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HomeMy WebLinkAbout0150 ABBEY GATE - Health 150 Abbey Gate cotuit i No. UO Fee ., Entered in computer: . THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for �Digo5df bp$tem Cow5truction 30ermit Application for a Permit to Construct( )Repair( )Upgrade(/)Abandon( ) O Complete System MIndividual Components Location Address or Lot No. /� �Q Owner's Name,Address andTel.No. Assessor's Map/Parcel Go 1L �`f Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 4 Lot Size ` V-3 sq.ft. Garbage Grinder( ) Other Type of Building 61Z No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow llz4 gallons per day. Calculated daily flow gallons. Plan Date Nu ber of sheets Revision Date Title S Size of Septic Tank Type of S.A.S. — C Description of Soil j�s-5—X �•83 X Nature of Repairs or Alterations(Answer when applicable) ve DESIGNING ENGINEER MUST SUPERVISE INSTALLATION AND CERTIFY IN WRITING Date last inspected: THE SYSTEM WAS INSTALLED IN STRICT Agreement: ACCORD;..I`,E TO PLAN. 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 b 's B ar H h. Signed Date Application Approved by N''- - Date 3 Application Disapproved for the following reasons Permit No. "L003 Date Issued �s d -- — -- -- — ----------------_--_--------- I No. l)d I S6 — ::a " �.�.. w .— e s_3k Fee � � 4 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS- 0[ppYication for Mi!50aal *pgtem Construction Permit Application for a Permit to Construct( , )Repair( )Upgrade(/)Abandon( ) Complete System LJ Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �l/ - Designer's Name,Address and Tel. for �1d N . Type of Building: ,°,b °= Dwelling No.of Bedrooms n Loi Size O/W _3sq.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 y 3 Number of sheets R/ iisio ate Title r-1,-lP r �3/to I)XM 0 ,, X�p e � N� Size of Septic Tank /f��0' 1�l'� 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 C rtifi- cate of Compliance has been issued b��thB' , e th. ,.--Signed Date Application Approved by �.� '1`'- 1 Date /� Application Disapproved for the following reasons Permit No. Date Issued s j THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that t e O -site Sgwage Disposal System Constructed( )Repaired( )Upgraded Abandoned L )by at 1-5?2 /� "I',"�Y ���� 2 _fkhtaG been constru t¢/in ��ordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated , Installer Designer �- The issuance of t s pe it shall not be construed as a guarantee that the syst w'11'f cMon Jesig d. Date � � Inspector --------------------------------------- No. d 0.03 S L Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Otoo9al *pgtem Construction Permit Permission is hereby granted to Construct Refpair�/Upggrde( 1'Abannd ny— System located at �f / 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 of this permit,:1\ eit.1\ y�S Date:_ l,� ��S /`�3 Approved by � I tel.(508)362-4541 939 main street rt 6a fax(508)362-9880 yarmouth port mass02675 down cope enbaineel civil engineers& land surveyors R � �� El F structural design Ar a H.Ojala P.E., P.L.S. Da)liel A.Ojala,P.L.S. land court JUN U 9 20 Tir�Sothy H.Covell, P.L.S. surveys TOMI OF BAr3i�3TA LE June 4 , 2003 HEALTH fJEPT. site planning Thomas McKean, RS sewage system Director, Barnstable Health Department designs 200 Main Street Hyannis, MA 02601 inspections Re: 150 Abbey Gate, Cotuit permits Dear Tom: On May 14 , 2003, Down Cape Engineering, Inc. performed a soils removal inspection and inspected the liner at the above-referenced location. This is to certify that the soils removal and liner were satisfactory. If you have any questions, please do not hesitate to call me. Yours truly, Arne H. Ojala, PE, PLS Down Cape Engineering, ,Inc. cc: Bortolotti Construction TOWN OF BARNSTABLE LOCATION - SEWAGE #,&0.7-/r6 VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. -4zl/✓ 07 �9?C SEPTIC TANK CAPACITY �•���' G I LEACHING FACILITY: (type) 5da GkC eA"I-f (size) /73:f X NO.,OF BEDROOMS _ BUILDER OR E �� PERMTTDATE: �� o� COMPLIANCE DATE: i 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 Furrlshed by clw✓ .3a� 3a �b le Q 5�19 SSG^ f w 1 5� 7 I COMMONWEALTH OF MASSACHUSETTS. z EXECUTIVE OFFICE OF ENVIRONMENTALAL'FAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED FAILED IMSOPECTION FEB 252003 TOWN OF BARNSTABLE TITLE S HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP Property Address: L55 PARCEL Owner's Name: Owner's Address: Date of Inspection:o/ ,e t.�4,/ LRE Name of Inspecto (please rint) , plUi Company.Nam Mailing Address: 4 � y�Telephone Number: 7 =� w„,.m.m. �— 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: Dater .r 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. Notes and Comments J ****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. 