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HomeMy WebLinkAbout0125 SAINT CATHERINE AVE - Health 125 Saint Catherine Avenue Hyannis L u 0 A=291 069 o i { a { h 0 r V N 1' e TOWN OF BARNSTABLE LOCATION / �� J�t n 1 W-(n t �Q-SEWAGE#�C�'�o® 7.? VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Cs� ��r..r��C.. SEPTIC TANK CAPACITY LEACHING FACILITY. (type) s ® (mac,L (size) I�1 NO.OF BEDROOMS �.., CL�Gs^6e15 W OWNER : PERMIT DATE: (, COMPLIANCE DATE: 11 `y/// Separation Distance Between the: Maximum Adjusted Groundwater-Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 �� i ::}✓�Cnl� � 6 ae ! � �e ee t � ' � ' � 0..t�11 !� 9 1/�1A/ V f. Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Zisposal *pstem ConstCUttion permit Application for a Permit to Construct( ) Repair('✓) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. U � ,co j\� C� rv-e¢ Xj Nam e,me,Address,and T 1.No. Assessor's Map/Parcel ���n�3 0`2 Gl e� � InstallerHN me,AA ess�,and de goys�n.(X� � De igner,'s Nam\�e,Address,and Tel.No. Sc.o rw �' .. w.r`j 3 OirNJF'*4 066 ' 6-,a6Y I 6 Sova. ". n)- 13a Type of Building: Dwelling No.of Bedrooms Lot Size o�sq.ft. Garbage GrindeM Q Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 2 M gpd Design flow provided �7 L gpd Plan Date t I E7 l ( (o Number of sheets Revision Date Title Size of Septic Tank Q 0 Type of S.A.S. /kc) V G e.11 D 1N Description of Soil Nature of Repairs or Alterations(Answer when applicable), �, (7 (q G.�, GEC 6� �U 2 hi 6 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by e - Date Application Disapproved by Date for the following reasons Permit No. 6 Date Issued —" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Npfication for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(v) Upgrade( ) Abandon( ) ❑Complete System ©Individual Components Location Address or Lot No. S c o nAt Cc%%r\r-2. A j Owner's Name,Address,and T 1.No. S\j Assessors Map/Parcel oZ 5 I— G,Gt Installer's Ilame,Address,and Tel.JNo � txjk De:§igne'r's N ?e,Address,and Tel.No. Sc-ot1 'FFr�,�.� t 3 U� Y� .f2J Sty \t��5 r ��� cnnn� s oY�`"�t oov5 p.o s t soufi�.. �;s 6a�►3a Type of Building: Dwelling No.of Bedrooms Lot Size 7 sq.ft. Garbage Grind Q Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _�G gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Q 5(1 t Type of S.A.S. /A:y U 9 S'00 G'0 1 0,\ Description of Soil M e c) coc rS-t —,)C."o W l i le 2 k c ro,j/\ Nature of Repairs or Alterations(Answer when applicable) A a d �o C-. o_ CSC � -1r) e x Skt�� 7� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date rf Application Approved by &JVDate Application Disapproved by Date for the following reasons i Permit No. 6 Date Issued ----------------------------------------------------------- --------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at c t�t= / "S&Y\4as been constructed in accordance with the provisions of Title5 and the for Disposal System Construction Permit No.,; ( -dated Installer C d{\ M R'./� Designer�G�-�J e �A G et,S #bedrooms Approved design flow,/ (r X gpd The issuance of this permit shall not be construed as a guarantee that the system wil�fim on/as designed. f Date , `j' Inspector --}----------------------------------------------------------------------------------------------------------------------------- No. 6 — 3 l Fee I"v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair(f) Upgrade( ) Abandon( ) System located at 5 r 1 n nt QT and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:Construction must be completed within three years of the date of this permit. Date -/ t }o Approved by S TRANS.NO.: CITY/TOWN: APPLICANT: ADDRESS: lZS S°r DESIGN FLOW: gpd REVIEWED BY: DATE.: I N/A OK NO GEI\7ERAL ;, i t Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310.CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, P'=20' or fewer for components) [310 CMR 15.220(4)] / Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required.[310 CMR 15,4.12(4)] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR / 15.220(4)(c)] e/ Location and dimensions of system components and resene areas. [3 TO CMR 15.220(4)(e)j System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity(required and provided) soil absorption system (required andprovided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] .Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] :Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] ✓ Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)) Observed and Adjusted'groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address 2`t1 co'? Sheet 1 of 7 N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the.case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system / components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer[310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15'.102(2) or as / approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75'. of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR . 15.000] System components not> 36" deep (unless Local Upgrade j Approval or LUA requested) [310 CMR 15.405(1(b)] Address —ct t.A.17 Sheet 2 of 7 I N/A OK NO Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth[310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter[310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR: 15.228(1)] / Separation between inlet and outlet tees (no less than liquid depth) [31.0 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have.risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - . middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 of grade - one port for systems<1000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access?. [310 CMR 1.5.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks fiom resources [310 CMR 15.211] .cam Required when other than single-family dwelling or flow>1000 f gpd [310 CMR 15.223(1)(b)] First compartment 2000%daily flow; Second compartment 100% daily flow [310 CMR 15.224(2)and(3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address . 24 1 l 409 Sheet 3 of 7 f N/A OK NO BUIL�ING�S_EW_ER��,1�1tD�OTHE��Pi�Y�G � � Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross; see 310 CMR 15.211(1)[11) Cleanouts required/provided ? [310 CMR 15.222(8)] ,Thrust blocks specified in force mauls? 310 CMR 15.221(6)(c)) Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / [310 CMR 15.222(6)] ✓ Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)) q% Siphon problem/(leachfield below pump chamber) ✓ Endcaps or vent manifold specified? ✓ Size and orientation of discharge holes specified. (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 / CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe y types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when . pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole'if>2000gpd [310 CMR 15.23.2(3)(d)) - PUMP C3A11IB RS ram, Capacity(emergency storage above working--design flow)?,[310 / CMR 231(2)] Proper setbacks J310 CMR 15.211 (same as septic tanks)]. Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible(not too deep with piping, disconnects accessible) Alarm floats - alarm:on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address t -� Sheet 4,of 7 N/A OK NO SoxBsoRPoNssE �sA ) ES ` : tf r, � .3 Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 1.5.211(1)[4] and Guidance Document] GALLERIES4PI 'S"C F[<A IYXBF RS310 C1ViR75 253 Y r 4 f r , , ; .. Chambers and Gal. in trench configuration supplied with inlet ` every 20 ft. [310 CMR 1.5.253(6)] Each structure with one inspection manhole (if->2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate I' minimum- 4' maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] TRE1vCHES3103C1�ZR525r N , t 3 s �. a,�p.e°' ,?�$a,�"..r Width 2'muiimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet- maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater (3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] BED SAS (Maximumsize o£ ed or' field SOOO gPd) ' � x a F' - .o+w,�. ?,. .`ski '7ti• rn �. .t minimum 2 distribution lines [310 CMR.15.252(2)(a)j Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(01 Bottom area used in calculations only [310 CMR 15.252(2)(1)] 4 Address `Zc1 / 9 Sheet 5 of 7 N/A OK NO �- ;D]� Pressure Dosed System ? Provided pump and piping, calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and UA Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR. 15.254(2)(d)] Construction in fill - Did the plan specifij that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional / Engineer [310 CMR 1.5.255(2)(a)] r✓ Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] - Grave�less:system' Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface 2T Alte»iatz�ey;Septic}Systei�z[I/ArApproval ettersj, ,� ' ,z M x} <4 F-M Was DEP Approval Letter provided and/or have you J reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant-submitted a copy of a maintenance �-�� � <.; l�krzarzcesf � xr x � � .