HomeMy WebLinkAbout0664 STRAWBERRY HILL ROAD - Health 664 Old`Strawberry Hill Road �-
Hyannis F/R
A = 249 086
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TOWN OF BARNSTABLE
`LOCATION cAd zAr AKp(,, SWAGE#
(PILLAGE /-/r`SASSESSOR'S MAP&PARCEL o t
gINSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY k(1 C3® it ,
LEACHING FACILITY:(type)r4 (S (size)
'NO.OF,BEDROOMS- 2
OWNER �y
PERMIT DATE:Ste[ [ 0 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY _Q[,1��
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AJ .2
A 4, �01
Liq
46.
3 Qy
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No. d`0 o l 16-5 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYicotiou for Mizpoor �pmem Cow6truction Permit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. ( ' ^/11 J r) .r �� Owner's Name,Address,and Tel.No. C!� P'•'
Assessor's Map/Parce 1 1(IJ 11�J(`�v �v d
— ;)A
Installer's Name,Address,and Tel.No. w Designer's Name,Address and Tel.No.
d Frc.,:k�C r t 6 t e� Yc j r-.0 qtt- GAS
'W�-
Type of Building: IF
Dwelling No.of Bedrooms Lot Size IS-0 14 sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided 37 S/ gpd
Plan Date d 6j Number of sheets Revision Date
Title Size of Septic Tank e X k SJ\ k0 QC: Type of S.A.S. 6 S-0 � 1U
� `kcz" U S� "L
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Qp CSc���
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 _ CY(I 1109 Date (n ( `0
Application Disapproved by: Date
for the following reasons
Permit No. d2 0 041 6 Date Issued
00
i No. d Feed
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. ,0
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zlpprication .for -Miopoe;al 4p!9tem Con.5truction Permit
Application for a Permit to Construct( ) Repair(. Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. } /\I )�) ►}. Owner's Name,Address,and Tel.No. Crest-)
Assessor's Map/Parce ^ l' t', 1L
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Id Yc..r--,(jvffi- Sf Gve G S ��
;�
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Type of Building:
Dwelling No. of Bedrooms .� Lot Size 'J Q y sq. ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
g, Design Flow(min.required) 3 3 0 gpd Design flow provided �7� gpd
Plan ' Date (,p N. 1(�Grj Number of sheets Revision Date
Title
Size of Septic Tank e X\S-\ \U OU Type of S.A.S. 3
Description of Soil S ()--- (oneJ cp „ram Cam, A)
Nature of Repairs or Alterations(Answer when applicable) q. C k A
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 /`i d
Application Approved by Date (0
Application Disapproved by: G Date
I
for the following reasons
Permit No. a2 0 09 6 Date Issued 6— / 0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Dispos398ystem Constructed ( ) Repaired V/1",Upgraded ( )
Abandoned( )by
at (O cO N s4a has beenDc�onstructeCd in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 90C ( ^�6J dated
Installer SCd Designer Cit.S rc,C,
#bedrooms Approved design flow gpd
The issuance of tlys permit shall not be construed as a guarantee that the systemw'. cti-OA, as desi = ed.
Date h � ! Inspector
--__—_--
No. � ! ❑--_—�_--_—_—�__--==---=--
0-0 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'Wi5po5al �&p5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair (L,,'I" Upgrade ( ) Abandon ( )
System located at ,,des,- yk�� L
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions P-special conditions.
Provided: Construction must be completed within three yE .rs of the date of this permit.
Date (� C Approved b
PP Y i
Town of Barnstalbl
�kIME t
Regulatory Services
Thomas F. Geiler, Director
* B"NSTABLE,
9q� MASS.