6/15/20.0.0 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A `CERTIFICATION (cont nued) Property Address: da-o�� ��� � Owner: _ Date of Inspection-:JAM Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D . A. System Passes: C ', I have not found any information which indicates that any of the failure criteria described in 310 CMR .15.303 or in 3.10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health will pass. Answer yes,no or not determined (Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent:System will pass inspection if the existing tank.is.replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank,will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatingthat the`tank is e less than 20 years old is available. 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 is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 1- Page 3 of I 1 OFFICIAL INSPE:CTI.ON FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A . CERTIFICATION(continued) Property Address: Owner. Date of Inspection:_'_Tr� 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(MR 15.303(t)(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 aseptic tank and soil absorption system(SAS)and the.SAS is within.100 feet of 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 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 that no 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: Owner. Date of Ins pection: 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 invertdue'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 _ 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. -7 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 I of a,public well. Any portion of a cesspool or privy is within 50 feet of aprivate 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 facility 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.] (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 facilitywith 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 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 lI 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART B CHECKLIST Property Address:. Owner: , f Date of Inspection:SL�� 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 7 ✓_ 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: Yes 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION Property.Address: Owne Date of Inspection: 17__� //u y X� FLOW CONDITIONS RESIDENTIAL f,� Number of bedrooms(design).� Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 for example: 11.0 a d x#o�bedrooms): .Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no): .[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no Water meter readings, i (last 2 years usage(gPd)): Sump pump(yes or no)• rr� Last date of occupancy: COMMERCIAL/INDUSTRIA Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the nspection(yqs or no) a If yes, volume pumped: gallons--How was qu ntity pumped determined? Reason for pumping: TYPE OF SYSTEM _V�eptic 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 copy'of the DEP approval _Other(describe): Approxima a age of all components,date installed(if known)and source of information: Weresewage odors detected when arriving at the site(yes or no) 6 Page 8 of 11 OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: CAP Owner Date of Inspection:ect ion• 0 3 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: y CaP acit : gallons . w: allons/d.aY Design Flo g g 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:.z(if present mtast be opened)(]ocate.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 age into or out of box,etc.): 69, 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.):. ' r 8 Page 7 of l I - OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of Inspection: o/ BUILDING.SEWER.(locate on site plan) Depth below grader Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below,grade: Material of construction:_keoncrete_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 certifcate) Dimensions: )(& k5 Sludge depth: Distance from top�R,fsludge to bottom of outlet tee or baffle: Scum thickness: $' Distance from top of scum to top of outlet tee or baffle: o� Distance from bottom of scum to bottom of outlet t e or baffle: " 3� How were dimensions determined: _C192,1'_/t� Comments(on pumping recommen ations,�inlet and outlet-tee or baffle condition,structural integrity, liquid levels as elated to outlet invert, evidence of leakage,etc.): CL GREASE TRAP locate on site plan)" Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other. (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet 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 wT _`. Page 9 of l t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION(continued) Property Address: Owner: Date of Inspection: O SOIL ABSORPTION SYSTEM (SAS): i/ (locate on site plan,excavation not required) If SAS not located.explain why: Type -Z-1eaching pits,number: leaching chambers,number: 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. CESSPOOLS./ �►A_(cesspool must be pumped as part of inspect ion)(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-,or no): Comments(note condition of soil .signs of hydraulic failure; level of ponding, condition of vegetation,etc.): PRIVY (locate on site plan) Materials of construction:. Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic.failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property A dress: Owner Date of Inspection: " SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. i Yj) 1� O 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: ,j j Owner: � Date of Inspection: n" q3 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 property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with,local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 'Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 7(� ,� ��f Lot No. Owner: Address: Contractor: � �o���T t� J Address: Notes: �/�S ��� STEP 1 Measure depth to water table to nearest 1/1.0 ft. ...........................................................................:... .Date z /r��3 zZ month/day/year STEP 2 Using Water-Level Range Zone and Index Well'Map locate site and determine: O Appropriate index well........................ .............. /ilr`!✓ OB Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to ®lAo water level for.index well .......::.................. z month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),.curr.ent depth. to water level for index well (STEP 3), and water-level zone (STEP 2B) 7,1 determine water-level adjustment-............................:.............................................................. STEP 5 . Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ....................................:............................................................................ Figure 13.--Reproducible computation form. 15 f ,� .� - - - �";�"+. ';�;,, �n,.,-,j �,� _�. ' �_Y �a. „• �� �� x�„_._.� �,..,.�,,.... jQ 1 i t t-... �i �� `"'�, :_.__ �' """'"� a. � � �ii }«:..� - � � ��4 �' � y f � �.--- - - , � �� � � I ' BORTOLOTTI CONSTRUCTION, INC. `� 9 765 WAKEBY ROAD,MARSTONS MILLS,MA 02649 508-771-9399. 508-42.8-8926 FAX:. 508-428-9399 y 4 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIC kTION Property Address: AIA Date of Inspection: I pector' Name: Owner's Name and Address: OERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal tems. The System: 7Passes Conditionally Passes Needs Further E on By l Local Aproving Authority Fails Inspector's Signature: Date: Y��S The System Inspector shall sub a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of.the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION JMMARY• A)SYS M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated 4. below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If "Rot determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or.tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): 1 - ,K 1 �? � ✓s's` tip* _.r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION(continued) Broken pipe(s)replaced i Obstruction is removed Distribution Box is levelled or replaced The System required pumping more.,than four times a year due to broken or obstructed pipe(s). . The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction_.is.removed, C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or,privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a sait'marsh: 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT-THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT;THE PUBLIC,HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 5,0 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and-the presence of ammonia nitrogen and nitrate nitrogen is dual to or less than 5 ppm. D)SYSTEM FAILS:-. I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 invertAue to an overloaded or clog- ged,SAS.or cesspool. ,_ x,;;:','c :':••.. , . Liquid depth�in cesspool is less than 6"below invert oi1vailable'volume is less than 1/2 day flow. y Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- { ' SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM ' PART A p CERTIFICATION (continued) i Any portion of the Soil.Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of ip' ivate water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach.copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen., E)LARGE SYSTEM FA M: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant. threat to public'health and safety and the environment because one or more of the following conditions exist: y 4 The system is within 400 Feet"of a surface dn'nkmg water supply " "`The system is within'200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area ` (IWPA)or a mapped Zone II of a public water supply well: The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST .-r^.r. .n :.T"� ..+' r�4:rM1• ,y� .+�.f .,.�» ..rw ., fa u..a.- .. :. Check if the following have been done: _Pumping information was requested of the owner,occupant,and Board of Health. ,_&,::� Flone of the system components have been pumped for atleast two weeks and the system has !,been receiving normal flow rates during that period. Large volumes of water have not been / introduced into the system recently or as part of this inspection. I/ As-built plans have been obtained and examined. Note if they are not available with N/A. r�j facility or dwelling was inspected for signs of sewage back-up. system does not receive non-sanitary or industrial waste flow. site was inspected for signs of breakout. ^F - , f he components,excluding:the Soil Absorption System; have been located on site. �! The septic tank'manholes were uncovered,opened,.and the inteiior.of the septic tank was,in- :. •^ ; spected for condition of baffles-6ftees,matOial'ofconstruction,dimensions,depth of liquid, v ' depth of sludge,depth of scum. 17:`,•• The size and location of the-Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- f /f Y i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) '' Th facility owner and occupants,if different from owner were provided with information on efa tyo ( p ) the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r_ PART C` SYSTEM INFORMATION FLOW CONDITIONS •� Design Flow: ions Number of Bedrooms: Num r of Current Residents:�'ILsddl6 Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter ,if vailable. Last Date of Occu - Q._ Type of]sstablishateni: r. Design.Flow: . sallonstday Grease Trap Present: (yes or no) Industrial,Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection: ,w If yes,volume pumped: ,gallons Reason for.pumping. TYPEf QF.SYSTEM: P Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) ; Other(explain): = . APPROXIMATE AGE of all components,date installed(if known)and-source of,'inforroatioriS ' Sews odors detected when arriving at the site: I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,� 'PART C': GENERAL INFORMATION (continued) 41 SEPTIC TANK: Y ` Depth below grade:y Material of Construction: concrete metal FRP—tither (explain) Dimisions:&),5'X 6 'X6' Sludge Depth: 7 Scum Thickness: S .4 Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ) ' Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation outlet invert structural integrity, vidertce o leakage,etc. ' - GREASEIRAP:/t• U Depth Below Grade: Material of Construction: oncrete metal FItP Other (explain) . —c oi.ic — — — t i... Dimensions: - Scum Thickness:" _ Distance from top of scum to top of outlet tee or baffle: f Comments: (recommendation for pumping,condition of inlet:and'outlef tees of biiMes,,depth of liquid "levelin telation'to outlet'invert- tnicturaI integrity,'evidence'of,leakage,'etc:)" . a ' TIGHT OR HOLDING TANK: AAJ Depth Below Grade: Material of Constriction: coiicrete_metal_FRP—Other(explain) Dimensions: Capacity: gallons Design Flo«': gallons/day Alarm Level: Comments:(condition,of inlet tee. condition of alann,and,float switclies, etc,),. _ DISTRIBUTION BOX: , Depth of liquid level above outlet invert: Comments: (note if el and distribution is equal,evide a of solids carryove , evidence of leakage into r out-of box,etc.) -PUMP CHAMBER A) 4 . , .... Pump is in working —� P g order. Comments:'(note'conditionof pumpchamber,condition of pumps and appurtetiances;-etc) -5_ f SUBSURFACE,SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): ✓ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments:(note condition of soil,sinp of hydraulic failure level pf ponding,c dition of vegetation CESSPOOLS: Number and configuration: Depth-top of liquid,to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: - Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: . Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL*SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH.OF SEWAGE DISPOSAL SYSTEM: Include ties to atieast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. I l0 n ib '. .i ..... ..., . ....- DEPTH TO GROUNDWATER Depth to groundwater: Z Feet Method of Determination or Appr xima ' n: �i�'% ?�`�, �/��►� . !il/f t�� J` Ou _7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR'I'B -• ,; CHECKLIST(continued) - The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RIZS1[DRNT1n2gs Design Flow: lons Number of Bedrooms: N ber of Current Residents: Garbage Grin Laundry Connected To System Seasonal Use:Water Meter Rea ,if ailable: Last Date of Occupancy: — .O MF.R AIJIND ST IAL Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection:�(L If yes,volume pumped: gallons Reason for pumping: TYPE"OF SYSTEM: I/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool . Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP XIMATE AGE of all components,date installed(if known)and source of information: Sewag ors detected when arriving at the site:_() -4- 00 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any W rtion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less titan 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coli.form bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant. threat to public health and safety,and the environment because one or more of the following ,,,conditions exist: A t The system is within 400 Feet of a surface drinking water supply r The system is within 200 Feet of a tributary to a surface drinking water supply ' The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CH ECKLIST Check i the following have been done: t/ Pumping information was requested of the owner,occupant, and Board of Health. —AZ None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As-built plans have been obtained and examined. Note if they are not available with N/A.. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on site. t=The septic tank manholes were uncovered,opened,and'the-interior of the septic tank was in- spected for condition of baffles or tees,material of construction,,dintensions depth of liquid, depth of sludge,depth of scum: The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- TOWN OF BARNSTABLE LOCATION 18G � �y 1<41 SEWAGE #a2003-1r6 VILLAGE GaIii.,7' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �er�.�i •`�a�r�nro✓ /1 p9?` SEPTIC TANK CAPACITY /,ypc Gt L LEACHING FACILITY: (type) raj c l eArv1,-f � (size) iJ X73 r .47 ' NO.OF BEDROOMS BUILDER OR R PERMITDATE: �� �� COMPLIANCE DATE: �5 0 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 cbw✓ visa lb - a i 56 5� v v A z �.GO s s � v A -♦ � a Z N •• s f'�1 C NI � a � C a N N � A 1�1 A V� 1 $ O FRn�t , FT `� M No..............fz:.Y3,, 3 F�s..''n..`.... • THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......... ....... ---._...---.....OF.n.....................................----..............--------------.................. Appliration for 3lispos al Works (> owitrur#iun ramit Application is.hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: / ........... 1 ..... ........ _.... ca .----•- ......•--•--•-- •-•-----•--•---•----•-•....................... ocatio ddr or t No �Fs. .../¢ - .._ . . --....66•...5:N.. ..1' .t..pT__..... .. Owner H Ad ress w .......................................................... 'r ............................. ..................•...•..................................................................•........ Installer ' Address PQ d Type of Building Size Lot__ .....Sq. feet U Dwelling—No. of Bedrooms.............. _ .....Expansion Attic ( ) Garbage Grinder f ►� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ...................................................... W Design Flow..........................11.0..........gallons per person per day. Total daily flow-------33 O........................_gallons. Septic Tank—Liquid'capacity...''' "3_gallons Length_-___.-__-__ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter....�.: ?....... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin tank ( ) aPercolation.Test Results ����pp Performed by. � a[,� (- Sd'-�----------------------------- Date...M/A---------------- a Test Pit No. 1_�l1_�_l�P�iinutes per inch Depth of Test Pit.................... Depth to ground water........................ LL, Test Pit No. 1,2.&C.Uslinutes per inch Depth of Test Pit.................... Depth to ground water........................ t� 0 Description of Soil........=............................................................................................................................................................... x W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------------•-••----•----•--•--•------•-•--••----••-------..........................------------------._........•-•••-•••••-••••••-••••••••••••...-•--•••-•-•---------•••-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLi� 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 f health. 3 ,q's C,, .. . 1 Sig, d•••••_... �� J�!v!. � ._ a Application Approved By •.••• -- ---`--------------- ------------------------- ....� ;'zl) Date Application Disapproved �or t e following reasons------------------------------................................................................................. --------------------•-------•-------•-------•------...---------------------------•----------------.........-------------•--------•-------------------------------------....----•••---•••••••••••••-•-•-•- Date Permit ......................... Issued------------------------------------------•----•••-•--- �, Date IV .. e NO................_...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ..._ ..