�#....Fv r Are the variances listed on the plan? [310 CMR 15.220 (4)( )] ✓ RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] Address 29 Sheet 6 of 7 N/A OK NO Nitrogen � r Is the system in a Designated Nitrogen�Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] is the system proposed on the same lot as served by private well ? .[310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Pumping to septic tank ? j 310 CMR 15.229] Shared System [310 CMR 15.290] i Address 24/ �`� Sheet 7 of 7 I Town of Barnstable Regulatory Services Richard V. Scali Interim Director KAMA s�srrsu►�us. • Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: I 1 b Sewage Permit# r� 3 Assessor's Map\Parcel.,/Q Designer: !MP RE1J X. 1AA IDS,PC Installer: 5e_45M I.A. Address: 0. rk!)Ok 16 Address: US Ol.11 YXP..1-{OOT-4 A. 024% r ii O ZfcloO On `` I `� T- ►�. �j2>�1 K was issued a permit to install a (date) (installer) septic system at �r S _ (,� C�_& ,, I f based on a design drawn by (address) (designer) -1 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. . greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system.referenced above was constructed 1 nce with the terms of the IAA approval letters(if applicable) (Installer's Signature) At (Designer's Signature) (Affix Designer's Stamp 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:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable P# Department of Regulatory Services I i Public Health Division Date 200 Main Street,Hyannis MA 02601 -p • �iOIED M1K� � rV Date Scheduled Time , Fee Pd.' _ • s Soil Suitability Assessment for Sewage Dispo al Performed By: Witnessed By: , LOCATION&.GE�INFORMATION Location Address ^ ``ll C c�C 'I oZ 7s . C C, '`•`;VyV e, . Owner's Name M e�G(� J v 1\ 5 V 6% vIf; Address Assessor's Map/Parcel• ..�� ` `0j Engineer's Name NEW CONSTRUCTION REPAIR hone#TeleP � 5 0 .J Land Use 4 Slopes Surface Stones A_.A0 Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ; ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) -A.L Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ �� Weeping from Pit Nee Estimated Seasonal High Groundwater DET ,RNIlNATION FOR SEASONAL-HIGH WATER TABLE Method Used: t4- Nth Observed standing in obs.hole: In. Depth to soil mottles; Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well-0 Reading Date: Index Well level „ Adj.-factor a.' Adj.Groundwater-Level„p UJIC.QLATION TEST Data 'Alma ObservationZ�{. Hole# Time at 9" Depth of Pere Time at 6" Start Pre-soak Time @ . Time(9"41) End Pro-soak Rate Min./Inch Site Suitability Assessment: Site passed&I—/— Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observiitlon Hole Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICVBRCFORM.DOC I DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stonert;Boulders. �sistency.96't3ravell Lt DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon, '. Soil Texture --Soil Color ' Soil f Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Coslatency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulders._ • ' 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sail Other Surface(in.) (USDA) (Munselq Mottling (Structure,Stones;Boulders. consistency. 0myel) I � ' Flood Insurance Rate Map: Above 500 year flood boundary No— Yes •—r`P Within 500 year boundary No Yes Within 100 year flood boundary No.Y Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on `� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tralni ertise and experience described in�10 CNM 15.017. -/ Signature D ate Q:WEMC\PERCFORM.DOC Fee /UU No. THE COMMONWEALTH OF MASSAChkISEI'TS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for �Diq;po5af *p�tem COn!tructiOn Permit Application for a Permit to Construct(6-YRepair(grade( )Abandon( ) omplete System ❑Individual Components Location Address or Lot No. /2 S S j i J �,O4Ti�I�///lft1k,=0wnq's Name,Address and Tel.No. �•%L G�rTS Assessor's Map/Parcel D 9 Ins aller's Name,Address,and Tel.No.5,0?'CV2C` 5I�38 Designer's Name,Address and Tel.No. V Type of Building: Dwelling No. of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No,of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil, Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has bee ed by this Board of Health. ed Date Si Application Approved - Date