�0� Public Health Division
AIEDMA'�A Thomas McKean,Director
200.Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certif
ication Form
Date: j! m Sewage Permit# 2005 - /4 Assessor's Map\Parcel Z73 Zo�v
Designer: 5777--9,4&,-3 N.A� pE Installer: SCe, '
Address: Address: 1/3 v e-6
On e- a 5 was issued a permit to install a
(date) (installer)
septic system at (o G Oib s 6 L-,2-A q based on a design drawn by
(address) ol"c-4 rz-S
dated
/ (designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
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
5, of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
0 OF
3T PUCU
A.
staller's SignattVi�,� WAS
CML
W 35401
MAt
(Designer's Signature) (Affi c Desi er'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 Revised.doc
of
Town of Barnstable P#
Department of Regulatory Services
a i Public Health Division Date
�Ar 16s +� 200 Main Street,Hyannis MA 02601
Date Scheduled G -
--G C Z� Fee
Soil Suitability Assessment for Sewage Disposal
Performed By:
Witnessed By: V Iayi �N
LOCATION& GENERAL INFORMATION
Location Address �, f (S ` C �r�� Owner's Name
���-1� \, �
Address S'C
Assessor's Map/Parcel: p� a (J L Engineer's Name 'c w `AG �
NEW CONSTRUCTION REPAIR le
_ L J
Tephone#
Land Use Slopes(%) GZ
Surface Stones �y
Distances from: Open Water Body 4.A ft possible Wet Area�ft Drinking Water Well ft
Drainage Way�ft Property Line �'���Y�4 ft Other /Uf
ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
k
o
Parent material(geologic) o 5 H Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Race_ ti 1 A-
Estimated Seasonal High Groundwater iU A
Method Used:
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Depth Observed standing in obs.hole: In, De
ndex Well level pth to soil Inotties: jn
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: I Adj.factor -•.- Adj,Groundwater bevel
PERCOLATION TEST oats 2 �S7rinte ��:�•
FPre-soak
Time at 4"
8 Time at 6",
e @ D: 66 Time(9"•6")
S' L
Rate Min✓Inch /— Z-
i
Site Suitability Assessment: Site Passed irk Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation 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:\SEPTICIPERCFORM.DOC
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil. Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency, Gravel)
3
� ' a • Ls `lv � ,
3e> , LS lam s �
DEEP OBSERVATION HOLE LOG Hole# Z_
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
L. S o YX s�e
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.%Gravel)
r
i
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Co e 0/6 ammel)
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes ._
Vithin 500 year boundary- No 'L Yes
Within 100 year flood boundary No Yes
Depth 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? y� 5
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on �� �� '`r (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 tramin pertise and experience described in 310 CNM 15.017.
Signature_ Date 6 A °
;.
Q\SEPTICtPERCFORM.DOC
Town of Barnstable Barnstable
-•y Regulatory Services Department A&Ama9ca
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V$ 16 9 � ' Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205008529
4/23/2009
Tia Decoito
664 Old Strawberry Hill Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 664 Old Strawberry Hill Road Centerville,MA was last
inspected on April 03, 2009,by Robert Paolini, a certified septic inspector for the State
of Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
• Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
UAMMAMUTWILim,
CO
CO `U` . r
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0 Postage $ T 600Z 9 I
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Certified Fee �1�4
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O Restricted Delivery Fee
(Endorsement Required)
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C3 -b°beet,Apt.No.: I��JJ '�..� ----l-----------------
------PO Box No. •{ Y/V' + I l—P49A
City,State,ZIP 4
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ahh �s h/IA 07�D
Certified Mail Provides:
a A mailing receipt
® A unique identifier for your mailpiece
to A record of delivery kept by the Postal Service for two years
Important Reminders:
to Certified Mail may ONLY be combined with First-Class Maile or Priority Maile.
o Certified Mail is not available for any class of international mail.
e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
a For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
to If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT.Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
1111
�p THE ipN,O Town of Barnstable 'foes Pcs?t
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Public Health Division
9 HAHNSTAHLE,0• 200 Main Street
MA55.
iF0 MP'� 0 Hyannis,MA 02601 ? PITNEY ROWES i �
0004606238 APR 6 20 9
M ZIP CODE 02601
7008 1830 0002 O5O0 8482 MAILED FROM r1
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SENDER: • •N comPLETE THis SECTIONON .