__..............OF.......................................................................................... Allpfiration for 14"naal Works Tnnitrnrtiun Prrinit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: r � r _ ............ ...... ........... { ...... r Location Addres. � or t No ......................................... .........-_.... ---.-•-- •--•--._._..._ ......._..................................�-'...-�.........................,, ............. Owner Address W ✓ / L L A�i r-F a _.... ------------- -------- Installer Address Q Type of Building Size Lot_.'��/ �K�o ..Sq. feet U Dwelling—No. of Bedrooms................. ........................Expansion Attic ( )• Garbage Grinder p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .:................................ Design Flow..........................�.-10......__..gallons p person per day. Total daily flow....... ....._....................gallons. WSeptic Tank—Liquid capacity............gallons Length________________ Width_............. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by _C4XC.._ :L_J... _ -e.............. �/ . /A..__.______.__... •. ......... Date--•- ; a Test Pit No. 1.&0(I Ainutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 21..dr.&Sinutes per inch Depth of Test Pit.................... Depth to ground water......................... a ••-•-•-•-•-•----------------•-•••••••••••-----•---••--••--••••-•----......-••--••--------------•----••------•-....-----•---•••-------------•---------.------ 0 Description of Soil........................................................................................................................................................................ W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------------•------------------------......----------.......-------••-------------------------------------._...---------------.....---•-••••------•--------•----•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by the board f health. /r Slg e*d Vt i!`�......................... �!? }Cf 9�"•... ......- ate 4_. Application Approved BY ° = --------------------•---------•--..........,-•--.............--••- Date Application Disapproved f or t e f ollowing reasons:... -•...............•-•--••-•-------------•-----••-•----•---._...------••---....-----•---------••-•••------••---•••-•--•------•----•-------•-••--------•-••••----------•-••••---•••-----••-•••-•--.._....-- Date PermitNo..... ------------------------• Issued........................................................ THE COMMONWEALTH OF MASSACHUSETTS �-•� BOARD OF HBALT Tntifiratr of Touttpli attrr THIS ISf,TO G�R�'�FY, That the Individual Sewage Disposal System constructed (N,)�o;? Repaired ( ) by =={• r• S`r=fr�" 4� ........ �........ rs all.a . ... ........... ................................................ •_ •. / at......... "- ';. ........ ._�Mw/' � !` ` �'--------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod ascribed in the application for Disposal Works Construction Permit No.__ �_. _�.................. da.ted_... :..�y _`._._.._._._._._...__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATE FACTORY. DATE............................... � .. ...................... Inspector......... . .1¢................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD` ?F HEAJLT,H/ ...........................OF....... -'� ' .rr=t`E ,......:................................ FEJ''" .— ii E_ Miposal Workii Tnntrnrtion antit Permission is hereby granted.."�_rxf......_ ---.__-•--•-••------- -- -- --•__.__..,_.. ._ __ ------ ------------•.----•-_----------•------------- to Construct ( /)or Repair ( ) an Individual Sewage Disposal System,,", - at No.............z ---��-' f wl.f_9,,?. `?2!s 7, --_ '` ... ..... Street -- �' / as shown on the application for Disposal Works Construction Permit No.��.._ __ _j Dated... f ._____'.................... -------------•-••-------•----........--------------•---------------....-----..........•.._............._ Board of HealthDATE. -•---•-•....................•----...------.......................•--......_... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS A all— OF Z- S epTt C. n6 X ZO ), ��'•Z =�.(,� L�t.'S l ` : . U S E t O UCj G f'cLl Y. °J13 �I DE�/AL.L. /aer�o+ • 2z 4_.�F.x. :Z,���. _ .s���-���-,-=--=-_ -- :__.._ � _ .; -- _ , WILLIAM c.c/rMgT7C-9 4•.PPE subst�+�t "Pvc p15T 14u A.L. ��� J. Cl .5 SE+PfIC r TAQV. Iuv. + ; I"IT WITtd cTo W to ' iIj 8 NO SGLsk�a 6 ,- t Cr&=it+*f TKAT Tfvl� PQrJ�'s Mai, 5l4cm, ,J 1-1E2EO N 'COM fzL-Y 1; W t TH T"F- StiDC-L11-4ft. i AwD SL:-=rUAGtC Tbvi" OF C'� -IDS V�t.E Qun ►�, Q)t� Lv�•A.r VITkl N ' THE }r'L 00t-) Pt-AIW- �4- ►J.Qg�� IS('r. ¢EM3, L ,L)evey!oeS TI.IIS PLAW 14• I.IOT $A5ED OU AU t MFJ►•{T 0-9;TE!XVI' I ca SUC%-/M( 4 T"G- OFFSET; -SW09LD UOT SE USep laPPt..1GAuT' ��7, � To •n�t Kkt t tJ E. I•oT L-1 u E4• t44zt_L= ( -l.