rQ Application Disapproved for the following reasons Permit No. Co 5 Date Issued i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( e-Repaired pgraded( ) Abandoned( )by ,�o5�p�i %,� /�,etr� S at ���' ��ia, %Q rl�'d�Hi= �6LF �� r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q,C�6 .3 k dated 30 / Installer 12z Designer The issuance of this permits l�not th construed as a guarantee that the sy tem wil u do s designe Date ( Inspector .. _ ��� ---------------------- d_ No. �n�(o Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=i2;po5al *p�tem Con5truction Permit Permission is hereby granted to Construct( GyRepair( 6)�p rade( )Abandon( ) System located at r=h n4/=rzh�= /� 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: Construction must be completed within three years of the date f this pe t b Date: `�. I�D ( (A Approved i �� �� R V i �� C 330 Y 10/15/2009 08-2470 331 Y 10/15/2009 08-2471 332 Y 10/15/2009 08-2450 333 Y 10/15/2009 08-2457 334 Y 10/31/2009 08-2442 335 336 337 2009 Certificates of Registration missing: Please credit$150 forj6 units x$25/unit I TOWN?OF BARNSTABLE �~ LOCATION /Z SEWAGE # 2oDG-3g.�r VILLA"pE &9=1:5 : ASSESSOR'S MAP & LOT 29/- 069 INSTALLER'S NAME&PHONE NO. S08-y2U-973g� SEPTIC TANK CAPACITY XQ0 LEACHING FACILITY: (type) 2 SOo �j�4H'Ib��l` (size) USX/1 NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: =FS`30-U6 COMPLIANCE DATE: 9-7-06 Separation.Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching.Facihty(If any wetlands exist within 300 feet of leaching facility)_ Feet 'Furnished by • e s 0 '5TOWN OF BARNSTABLE LAC',ATION �i�Jff ` �� SEWAGE # VIL;ACE A ESSOR'S MAP & LOT PHONE NO. SEPTIC TANK-CAPACITY )5 LEACHING FACILITY: (type) � ' 1 (size) NO.OF BEDROOMS OWNER PERMITDATE: COMPLIANCE DATE:' Separation Distance Between e: 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. CAMtC7 Fee /®V THg-COM,IMONWEALTH OF MASSACHYSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Zi.5poor *p2lem Cun5truction Permit Application for a Permit to Constntct(6,)-Repair( grade( )Abandon( ) K-Complete System ❑Individual Components Location Address or Lot No. / 4::70vrh1 r/rlf 'wn s Name,Address and Tel.No. #/Z G r��TiS Assessor's Map/Parcel Installer's Name,Address,and Tel.No.S b`�' 2d " q73� Designer's Name,Address and Tel No X", Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Z&9T,�g/� 14''Dh 41 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 Certifi- cate of Compliance has bee ' ed by thi Board of Health. Si ed Date Application Approved k Date b Application Disapproved for the following reasons Permit No. CO 5 Date Issued No tp 34 J - n Fee �D U T kE COMMONWEALTH OF MASSACNV.S:ETfTS Entered in computer: rD y Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Y . 0ppYication for Migq!5ar bpztem Cori,5truction Vermit rApplication for a Permit-to Construct(Z,,)-Repair(4,)-Upgrade( )Abandon( ) omplete System ❑Individual Components Location Address or Lot No./Q,S S,4/!9 f¢ 'Owner's Name,Address and Tel.No. 601Z L elr rls Assessor's Map/Parcel Installer's Name,Address,and Tel.No.54,q- Designer's Name,Address and Tel.No. -- Type of Building: Dwelling No.of Bedrooms_� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil; Nature of Repairs or Alterations(Answer when applicable) Z&1 1<wl 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 Certifi- cate of Compliance has been issued by this Board of Health. Si ed Date Application Approved 4 __ _ Date Application Disapproved f�Or the following reasons .t , Permit No. �Cb Cy 3 5 Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( -Repaired ( y-Upgraded( ) Abandoned( )by �os� (a,- / �rvio S at i= L,z 4e_--- ,[a_�p S' has been constructed in accof dance with the provisions of Title 5 and the for Disposal System Construction Permit No. D Cb6 3�C'_rlated P- 36 /Z Installer�o �/��n� /�,u�-.-,�S Designer _ The issuance of this permits 11 not�'�construed as a guarantee that the sy tem w 11 un do s designed. Date _ Inspector No. �Q "` �2S 5 ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigponl *p5tem Conetructiou Vermit Permission is hereby granted to Construct( ,.