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. ❑Agent I
X
■ Print your name and address on the reverse ❑Addressee I
so that we Can return the Card to you. B. Received by(Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits. i
1. Article Addressed to:
D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑No
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4. Restricted Delivery?(Extra Fee) 0 Yes
� 2. Article Number
% I (Transfer from service label)
7008 1830 0002 0500 8482 1 i
PS Form 381;1,.Febtuary 2004 Domestic Return Receipt 102595-02-M-1540
I/
Town of Barnstable Barnstable
oFt�r� ,
Regulatory Services Department y ��a�
BARuvsrasM
]6 4. , ' Public Health Division
°"'°�• 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205008482
4/15/2009
Tia Decoito
664 Old Strawberry Hill Road
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 664 Old Strawberry Hill Road Hyannis,MA was last
inspected on April 03, 2009,by Robert Paolini, a certified septic inspector for the State
of Massachusetts:`
The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
• Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean,R.S., CHO
Agent-of the-Board of Health
.g'; s, ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for A gnln IS Ma. 02632 4/03/2009
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. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out � �� 03
forms on the
computer,use 1.` Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.o>Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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 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 ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
4/03/2009
Inspe or's Sign ur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of'inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town 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:
The stptic system is in hydraulic failure at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of-Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
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 '/z day flow
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a 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.
® ❑ 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.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the 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.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town 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)]
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,distribution box and four infiltrators.
Number of current residents: unknown
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 ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007-
g ( y g (gp ))' 2008:226,500
Detail:
2007-2008:310 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/03/2009
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® 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/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M01664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
New leaching installed in 1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
1'
Depth below grade: 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 gallon
Sludge depth:
8°
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
23"
Scum thickness
15"
Distance from top of scum to top of outlet tee or baffle
1"
Distance from bottom of scum to bottom of outlet tee or baffle
2"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town 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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Yes
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.):
Box is Ievel.Box has one outlet Iateral.There is evidence of solids carryover.There is also evidence of
leakage out of box.
i
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note.condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.Leaching area is in hydraulic failure.System was full at time of inspection.
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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
Town of Barnstable Geographic Information System
Parcel Viewer I Custom MapIF Abutters Map Size M MIN zoom Out ]jfljj9j1In
0
/
O
r�
20 Feet
Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER
r-,,inhf')00r-')O 1A Tn...n of R-f.hlc RAA All rinhfe rceeni.
http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=273206&mapp... 4/1/2009
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. Cityrrown 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: Bottom of leaching 63.7'
feet
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:
As-Built Card
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 664 Old Strawberry Hill Rd.
Property Address
Tia Decoito
Owner Owner's Name
information is required for Centerville Ma. 02632 4/03/2009
every page. CityrTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF ARNST �� �
LOCATION ✓,' �"�`�"9 SEWAGE #
V14 AGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 0 s G S
SEPTIC TANK CAPACITY _e jC�j�l li n a
LEACHING FACILITY: (type) %aI �`1 C&ir�f (size) 0
NO.OF BEDROOMS
BUILDER OR OWNER,
PERMTTDATE: !Y )(�?f COMPLIANCE DATE: = �1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
iL
Zzcr-
q.
VQ
No. f 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes /
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[pprfcation for &-oozar 6potem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ZCompleteSystem 5KJndividual Components
Location Address or Lot No. .� 0� c��O�GC. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms �Z Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �3 d gallons per day. Calculated daily flow � ( gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �t�a ST �07� —��w Type of S.A.S. oc
Description of Soil R
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 an not to ace the system in operation until a Certifi-
cate of Compliance has been issued by_1W&BDatdof
Signe Date
Application Approved by Date'(/Ila/ lq?�
Application Disapproved for the following reasons
Permit No. ' Date Issued
;.. �'^..-...7....., �f,.,r.r• ..��"'-P - i ,,. <...,- +¢e.-...� 4„%a yr « -t. --. .. «»..�.y:+.-e>rt...M,. —--,-.s... .. - . .�. «-. ...,,,5.
No. .fit .d Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01pprtcation for Mtgogaf *potem Comaructton Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ZComplete System .9adividual Components
Location Address or Lot No. 6, o/ aOy�11_ ,(—'y�� ' Owner's Name,Address and Tel.No.