�l d -�ol t7 S T (dvX � Cl ., � �G�` �+ Per w'3 SrN• p °ou r No. Fmc....... ............. THE COMMONWEALTH OF MASSACHUSETTS L / 0 BOARD OF HEALTH =`T 0110 'J f . Appliration -far Ui_qpuittl lVarkii C omitrurtiou Prrulit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ---------- Location.Address or Lot •o. -.�4-:�'-�----�----��-�------ -......:���.'� /yAyddress a ��/✓FJ_ 14 .�4�`l«-�........................• !!fit_ ./._�................. ... Installer / Address Type of Building Size Lot.a_ .-Df-----Sq. feet Dwelling—No. of Bedrooms---------��`.............................Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building --.--___.--_-------------- No. of persons..-------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures_- - ------ ------•-- - - �� W Design Flow.. ................:.. Mons per person per day. Total daily flow__::______ .. gallons. P4 Septic Tank l Liquid capacity _`�°gallons Length---------------- Width-........- Dia ter....-................. Depth---.------.----. x Disposal Trench—No. ..------ With ot. Len leaching area--------------------sq. ft. qep Seepage Pit No.------- Diameter l -- to mle 1 leaching4 a7a sq. It. z Other Distribution box ( ) Dosing tank ( ) ' aPercolation Test Results Performed by.......................................................................... Date--------------------------------------. Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.--._-..----.--.---.---- �14 'Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water...-.-.--------.----.... a ..........................................-•-------••-----------•-•---•---•------------------------ Descriptionof Soil ,%. ✓..°� --------------------------------------------------------------------------------------------------------------------------------- x W UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------.--------------- ----------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: 1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I 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. (L-•-----------•- ----•----- -- -------�• i- --�-•_-- -- Sgned —Date Signed:— Application Approved By..•---• ; •-- . ---••-• -•-• •-• .. ._ ..... -•--- ••.. Date Application Disapproved for the following reasons:........................................... .............. •-••-•-------•---------•-•--•---- -------._.__. --.......•••-••••••...---•------•---•.......................................•----•--••------•---•---.•..... Date Permit No.•-•---••-•-----••-••---••---••......................•-. Issued ! �� ------------•-•-........ ate s. No.... .. FEs.....:........................ THE�C®COMMONWEALTH�F MASSACHUSETTS HEALTH .. � ,. Appliratinn -for Dif4paiittl Workii TouBtrnrtion Vrrnfit Application is hereby made for a Permit to Construct ( or Repair ( : ) an Individual Sewage Disposal System at � Location Adflress or Lot o Ow r Address Installer Address Q Type of Building Size Lot,. .111.1 _....Sq. feet U Dwelling' No. of Bedrooms._.___.._ __-_.Expansion Attic Garbage Grinder Other—Type of Building ____________________________ No. of persons Showers Cafeteria a YP g p. __. ( ) _ ( ) Q' Other fixtures --------•----------------------- "'"Q W Design Flow .............tow- - _.:_ gallons per person per day. Total daily flow.... .:...gallons. WSeptic Tank r Liquid capacit gallons Length---------------- Width-------- _.. Dia ter-_.-_ Depth___-____._... x Disposal Trench—N , ..._.. = W•dth--------- t Le leaching area---------- --- -sq. ft. Seepage Pit No--------�___-____ Diamete�_ _ __. ept elo tnle al leaching ar a______ ____ _____sq. it. Z Other Distribution box ( ) Dosing tank ( ) i. . �- �ys // '-' Percolation Test Results Performed b � Y-------- ---------------------------------------••------.-.-..._.-•------- Date-------------------------------'-- Test Pit No. 1____ _________minutes per inch Depth of "Pest Pit.................... Depth to ground water...-_-_-_.__,_,_-____.. (14 Test Pit No. 2::.............minutes per inch Depth of, Test Pit.--_._-__-__._'-:_-" Depth to ground water:_._..:-_--_--._-_-.._. P4 _ Description of Soil--------..ai,, .r✓.A - --------------=--------- -_-- ----- --- - - U ------------------------------------ ------•----....•---•------------•--•-----•---------------••--------•--•---••--------------- W U Nature of Repairs or Alterations—Answer when applicable._._,,.` Y- --------=---------- _ _: Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been.issued by the board of health. Signed . .... •,..",, ... 1 Date j Application Approved BY------- ---- - --- . . - -.-�----- Date Application Disapproved for the following reasons:.......................---- ----- ----"--"-"---•--------------•-------------------------------•-•--------------"---•----•-•-•--"•---------'•--------•--._......._._....