� TEST S 10 FT MIN. GATE OF SOIL TEST - WITNESSED BY ' CONCRETE 4 SCH. 40 PyC PIPE CLEAN SAND PERCOLATION RATE MIN. INCH COVERS MIN. PITCH I/8 PER FT. OBSERVATION HOLE I OBSERVATION HOLE 2 CONCRETE 2 LAYER OF ELEV. = �% ELEV.= 4 CAST IR N PIPE 12 COVERS (OR EQUAL) MIN. ii 8 - 1/2 WASri�C PITCH 1/4 PER FT STONE Tv� ��vs_ `- ►: Z GOArZS't 5-f i0 FLOW LINE :EG%2.9 2 3 10" _ j E L = � Y"'f' - MIN. c o�72sa� EL._ EL = �j2.�� LEVEL = EL= EL. DIST - EL = 0 - BOX oov o Li WATER AT EL.= WATER AT 3/4"- I I/2 / G �o° v p o r��U GALLON WASHED STONE . ° o o u- p o u- 0 °o DESIGN CALCULATIONS W ° o EL.= SEPTIC TANK - PRECAST LEACHING NUMBER OF BEDROOMS BASIN OR EQUIV. GARBAGE DISPOSAL UNIT 6 DIAM. TOTAL ESTIMATED FLOW SEWAGE DISPOSAL SYSTEM PROFILE t __GAL./BR /DAY X BR ) GAL /DAY NOT TO SCALE ~— � REQUIRED SEPTIC TANK CAPACITY � %� GAL. ACTUAL SIZE OF SEPTIC TANK c GAL. BOTTOM OF TES' HOLE OR USGS PROBABLE WATER TABLE EL = LEACHING AREA REQUIREMENTS qs`� )BSERVED WATER TABLE ( / / ) EL = SIDEWALL AREA = GAL./S.F. �w BOTTOM AREA '% GAL./SF y0 v LEACHING CAPACITY,( BOTTOM+ SIDEWALL) GAL. LEGEND : RESERVE LEACHING CAPACITY y�o J GAL n ® L o 7 - �� EXISTING SPOT ELEVATION OUXO EXISTING CONTOUR — — — - 00- --- Iy 2 FINAL SPOT ELEVATION VINAL CONTOUR — - 0O NOTES 33 �j I ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E Q.E. 1 _ SOIL TEST LOCATION TITLE 5 AND THE TOWN OF rJ%Try RULES AND ' w.....�.�—.:w�.:� �—"'w. /• UTILITY P Jl.E♦u -..'�- ► - REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE I TOWN WATER W - =W 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO § CATCH BASIN WITHIN 12 • OF FINISHED GRADE . 3. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME. n �A 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H- 10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT OF DRIVES OR PARKING AREAS. H-20 LOADING MIN FRONT SETBACK _ SHALL BE USED UNDER OR WITHIN IO FT OF DRIVES OR PARKING. / MIN. REAR SETBACK 5. ANY MASONARY UNITS USED TO BR;NG COVERS TO GRADE +� MIN. SIDE SETBACK SHALL BE MORTARED IN PLACE. 6. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH 9 4 ' rr �►x°V¢ p`� /'�� / / DEEDED OR ZONING REGULATIONS. OWNER /APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. oo�,� TE! F� '60dv- & APPROVED : BOARD OF HEALTH .- �'}~��1, DATE AGENT Q v" I ffsf i� 0 PROJECT LOCATION, APPLICANT: l/,t?1 JE Ws3 y � JA ' `�f ROBIN W. WILCOX PROFESSIONAL ION SURVEYOR UCKETT ROAD t 385-64T8 SOUTH DENNIS, MASS. 02660 L o 7-5 Y i Z w InI4,A/ sr s� Sodr� SCALES _ DATES l Z����.�� "7 1 I REV. REV. LoT �� LOCATION MAP J0� N0'O/�3Z_ C, i SHEET 0F