Assessor's Map/Parcel �a `F
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
c v l 0.o_
Type of Building:
Dwelling No.of Bedrooms 1> Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
y--' Design Flow 33 d gallons per day. Calculated daily flow y Cl gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ��tnnS r� . kCTW —T`4L^�Type of S.A.S. \-Voc S Cct-UCT-1 9_m?_r L-
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ��- T �� O C V
C i c L'rv-c, to rz (.A- t S c It
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 an not to ace the system in operation'until a..Certifi-
cate of Compliance has been issued b thi_s_&w of
Signe Date
Application Approved by 19 Date
Application Disapproved for the following reasons
r Permit No Date Issued P/ }
l . . / r
—————————— —— —— ---————— —————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS 7
f
Certtftcate of Compliance
THIS IS TO CERTIFY that the n-site Sewage is osal System Constructed( )Repaired ( )Upgraded(
Abandon ( )by bV �"C�E
at s e constructed ' accordance
with the provisio s of Title 5 and e for Disposal System Construction Permit No. ated q—2 q()
Installer !e �bt tS Designer
The issuance 4 thin tall not be construed as a guarantee that the system will function as designed.
Date Inspector _
—— —— —y— ——————— ————————————————
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mtoozal *p5tem Cott.5tru 'on Vermtt
Permission is hereby granted to Construct( )Repair( Up d�ef( ")Abpdon( )
System located at (ib 1 C �t• � � C t ' _
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/h r duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Cons ction ust be ompleted within three years of the date of t Merrdit
Date: Approved by
v
• s To Be Used For the Repair.of Failed
NOTICE: This Form I
F Septic Systems Only
a
j
KETCH AND APPLICATION FOR A
CERTIFICATION OF S N PERMIT (WITHOUT
DISPOSAL WORKS CONSTRUCt'IO
ENGINEERED PLANS)
a .
hereby s
application for disposal W0*3
�ty that the aPP- .-
i '5�i conCeming the '
e dated
��uction permit signed by m ;
f� meets all of the
located at
�� propectY .;
r:
41,1
following criteria: ``
«� reposed IeeehMg}bdllq► 1 ,-
(/• 'f1�ae ue no wetlands loested Within 100 titan of The i
. �c
wells Within 1 SO fbet of the propoxd
F 'IherO we Ito ptwate
•fhete M no Maeese in flow endlor change In the proposed
` '1ltete ere no verienoe9 or needed.
e ` Z30 feet of any wetlands,the bottom of the
• ff the proposed h�dnMg tk{lih►will be located within
M facility will att be located less thanlfoutteen(14)feet above the maximum adjusted
p w g , .
poundWe table elevation. 4
t ,
j = left the fone+wlags N r ti
plettee comp 0
A)Top of 0NOW Elevatlon(aocotdMs to the En Divleton 0.1.3.tnep)
B)Observed0MWwW'fable Elevation(according to Health Divhion walltnep)
i.
i DATB.
`• SIGN :
i
INSTALLER iN THE TOWN OF STABLE NUMBER.
a I LICENSED SEPt"IC SYS?EIN y
DNA•pwPosM Mtn Ain Intl+•IhnNd Imb11M petlM•M
••utlti•d Plat PI•ih
Ek fAN"A to 4 Pion
lltOYM be Wbnlllted). P
4 4�. • .. .:. �m-+sue.
:
«tllt�l tt:ldlfo Nll �. I
z' �i i
,,
,-
S
� a � \
..
�.
, _
.,
LOCATION SEWAGE PERMIT NO.
L o Srp�',r«pr > LL �4
VILLAGE ? -7
I N S T A LLER'S NAME i && DRESS
4Z 7-Og 1A Q 9,ItO5 .7�-
"ILDE R OR OWNER
J, S m ITIf
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
7j-
ZIA
No...........6--l... Flcs.2......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
dl............OF........
C9. -n.. ..
Appliratiou for Diipuiial Workii Tomitrur#iou ramit
Application is hereby made for a Permit to Construct ( vj or Repair ( ) an Individual Sewage Disposal
System at:
L cat on-41V
- or - t-No.
`\c
-- aj`!`e. ............ =---------...._�- .................. -- Q. _,cif._�C._ . !' . ..--------=------------------------------
vner 1 Address
ao----------- .......................................... Y� C�.J�O
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms____________ ............................Expansion Attic (�� Garbage Grinder RJR
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..............._................................................
W Design Flow................\X.9.................gallons per person per day. Total daily flow........... O....................gallons.
WSeptic Tank—Liquid capacity\000gallons Length................ Width................ Diameter________________ Depth................
Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet....... Tot 1 leaching a ..................sq. ft.