--"---"--....... ---------•----------- •-----------•-------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f !�.Q..vv"--e.................OF... .r .eC'N '..r.. . .................................. , (TUprtifiratr of f ILImpliaurr THIS IS TO CERTIFY. Thane Individual Sewage Disposal System constructed <or Repaired ( ) j r w� 44,4 / Installer j y at.....y"'� •------- -Gr.----- ,.�t_�9t�_�..._....__�i� - _�74--.--- ---_- . ." . •�� � • !r,�_.l ^`._�_l.C•►I- / has been installed in accordance with the provisions of Article XI of The State Sanitary Code des,, ibed in the \ e2 ----- dated---! application for Disposal Works Construction Permit No.______ : 3 T.HE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE YSTEM WILL FUNCTION SATISFACTORY. ,. rt Fy � DAT-----•--------••----------------------"•--------------------------------------- Inspector....................................................................`�s�___.:.......---- f THE COMMONWEALTH OF MASSACHUSETTS - ' BOARD OF HEALTH t, j 4... ..: IZO No...f. aFEE... -•----..... Permission is hereby granted ' `, '------------ to Constr tRepat an Individual a e tsposal at No.- a ---- - ,�, reet � as shown on the application for Disposal orks nstruction it No ,_-,Dated__f��":w . + L DA .�. ..l P - ,!' TE----- 1 . - .. oard o ealth 1 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r r .-e MARCH INC. BOX 316 WAQUOIT, MA60. 026.96 rr"�^•.r _ VEK. 617-4774M40 � O T 2 8, 0 0 0 C I � f I � T , 0 o n1 , y� • E SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) (IF NEC.) ACCESS COVER (WATERTIGHT) TO ENGINEER: D.A. OJALA, SE /+ MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM WITNESS: SAM WHITE (BOH) _ .4 34.0 EL. 35.0' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONF DATE' 4/2/03 r " FOR FIRST 2' PE RC. RATE = < 2 MIN/INCH STING 1000 __ / 3' MAX. 417EXI ALLON SEPTIC 33.6'f* 31 q' CLASS I SOILS p# 10458 wG TANK (H- 10 ) _ RE-USE eA�nc 32.0' a' 31.83 'O CIC7 CI C� C G7 O LOCUS------ o� 30.17' © © Cl C] d © CI CJ 0 0 4' AROUND Q ELEV. 6" CRUSHED STONE OR MECHANICAL 0 [� O C] C1 C] Cl Cl 0++ COMPACTION. (15.221 [2�) ,� 2' E3 © E] E] 0 L� EJ E3 0 o0 28.17' DEPTH OF FLOW = 4' (. 5 % SLOPE) FILL/A TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE SL ' INLET DEPTH = 10" --- OUTLET DEPTH - 14" 24" 10YR 3/2 LOCATION MAP NO SCALE FOUNDATION- EXIST, SEPTIC TANK 32' D' BOX 13' LEACHING ASSESSORS MAP 21 PARCEL 43 P ACIUTY B *CONFIRM OUTLET INVERT PRIOR TO 5.67' LS INSTALLATION OF ANY PORTION OF SEPTIC 2.5Y 6/6 SYSTEM 42" 30.0' _ INGHAM WAY =--'-� 22.5' PERC C B Ms 2.5Y 6/3 180.66 / G LOT AREA E 44,853f SQ. FT. 132 22.5 L=46 �ryN _�_ NO WATER ENCOUNTERED a=25.o NOTES: G E w N SEPTIC DESIGN: (GARBAGE DISPOSER IS .____ )NOT ALLOWED 1 . DATUM IS ASSUMED - ----­__. BENCH • GARAGE DESIGN FLOW: 4_ BEDROOMS ( 110 GPD) = 440 ^^'- 2. MUNICIPAL WATER IS EXISTING SLAB. ELEV. = 34,5 E _._...... vry � , USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. o SEPTIC TANK: 440 GPD (_2 _) = 880 GALLONS 4• DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H--�,,,� _ "` 5. PIPE JOINTS TO BE MADE WATERTIGHT. G USE A 1000_ GALLON SEPTIC TANK (RE-USE EXISTING) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. w LEACHING. ENVIRONMENTAL CODE TITLE V. w C, 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE m . LA w / �. SIDES: 2(33.5 + 12.83) 2 (.74) = 137 USED FOR LOT LINE STAKING. .10 EXIST. BOTTOM: 33.5 x 12.83 (.74) 318 8. PIPE FOR SEPTIC SYSTEM TO SCH• 40-4" PVC. N<� AVED DWELL. TV TOTAL: -0 5_ S.F. 455_ GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT DRIVE w INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 5' REMOVAL OF UNSUITABLE ein � � \ USE (3) 5q0 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH. SOIL REQUIRED AROUND EQUAL WITH 4' STONE ALL AROUND PORTION OF PERIMETER OF TV ) 10. LEACH PIT TO BE PUMPED AND REMOVED. LEACHING FACILITY, DOWN TO ° I SUITABLE SOIL LAYER (TO C) REMOVE ANY CONTAMINATED SOIL WITHIN 5' OF NEW FACILITY REPLACE WITH CLEAN MED. W E G E N D SAND. PROVIDE 41' OF 40 �-' 100.0 PROPOSED SPOT ELEVATION MILLINER, 5' OFF ,� / TV TITLE 5 SITE PLAN A PORTION OF Io" HERw 10OX.0 EXISTING SPOT ELEVATION PERIMETER OF SAS, R OF IN AT EL�3q.2� BOTTTOPOM '�• W .--� ' /N 100 _� PROPOSED CONTOUR 150 ABBEY GATE IN THE TOWN OF: AT EL. 26.2' �, '6j 100 EXISTING CONTOUR { (COTUIT) BARNSTABLE PREPARED FOR: BORTOLOTTI CONSTRUCTION/MOGAVERO BOARD OF HEALTH 30 0 30 60 90 oob APPROVED DATE M � E � ,,. 0 LAU � co 0 21�86 N Z z SCALE: 1 " = 30' DATE: APRIL 5, 2003 fax 508 ff 562-•8541 8W W~ L"w wz Zpy0. ^y �1� v -- down ca e engineering, inc, a o , a7- OF M, z O -Lu s � ARNE H. yG �^�`i/ ARNE �� 6 CIVIL ENGINEERS cOt= wzd OJALA y H. LAND SURVEYORS Z ¢N o .o No 01792 ti F NOJ 6L a o4 939 main st. yarrlouth, ma 02675 o z rx a °F�9 �STER��\�, '1 03--055 ARNE H. OJALA, P.E., P.L.S. DATE