-�Repair( 4)�Pgrade( )Abandon( ) System located at A115/1aA i 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: Construction must be completed within three years of the date P6f this pe t. Date:_�__ / (c Approved by1Z, `��. Town of Barnstable �f"E Regulatory Services . Thomas F. Geiler,Director KAM Public Health Division FEo ;�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Fortn Date: Designer: 174 4/L Installer: Address: Address: On $-34-DG ���pLi /� ��rros was issued a permit to install a ' (date) (installer) septic system at based on a design drawn by (address) r �T dated (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 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. O c� j VMTS M CAtaper's Signature) i Mesigner' ign e) (Affix s Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTIR THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE 'DInul IC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form gf COMMONWEALTH.OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONME9=L A '�' IRS[ wLE DEPARTMENT OF ENVIRONMENTAL, PROTECTION UP 6 TITLE 5 ; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION All C, 9 Property Address: Owner's Name. �' �3 �� Owner's Address: Date of Inspectio l Name of Inspector: lease print) .'� t �����,',, Company Name: Mailing Address: Telephone Number: l• �(� v�'�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 the inspection.The inspection.was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I.am a'DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: AT The system inspector shall sub t a copy of this inspection report,to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I s Page of l 1i OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ezlsi Owner Date of Inspectioni Ins ection-Summa : Check A B C D or E.7 ALWAYS complete all of Section D P -Summary: p 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 inf ltration or exfiltration or.tank failure is imminent.System will pass inspection if the existing tank is replaced witha complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatingthat the tank is less than 20 e available.years old is a ailable. ND explain: 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 mr"emoved distribution box is leveled or.replaced . ND explain: The system required pumping more than times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval Hof the Board of Health): broken pipe(s)are replaced. obstruction is removed ND explain: 2 Page 3 of 11 ' OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL; SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: Owner Date o•�nspection'U�_A�2fj� ` C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in.accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50,feet of a bordering vegetated wetland or a salt marsh 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:ofa surface water supplyor.tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply;welL _ The system has a septic.tank.and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance -.**This•system-passes,ifthe well water analysis,performed4 at a DEP.certified laboratory,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,provided thatno other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4,of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:. �4 Owner: Date o nspectio C � � 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''/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 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. _..Any portion of a cesspool or privy,is within-a Zone'l of a:public well. _ Any portion of'a cesspool or privy is within SO 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 coliform bacteria'and volatile organic compounds indicates that the well is free from pollution from that.facilityi 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 Xform.] Yes/No)The system.fails.I 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes. . no the system is within 400 feet of a.surface drinking water supply the system is within20.0 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. Ifyouhave answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"it 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. 4 I Page 5 of 1] OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST o�u� o �0 PropertyAddress: Owner: Date o nspection. Check if the following have been done.You must indicate`yes"or"no"as to each of the following:. _. ... Yes� �,....•+�...- -.......t%,2 .. ,.a :. },. .[..- d �Y "L ,.:. .; J. , -;. ...- �..