Z Other Distribution box ( ) Dosin tank ( )�A\�--C IV b\ fin. M5 S o 11—
'-' Percolation Test Results Performed by- _____ De
Test Pit No. 1________________minutes per inch Depth of Test Pit__ pth to ground water________________._____-.
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --- --------------
O Description of Soil....�-T- -�.�=-�-----------�------ • v�D.S_.......:
x .... ---------•- O`..............�-r --.-..--- � `�S-1------•. --
V ---•--•--•--•-•-•--•••-
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLU 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.
Application Approved BY �� ---f l.._.._.
Date
Application Disapproved fo th following reasons________________•_________._..__..__..___.______________•_______-___-_-_-_______•----------------._._....________
....-•..............•-•---------------------•------•-------------•----_......----------.....----------------•----••----------------•-------•------•--••-•--•---••--•-------•-•----------------•-•-••----
Date
PermitNo......................................................... Issued_.......................................................
Date
No.9........1.......... .._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_0�*",I .----...OF..........�-�r�"�,ri �.�_�`�',.7-
.........................................
rliration for Uiopooal Work.5 Tonotrurtion Vvermit
Application is hereby made for a Permit to Construct (V1 or Repair ( } an Individual Sewage Disposal'
System at:
.......... .... •-•----— •.....
Location•Addre ? or,Lot No.
. :� . \..................... ��.��...... ��<\c.l1.�� �%�_.�?.K..�............................................
Q,wner :-� Ad ress
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............3.............................Expansion Attic (N� Garbage Grinder (0 7
a`4 Other—T e of Building No. of persons............................ Showers
Other—Type g ---------------•---•-------- P •--(----)._— Cafeteria ( )
dOther fixtures -----------------------•---•----•-•--------------•-------------••-------------------•.....-•---•----
` 5 Ions.
W Design Flow.................�_.____..........._......._gallons per person per day. Total daily flow....._..._:...._.................. ....gal
WSeptic Tank—Liquid capacity`'90gallons Length-___-_____-_-- Width................ Diameter--__-.-____._--- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter................_... Depth,below inlet......... Tot 1 leaching a ..................sq. ft.
Z Other Distribution box ( ) Dosing tank (
P." Percolation Test Results Performed by.+ ____. _ ..a.........
....... ......... ............... Date... .'___
1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_--_________---__---
fL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ..............................................•---•-------.......------..........._.._...... --
D Description of Soil.....C: - "...._...-`_ �? <� =-�------..... ? ?- `' - - ............................................
1
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 TITLE 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.
gned.----- tQ J (�i�
c
Dat
.-:.--
ApplicationApproved By...... _.! °,r>E --•-------•-.......-•-------------------------•---.....--•---------. ..... t
Application Disapproved f dF t following.reasons:..............................................................................................................
......... ...... .................•---------------------------•-----•--------------•-•-•--••----•-------------...-------------------------------------------• ---•-------------
Date
PermitNo.......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t ,
... : ....:.........OF....... ...At
wrtifiratr of Tontplianre
b THIS I TO CERTIFY, That the., dividual Sewage Disposal System constructed ( or Repaired ( )
y :e--?� � r - .�..�-�---------------------------------------------------- -...
Installer
......
PP P kle:•••- Y:-�-_.._.._..._. dated-.. . d cribed in the-
r has been installed in accordance with the provisions of TITLE f The State Sanitary
application for Disposal Works Construction Permit �,o._ �',___ ._.�___________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UAR NTEE THAT THE
- SYSTEM! WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
N f�/.........!••-�'.•-- FEES.................
io oo 1t vrhii �onotr ion Pr
Permission is he by granted........V.-!Z---------Q r - � f
...............................................................
Construct ( o Repair ( ) an Individual Sewage Disposal ystem ;
Street ��� ��
as shown on the pli on for Disposal Works Construction Permit N .........__ .,._ ted.._.. _.__. .. ...............
.................................... ---•--.....---a.................................................
-
(� and of Health
DATE ..._p
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
51NGLc- FAMILY -- BE0RQOM
IINo Gaa.gA�� GwNOEcz 4
DAILY Ft: �W 110 X 3 = 330 G.Pv
I5EPTtG TA► K = 33ox15o"/• = �495G.Po 4
U5E' 100o GAL.
