HomeMy WebLinkAbout0024 BRAMBLEBUSH DRIVE - Health 24 Bramblebush Drive, Cotuit
A_ °`�b- �
TOWN OF BARNSTABLE
LOCATION ��� �� �/� Zla.SEWAGE
VIU AGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO 0,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ec_,,41� .P (size)
NO. OF BEDROOMS
OWNER /���/���/''✓'
PERMIT DATE: COMPLIANCE DATE: /"/
Separation Distance Between the: idT�
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A 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
--- r j
NO
M
�0
' 4+
Lam,-,
014
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
n 01ppl.Lation for Disposal 6pstem Construction Vermit
Apica�t 1 a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.aT�/ �1.��/lJ��°6 '. v✓� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel� ���/ Cam%
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
77S' o,749 j
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building � �� No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) gpd Design flow provided (4 �/ U gpd
Plan Date "149, Number of sheets Revision Date
Title
Size of Septic Tank / J'/'�/i;$'�r 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 Certificate of
Compliance has been issued by this Board Ith.
Signed Date f
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. U 1 Date Issued 3 L
l—_ _—_��-- - --------- - - - - - -- - - -- --- - Yam,-=- --- -- -  — -
N
C {s=`�y 1 1
I cro
No. " { Fee
THE COMMONWEALTH OF M�AS'SACHUSETTS Entered in computer: Yes
tPUBLIC HEALTH DIVISION -TOWN OF BARNS-TABLE, MASSACHUSETTS
2ppfication for -Misposal 6pstem Construction Permit
Applica-do a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.,,o 8'G��Jj>�1�'�'u f�. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel f o� 0..•�9/ ,7"
�r
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Ol� � No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) !, d gpd Design flow provided Li Lf 0 gpd
Plan Date /O �/ /f� Number of sheets / Revision Date
Title
Size of Septic Tank s.=�!�'j- '� Type of S.A.S. Cow
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) J'tsC �L mil✓
Date last inspected:
Agreement:
I' 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 file lth.
Signed Dateoll
Application Approved by 1 _ Date (C
Application Disapproved by i Date
for the following reasons
Permit No. U� �- Date Issued
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(Z-o�/
Abandoned( )by ee >�iG
at l/ , jf/��� l t/;qhas been constructed in accordance
6� —� 3
/ (,
with the provisions of Title 5 and the for Disposal System Construction Permit No. a 1 { dated ��
P P Y I I�
Installer S�,Jl G��O�l� Designer 10A!!L OZ
#bedrooms 3 Approved design flow 1114 gpd
The issuance of this permit shall not ie cconstruedfas a guarantee that the system wil cti•n as desigg'ed. ; J
Date J Inspector % _ �)7/�, jIIIi"'
No. G( L( e Fee -
1 THE COMMONWEALTH OF MASSACHUSETTS `r
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at _� J<`
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
r
Provided:Construction must be c mpleted within three years of the date of this permit,--
Date 1 — s�' Approved by
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NOV/05/2014/WED 02:52 PM FAX No. P. 001/001
Town of Barnstable
Regulatory Services
Richard V. Scali,Interim Director
�+ Public Health Division
�OM Thomas McKean,Director
200 Main Street,Hyanis,NIA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: �� �'J �� Sewage Permit# %Assessor s 1VIa 1Parcel
Designer: w� Installer: l
Address: MA1% 6�_4&j W Address:
On ' ` ` was issued a permit to install a
(date) (installer)
septic system at � based on a design drawn by
(address)
i dated ® ,�
(desi er)
—4 } certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral.relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State&Local Regulatioxis. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed ce with the terms
of the I1A approval letters (if applicable) � �p10FIVA
DAVIC7
(Installer's Signature) o MASON ;i g
ca g No.1066 �
` ur ' V
esx s i ature) (Aff"m Desi i'- p Here)
,PLEASE RETURN TO BARNS'1;.'ABLE PUBLIC HEALTH DIVISION. CERTEFICATE
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:1SepticlDesigner Certification Form Rev 8-14-13.doo
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Bk 284.61 P's 4-5 a43557
10-22-21314 a 02 = 50P
DEED RESTRICTION
The Barnstable Board of Health requires that the following notification be
placed on the property deed;
The Massachusetts Department of Environmental Protection and as
interpreted by the Barnstable Board of Health require that the owner be
aware that the leaching facility installed is designed to accommodate three
(3) bedrooms and the dwelling shall remain as three (3) bedrooms due to the
property being located in a nitrogen sensitive area.
at the property at: 24 Bramblebush Drive, Cotuit, Massachusetts, Map 40,
Parcel 91, as currently owned by Martins Rafael M and Nogueira, Graziele
E„ as property referenced in the Barnstable Registry of Deeds as Book#
25475 Page# 255.
I, and
as the owners/executors of the property/trustee
referenced above acknowledge the deed restriction(s) being placed on the-
property.
i/V
ers xecutor i e Date
The person named above: JL
acknowled the fore s rument to b •s/her free act and deed,
be e m
Notary Public
M Commission Expires:
y
CRYSTAL JOY SMITH -
Notary Public
j Commonvreatth of Massachusetts
My Commission Expires Oct 16,2020
BaSTABI.E REGISTRY OF DEEDS
�r,E l�
Town of Barnstable >P
'. Department of Regulatory Services
eenmerAeru. Public Health Division Date
MABS
idJ9 200 Main Street,Hy nnis MA 02601
lfG M!d�
Date Scheduled Ti e Fee Pd.