� � _. Pumping.information was provided by the owner,.occupant,or.Board of Health . t, Were.any of the system components pumped out in the previous two weeks? _Vw s the system received normal flows in the previous two week period.? —j /— 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) V 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 — — y P g � _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected,for the.condition of the raffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth.of scum? /b P 9 P g P i//— Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal,systems? j The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 2Y ,,no , 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(3)(b)]. 5 Page 6 of l 1 ,OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS = SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. 9(W Date of.nspection: , wo / FLOW CONDITIONS RESIDENTIAL V Number of bedrooms(design) Number of bedrooms(actual): %� DESIGN flow based'on 310.94R 15.203(fo example: 11.0 gpd x 4 of bedrooms): ab Number of current residents/Q&A,y � � / Does residence.have a garbage grinder(yes or no): N0 .Is.laundry on a separate sewage system(y or no):�[if yes separate inspection required] Laundrysystem inspected()e .or no v Y P (Y � ) Seasonal use:(yes or no): � /O C Water meter readings, if ava' able(last.2 years usage(gpd)):0 -` Q TZ 7©d� Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL M Type of establishment: Design flow(based on 310 CMR.15.203)`. apd Basis of design flow(seats/persons/sgft,etc.): 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/use: - OTHER(describe): "then RAL INFORMATION Pumping Records : _ Source bf information: Was system pumped as (yes or no):Wo If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no).(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a cop of the DEP approval Other(describe): o_zimate age of all components,date installed(if known)and source of information: Were s; age odors.detected when arriving at the site,(yes or no 6 I Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: ,. S Date of nspectiot��p�+ /yytl�tpc �l� d BUILDING SEWER(locate on site plan) O Depth below grade: Materials of construction: . cast iron 40 PVC_other(explain): . Y .. . •. - Distance from private water supply well-or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC g TANK:ilocate on site plan) — P ) I Depth below grade: Material of construction: . concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: - Sludge depth: Distance from top of sludge to bottom of outlet tee or.baffle: 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: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAPl1(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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related.to outlet invert,evidence of leakage,etc.): 7 , os Page 8 Hof 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM.INFORMATION.(continued) Property Address: Owner: �� �✓� Date of nspection: � TIGHT or HOLDING TANK: b (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions` Capacity: gallons Design'Flow- Alarm Alarm present.(yes or no): Alarm:level: Alarm in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX/�(if present must be opened)(locate,on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER:(locate on site plan) Pumps,in working order(yes or.no): Alarms in working order(yes or no):- Comments(note condition of pump chamber,condition.of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , Owner: Date o nspection - SOIL ABSORPTION SYSTEM(SAS): Zlocate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 1 chin-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.): CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan)Number and configuration.. Depth'—top of liquid to Vie invert: Depth of solids layer: Depth of scum layer: ' Dimensions of cesspool: X Materials of construction: ��e4- Indication of.groundwater inflow.(yes`or no): ' C mments(note condition o soil,sins of hydraulic failure,level of ponding,con ition of vegeta 'on,etc.): ' Y PRIVY:. (locate on site plan) I. Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): L, 9 Page 10 of 11 OFFICIAL.INSPECTION FORM-:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: Owne Date'o nspectio 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. R uCo _: 3a c 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting properly/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:; /j I - 11 - Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION 40 40 40 40 40 40 40 ,~ Site Location: v� (5/S 1 Lot No. Owner: Address: Contractor: • Address: KJN G1�5�` ,V yy,� Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ..................... Date lZ Z dv month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: /•/, OA Appropriate index well............................... / w g�. OB Water-level range zone ........................ 