I DI.5P05A1- PIT V5E 1000 6AL. � � I
150
gpTTO/K AREA= Icy 5F• 9? %
5 p S.F X 1• o � 5 o G.P p- /GG � Sr� I�
'TO-TA1- DF.51CN = .g25 G.P�- 3
-ToTAt_ DA►LY
PE2GOLAT►oN RATE I'�1N ?-AIM OP-L>~55 ;r T-K.
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,Aes-7-Z ��sr.
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ICERTIFIED PLC> PL.A1J
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NO SCALE •rjCALE / - Sod_ VATa 4--
REF 6tZEN GE
P A
1 tE RTIFY TNAT 'CNE �ovN,�,arro/I/5Ko4YN .. I
NE-R6o1.1 GOMPL.`(5 YJIT1-1"THE S I DEL1t1 E .. .. ,LaT
A P S67PAGK 9,6Qu12EMEN`t'� OF •TNE _`- - =
'f o W N O��3H,e/�%s7:��3�c A N v ►S No T ,L�- �Sd PG ail
LOGP.TED WITNIIJ Nr~ FLoaD PLd.IN
p A-r G / `3 VV6Jj B AXT E e 1�.1`{E I N
r ' REGI'SZf�Q6rU I..A►JD'Sui�YE`�oZ'S i
TulS`PL&IJ ►� NCYT (3A�jFD p►d AN 03TE2VILL� • MA-`�s
�j I►�S-i-R.uM�NT 5�2.vEY �-rNE oFFSE'r5 5uou� '/ .
NoT D� 'v9EDTa DETF-F-P I AG Lc"r t-11-1E�j APPL_ICA►��'T
... .. .... ...................
_ a=.-n.. a :. .o,. a :. ♦... a :..:.,..., , -.a .. .P.. ....-.,v N'L. ..... z, >.q;' .,
.. .. a .... :.-.. .' R 'x•: .. .-.. ., r. .. ... ¢:'' .,. , .. ... -.... .. .... .-: .:.,., .... ..., :, :
,
ACCESS COVERS MUST BE WITHIN
INSPECTION 9 MINIMUM. , INVERT EL EVA T I ONS• DES I GN CR I TER IA : GENERAL NOTES :
6 OF FINISH GRADE PORT 3 .MAXIMUM COVER ,
INVERT OUT SEPTIC TANK: 95.4 DESIGN FLOW:
FIRST 2 • I. THIS PLAN IS FOR THEDESIGN AND CONSTRUCTION
MIN 2' ,OF PEASTONE INVERT IN D/ST BOX: 94;77- 3 BEDROOMS AT l!0 G.P.D. PER
BE LEVEL OF THE SEWAGE DISPOSAL SYSTEM ONLY.
OR FILTER FABRIC INVERT OUT DIST. BOX: 94.6 BEDROOM EQUALS 330 G.P.D.
DIAM PIP 40 4 DIA. !NVERT IN LEACH CHAMBER.
3/4 / l/2 2. VERTICAL DATUM /S ASSUMED. FOR BENCH MARKS
95.4 p• %0 DOUBLE WASHED STONE
BOTTOM OF LEACH CHAMBER: 92.5 NO GARBAGE GRINDER
SET. SEE SITE PLAN. ;
6AS $ 92.5 ADJUSTED GROUND WATER; N/A
BL AFF E 94.77 SEPTIC TANK REQUIRED:
.,
3 INFILTRATOR 3050'S OBSERVED,GROUNDWATER: -N/A 330 G.P.D. X 200V - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND
3 OUTLET • 87.5 MAINTENANCE OF THE SEPTIC SYSTEM SHALL
EXISTING W/4 t STONE AROUND BOTTOM OF TEST HOLE 2. SEPTIC TANK PROVIDED. lOOO GAL. EXISTING
_. D-BOX
1000 GAL 12'w x 29'1 x 2'd - CONFORM TO MASS. D.E.P. .TITLE 5 AND LOCAL
SEPTIC TANK ' CRUSHED STONE OR STEM REOUIRED: BOARD OF HEALTH REGULATIONS.