4 STEP 3 Using monthly report "Current Water Resources:Conditions" determine current depth to izlOs- zZ water level for index well ..................... month/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 2B) determine water-level adjustment.................. Z 7 STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............. IZ•J Figure 13.—Reproducible computation form. 15 I 4 I v� i t / bS 9�l � Nd -7cl �11S � INNb�CH 3AV 3N16 -3HIVD 1N n Z �,3 1 1 � l i r ter. i - L 7 ok ' .- 9 - A-0'e7,9/ 7 ��,✓� ; .��C�T rnlG Co�,/Tad12S' .r '_'` \ � �--��a,a . l,ji�I.'•>T'r F��✓�I/�a�JS s �G O.�r � ... 9 ' ,4✓F 1141-L TES j. l rT. ✓LLB �i9 Q�6572 z HOLE - LOG . DEEP 08SER VATION �r• L'� /x� ��,��F CraCa� fa��G _ 4�;- C h::y/P� rr TOP OF FOUNDATIOPI COlICRETE COVERS 'ell 36 ,j i 4 CAST IRON LEACHING ,TRENCH (/)REQ. OR SCHEDULE 40 4' SCHEDULE 40 P.V.C. (ONLY) 9- MIN . „ 35 MAX. P.V.C.PIPE MIN. PIPE- MIN. 1/8 - 1/2 WASHED STON ' PITCHI/4NPER.FT PITCH 1/4"PER.F1 �-{ u ,__jjj���,,, •., d/dl`TY� 2 4.r`a�I.� ? .. G INVERT �INV':RT � ,tq'%�1'C]�t�� ta'6, 24 A;° SEPTIC TANK EL. 79..` BOY ,:. INVERT /SGY� . . GAL.. INVERT EL9�:��_ •• •._.... EL!9,�.,7... INVERT ,F'r@COst- 500 Gal.Leach �RUSHED STONE EL.:9Td7 (Z)REQ. Chamber aaa/ASHED STONE 17 �•' ___, PROFILE •.• �.°, sl /1/v GROUIID WATER TABLE 4reG SEWAGE DISPOSAL SYSTEM TYPICAL CROSa SECTION SOIL,,,.�LOO tfo SCALE LEACHING TRENCH . 1 OATE N 0?'Aa TIME ./�;CSQ.. . NO 5CA1�. S TEST HOLE I TEST HOLE Z DESIGN D� A ���'� • IT , ELEV. y�• '. ... . . ELM :y�v:�..... WASHED -36°MAX. ,,,,.• '� Y NU'd3ER OF BEDROOMS -��. . . . .. . . .. SME45 2� TOTAL ESTIMATED FLOW GALLONS/OAY ti"''` ""' "`'' 6 /eI BOTTOM LEACHING AREA lk_-Qt;.4; . SO.FT./TREtl . `' 1:5:1�;L7Y, 24` SIDE LEACHING AREA . . . .��/� ?. SOFT./TREtICH : ;;._L7.)_Je „ GARBAGE DISPOSAL /6 . . ..(50% AREA INCREASE) t1%q�✓� �r•7Z a�• � TOTAL LEACHING AREA SQ.r1. . . �-- PERCOLATION RATE 'PErR.INCH LEACHING AREA PER PERCOLATION RATE4:-V -r,SO.F-T.6Po - 4ZZ..o7x,79 GROUND VIATER TABLE �✓c APPROVED ��// , i30A?0 OF HEALTH !A ../ g;.WATER Et'I COUNT EREO DATE ... . . .. .. ... RI1 OF AGENT'Oil IIISPE:,TOR WITNESSED BY.: 44� BOARD OF HEALTH . . . . . . . . . . R i A l c'tlGit!' ER L �.� �+ ;�1'iF�rc:�.✓.!�,��9 . . . . . . . . . . . :. . . .. . . . . . , •5 Q . . , . . . . s.,.. REDSP ,•T .. ACCESS COVERS MUST BE WITHIN 9" MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NO TES : 6" OF FINISH GRADE 3' MAXIMUM COVER FIRST 2' TO INVERT OUT DIST. BOX: 43.53 DESIGN FLOW: BE LEVEL MIN 2" OF PEASTONE INVERT IN LEACH CHAMBER: 43.0 3 BEDROOMS AT I l0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION OR FILTER FABR!C BOTTOM OF LEACH CHAMBER: 41.0 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4" DIAM PIPE 3/4" - 1 1/2- DIA ADJUSTED GROUND WATER: N/A o NIA NO GARBAGE GRINDER 2. VER T l CAt DATUM IS ASSUMED. FOR BENCH MARKS q DOUBLE WASHED STONE OBSERVED GROUND WATER: 43.53 2' 35.2 SET, SEE SITE PLAN. cAso�$0 43.0 °� 41.0 BOTTOM OF TEST HOLE s l: BAFFLE SEPTIC TANK REQUIRED: 3 OUTLET 2-500 GAL LEACHING CHAMBERS 330 G.P.D. X 200% - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND N EXISTING D-BOX W/4' STONE AROUND. 12.8's x 25'1 x 2'd SEPTIC TANK PROVIDED: 1500 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1500 GAL CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6" CR USHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DES 1 GN PERC RATE C 5 M!N/l NCH PROF I L E : NOT TO SCALE SOIL TEXTURAL CLASS - ! 