6 SOIL ABSORPTION SY
COMPACTED ;BASE f DESIGN PERC RATE ( 5 M l N/I NCH
SOIL TEXTURAL CLASS l 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
PROF I L E • NOT TO SCALE AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
EFFLUENT LOADING RATE - 0.74 GPD/SF
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: 3 INFILTRATOR 3050'S
: W/4*± STONE AROUND. A-5I2 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
512 S.F. x 0.74 - 378 GPD APPROVED EQUAL.
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
/' SOIL TEST PIT DA TA & PRECAST CONCRETE OR APPROVED POLYETHYLENE.
BOTH SHALL BE WATERT
� I ND/CA TES y I ND l CA TES IGHT, D-BOX SHALL BE WATER
PERCOLATION = OBSERVED TESTED FOR LEVEL WHEN THERE I S MORE THAN ONE
N 89022'43'E 188.67' TEST GROUNDWATER
OUTLET.
i
1 ���/ ..• TP / Pw12570 TP *2
7. BEFORE CONSTRUCTION CALL 'DIG-SAFE'.
I �� . ;0 ''�� I-888-DIG-SAFE AND THE LOCAL WATER DEPT.
LOT 2 I cqy HORIZON ZON TEXTURE COLOR HORIZON TEXTURE ' COLOR FOR LOCATION ION OF UNDERGROUND UTILITIES.
0' 98.0 0" 97.5
15.044+ S.F. BM. SL I DER THRESHOLD // b
EL-100.85 EXISTING SAS +98.4 A LOAMY IOYR A LOAMY IOYR
�` .. 27.9 SAND 3/3 SAND. 3/3 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
t. 4A.g ' : 3 INFILTRATOR 3050'S 7. .......................................... 97.4 6' 97.0
/ TONE AROUND 35' : '• d-eox wig s R o, p B THE SYSTEM T L OR SCHEDULING N F E
LOAMY l O YR LOAMY IOYR
DES I GN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
•. ' OF TO S G0 TH
SAND 5/6 SAND 5/6
•. .. , ;.: ., r TPr/ 30' .:......................................,. 95.5 28- .:..:.................................... 95.3
CONSTRUCTION INSPECTIONS.MED-COARSE IOYR C I MED-COARSE IOYR
PAVED DR VE! : °'� TP.2 SAND AND 5/8 SAND AND 5/8
m +97,? GRA V r-- `• l�.� _ h GRAVEL
EL
48"-
v DECK_ E
:,.
_._.T
w r 12' OAK
00
•�' EXISTING "'J .� '
SEPTI TANK �� I20. NO WATER 88.0 120 NO WATER 87.5
97.6 / IN'LINK DATE: MAY 26. 2009 r ..�
��sNA TEST B Y: S TEPHEN HAA S
WITNESSED BY: DAVID STANTON STEPH
EQ to' a A. -
/� . Q0Og'3 PERC RATE: C 2 MIN/INCH CAAS
N
f 5 6 No.354 tI �
t7
O :
d
S E P T 'D E S / G/\/
664 OLD S TRA WSE'•RR Y H / L L RD , MA P 27.3 . PCL 2045
- c w �
46 A R /V S T A S L G . < CE`N TER V IL L E ) /V/
� N
PREPARED FOR
9p
LEGEND S C O TT M . R A /V K
A 0 OLD YARMOUTN ROAD • HYA /V/V / S . MA 0200 /
■ CB CONCRETE BOUND
�\ -W WATER L l NE
O HYDRANT S CA LE- / '• 2 0 J U/V E 2 . 2 0 0 9
LOCU�s , -G CA3LINE EAGLE SUFRVEY I NG 1, 1 NC
I ! #W- OVER HEAD WIRES 923 Rou t e 6A
o -E- UNDERGROUND ELECTRIC LINE Y a r mo u t h p o 0 2 6 7 5
r t MA .
-T- UNDERGROUND TELEPHONE LINE ��/ %�� 1 1 5 0 8 3 6 2-8 1 3 2
-CTV UNDERGROUND CABLEVISION LINE ��i��/ 508 432-5333
+40.4 SPOT ELEVATION
1 _40-` EXISTING CONTOUR
4( 0]__- PROPOSED CONTOUR
H
L OCUS MAP 0 10 20 40 FjOB NO: 09-035 1 FIELD:CFW/EEK CALC: SAH/CFW CHECK: CFW DRN: SA
a