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 2-500 GAL LEACHING CHAMBERS W/4' STONE AROUND. A-47I S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR Al 471 S.F. x O.74 - 348 G.P.D. APPROVED EQUAL. /✓ 98°2S'40.0- j SOIL TEST PIT DA TA& 6 SEPTIC PRECAST ANK AND CONCRETE CONCRETE OROX SHALL APPROVEDBPORYETH�RCED ENE. PERCOLATION OBSERVED i 180'04 INDICATES V INDICATES- BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER _ / TEST - GROUNDWATER TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE TP*3 Ps15175 OUTLET. TP #3 0" HORIZON TEXTURE COLOR 46.5 EXISTING SAS �' LOAMY IOYR 7. BEFORE CONSTRUCTION CALL "0/G-SAFE". ay, ,•�. �6 A SAND 2/2 1-888-DI6-SAFE AND THE LOCAL WATER DEPT. TP«I FOR LOCATION OF,UNDERGROUND UTILITIES. I .. ...:' .. / - - - - -LOAMY- 14 A� 5 "' 2-500 GALLON B SAND 4/4 LEACHING CHAMBERS / 28' - - - - - - 44.2 8, SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE \ I D-BOX C MED-COARSE IOYR W/4' STONE AROUND / l SAND AND 6/4 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION 46.3+ o / GRAVEL OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE TP#2 EXISTING CONSTRUCTION INSPECTIONS. 1500 GALLON SEPTIC TANK BM. TOP OF FOUND EL-47.I6 1201 NO WATER 36.5 EST BY:S 6 TEPHEN HAAS WITNESSED BY: DAVID STANTON \I N PERC RATE: C 2 MIN/INCH / -- SEE'Poll IZ41 FOR'TP`s/ A 2 co DATED MARCH 22. 2005 . kl 4 b 6 01 ,a c 2 °25'40.0" a . L 0 T 6 . , / 6Z 44 G 27. 801± S.F. SEPT I C S YS TEM CUES l GN L_4NE a6 / 1 2S SA / NT CATHER I NE AVE . MAP 29 / . PARCEL 69 //9.96 27g°2`3 30.0" BARNS TABL_ E . ( HYANNI S ) MA . ROUTE28 / --- PREPARED FOR L EGEND y�s� Ry ■ CB CONCRETE BOUND M E G A N S LJ S , D / \ O L OCUS ' —W WATER L 1 NE HYDRANT SCALE : / ' 2 0 N O V E M B E R S . 2016 o step rr�`` G GAS L I NE z W BR V OHW— OVER HEAD W i RES Q OVERHHT EAT STEPHEN A . HAAS h —E UNDERGROUND ELECTRIC LINE _ ENGINEERING , INC —T— UNDERGROUND TELEPHONE LINE / �' ° P . O . B o x 16 —CTV— UNDERGROUND CABLEVISION LINE �j� i��' 1 1 � \ South D e n n 1 s MA 02660 t +40.4 SPOT ELEVATION �-��� /� j �� \ ( SOB ) 3 6 2—B 1 3 2 "1 _. _•••-40--•-_._ EXISTING CONTOUR / 40 PROPOSED CONTOUR LOCUS MAP 0 10 20 40 JOB NO: 16-061 -sue if �'f'o-3'9 y, �'f�ET/ .9/✓o ram`--`"�o'4�E� /�✓ '�,', I• / `��� �9�.�/�/ry�,Ai✓� Gov ?' � 3 s� q�'� �G��v : �x�tr�✓G- co•JTavf?S' ! �� _ �Ca. o ' �� ?.3 t7 qd 1,t, 'u t CLTi11),5 Ce,„2rtZ 5, C ��\lLH�►lo / �/ti"' v ` 3 X \� ? ���; �t•7�_7C1'on/ i'C, ,�r/�L� �S d"�•�E�'%/�13�R�.�: /�5�.a..✓.Lf��P,/1/�` ,a- 5e C %� � � ��-�G�� � �, \ r,.. �r'Tr,,,�✓'LLB- � �.�- o�6SS DEEP OBSERVATION HOLE LOG i �� .. � U•`n �<•.-F ' 1 � � � �.�i'/�f•('O"1 �,I`o�L o•L l��.0 alb.[ �f/�%� BE.i/�//r✓�,�p� vac� � l ��'�� /;6� �xTv�� c'cY•a� �r��G ' 8 1 S 8 �� �i.✓o �o)'�G/r9 29 �� y'�e � 9,da �x�s,,,✓G�� � i �,� �...� / \ / , Ts o T.���� �- =�l97-/6' , `J � `� � � �G/1•� " `�� ' ��_�,• � >l�n/D /�y�-S�-y � �9G�J� ��c..ro�.,c 9,'S� i / � � ��,,� �3/ -/j,-a C _ — ��'s.9✓a �a��rlo — P G rS Tc t� �.✓ �1 EL. . .... roT£ -U-SE o 0dL3LF b✓�t/�F..G sTar✓E TOP OF FOUNDATIOrl _�.. COtiCF;ETc COVERS 4� 1, i /. / 3�., ,� 4"CAST IRON 9� '' -III O / / , • 4"SCHEDULE 40 P.V.C. (OIJLY) 9. h11N _ „ \ , , OR SCHEDULE 40 LEACHING TRENCH (/ '— --,T )REQ. 36 MAX. �. P.V.C. PIPE MIN. - T PIPE- 1/4"p 1/8"- 1/2" WASHED STON - 7' PITCH I/4"PER.FT. PITCH 1/9"P�'t.r is 2': v M a \ i •'' I IIV�E�T 6/Is QgF,q� +d, ti ,CI%4. EL!/�/.. SEPTIC TANK E ifIVEP4, DIST. Ifq`-Rr ' ,A���'o.d� , t_i' 4;�15' 24„ ' ' I INVERT /S�j GAL. Ll�ERT BOX EL.^, ` �! EL'��. .. "cL.!9,3?... INVERT .Precast 500GaI.Leach 3/4"-I1/2",/ 9� _ 6„QRUSHED STONE (21 HEQ. Chamber �LVIASHED STONE o� L 44,14 PROFILE OF : : �� //�9/ /1/a GROUND WATER TABLE Vc SOIL LOG SEWAGE DISPOSAL SYSTEM TYPICAL CROSS SECTION OATc! �����, +.+c . ��-m!�"? 110 SCALE LEACHING TRENCH NO Sr-ALE , TEST HOLE I TEST HOLE 2 V ELEV.�I�- '. . .. . . ELM s'�:�. . . . DESIGN DATA M :r�r=�:✓o !o•►^'� !iU!.15 R 0' BEDROOMS —�. . . . . . . . .. =ED~ 36 tAA 8 .La9 6 y .._ORO . . . . . .. . WSTONE Y.. TOTAL ESTIMATED FLOW .,. ? GaLL01lS/0AYBOTTO : :y: •t•z• _ g" %Ikk px Z.B3+ 'HI1i �A7S ., ^Q; 7.S . SQ.FT./Ti1EfIC}I L7:T�,�_,�, 24„ ���, s ` SIDE LEACHING AREA . . . . ..�5/�,3?. SOFT./TPEfiC}I �'��d�� i EDWARD �` ��9�` /'a'�C / 3 sad g37Ls sLs xz = /S/.3z _C7.}=J;1� , E. i' Tt F� Loq?.T� GARBAGE DISPOSAL . ./1�fi . . ..(50% AREA INCREASE) kELLEY H n No. 2'100 C� Co9tZS� G - , TOTAL LEACHING AREA . .. '�7Zd7: SQ.FT. Al LAA PERCOLATION RATE.. . . .. PER.INCH / 3 LEACHING AREA P-A PE,RCOLAT 1011 RAT-E4W,.4 SOFT,��'•� y�7 v 7 x . 79 =�9�. �,-�- Ise- cL3S.d /� C� 7 GROUND 'HATER TABLE E"/c APPROVED .. . . . . . . . . . . . .. BOARD OF HEALTH SITE PLAN 125 SAINT CATHERINE A VEo� HYANNIS� MA _ DATE ... , . .. I b�S2 Azp..1VATER c ICODUTErREO . • SF►OF Mq5 WITNESSED BY.: AGENT 0.1 RISPECTOrj FOR BOARD OF HEALTH . . . . . . . . . . . . . . . . . . R` v �diFr4.,/• /a�LL h'.�. . EfiGIrIEER . . . . . , . . . . . . . . . . . . . . . 9 .5 Q s RED S GA IL CUR j I S PENTIo1IcR EVA03t 1