J
t" -
Sa►il uitabiiity essment or' 'Se . e is os
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATIO A
Location Address �i �jJ � �a Owner's Name
pV
Address
Assessor's Map/Parcel: Engineer's Name
g
NEW CONSTRUCTION REPAIR
Telephone#
Land Use !— - Slopes(96) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
a_
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
" `A
44
Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL-HIGH WATER TABLE
Method Used:
-- Depth Observed standing in obs.hole: In, Depth to soil mottles:
Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj,factor At1j.Groundwater'Level, e
�PERCOLATION TEST mote Time
Observation )
Hole# (/ _ Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ Time(9"-6")
End Pre-soak Rate Min./Inch �2,Of
Site Suitability Assessment: Site Passed 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:ISEPTIC\PERCFORM.DOC
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DEEP.OESERVATION HOLE LOG Mole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders.
// __ onsistency.96(3ravel)
t--27—
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,St 'es.
Boulders.
onsisten %Gravel)
f
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DEEP OBSERVATION BOLE LOG hole#
Depth from Soil Horizon Soil Texture „ ; Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulders.
Consistency, a
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders.
Cons' to
Food Insurance hate Man:
Above 500 year flood boundary No_/Yes
Within 500 year boundary No 1� Yes _
Withiq..100 year flood boundary No. Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring perviou .terial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per ious material?
Ceftification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Envir nmental Protection and that the above analysis was performed b m/co sistent with .
the required training, er' a d xperience described in 10 CMR 15.017.
Signatur Date f� �� ��
Q:\SEPTIC�PERCFORM.DOC
Commonwealth of Massachusetts
Executive Office of Environmental Affairs „
Department of \ �
Environmental Protectio `� �
William
F.weld �6yTrud
cioNry
Arrm Paul Celluccl Da hs
u.covsmor
5 �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
//jy S h CERTIFICATION
o2y A&
Property Address: C Address of Owner.
Date of Inspection: (Q_a q-1' 0 (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-si7Passes
disposal systems. The system:
_
Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Xv` Date: off-'!
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] S�YSS PASSES:
to I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,panes
inspection.
Indite yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
_ The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exAltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
.(rev ed 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
i J Printed on Recycled Paper
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property� ,2 y A -vmal/e 1-3m 4 h
Owner.
Date of Inspection: 9`9
81 SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution boa 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):
broken pipe(s)are replaced
obstruction is removed
distribution boa is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(*). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C1 THER 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 salt marsh.
2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and 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 within 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 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
9 OTHER
(revised 11/03/95) 2
III
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: p2 /71
Owner.
Date of Inspection: Y
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure. _
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
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 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
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El GE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:'
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The r or operator of any such system shall bring the system and facility into Rill compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Add �-
Owner.
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
—.M/One of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
-/As built plans have been obtained and examined. Note if they are not available with N/A.
V The facility or dwelling was inspected for signs of sewage back-up.
v The system does not receive non-sanitary or industrial waste flow
1/The site was inspected for signs of breakout.
/All system components,excluding the Soil Absorption System, have been located on the site.
_41'he septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
bthe•size and location of the Soil Absorption System on the site has been determined based on existing information or
a �axfmated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: f�/`fJ l�d��. /�j d t�$ `i Co 7dG�r 7�
Owner. fj✓'/'�/Date of d
Inspection: // /
FLOW CONDITIONS
RESIDENTIAL+
Design flow: :53 O gallons
Number of bedrooms:3
Number of current residents:
Garbage grinder(yes or no):4'o
Laundry connected to system(yes or no):
Seasonal use(yes or no):N 0
Water meter readings,if available:
Last date of occupancy:
COMM�CIAL NDUSTRIAL:
Type of es
blishment:
Design flow: ons/day
Grease trap resent: (yes or no)_
Industrial Holding Tank present: (yes or no)_
Non-rani waste discharged to the Title 5 system: (yes or no)_
Water in r readings, if available:
Lest of occupancy:
OTH (Describe)
Last da H�of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)L C
If yes,volume pumped: gallons
Reason for pumping-
TYPE O SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yea or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known)and source of information: _J-!5 'S/R S Bye. �2
odors w at the site: or no C)
Sewage detected when arriving h (yea )
(revised 11/03/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: `7 /cJ/'�!�'/b/� 1-3 zC s
Owner.
Date of Inspection:
SEPTIC TANK
(locate on site plan)
Depth below grade:}�-
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions: ,-4 !i
Sludge depth: 4r 1'
Distance from top of sludge to bottom of outlet tee or baffle:3
Scum thickness: y ,'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 9 y
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) o C. r
G E TRAP._
(k�ca on 'te plan)
Depth belo grade:
Material of natruction:_concrete_metal_FRP—Other(explain)
Dimensio
Scum ess:
Distance m top of scum to top of outlet tee or baffle:
from bottom of scum to bottom of outlet tee or baffle:
Comm ts:
(repo endation for pumping,condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert,structural integrity,
eviden of leakage,etc.)
(revised 11/03/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address:02 7 ��//i�lYt G/-� ,3 ct.S 1 (fa-7'z�"' 7`
Owner. ��n� (g S I e,-
Date of Inspection: /
6 - 17- C74,
TIGEr, OR HOLDING TANK:_
(locate site plan)
Depth be grade:
Material construction:_concrete_metal_FRP_other(eaplam)
Dimensions:
Capacity: ons
Design flow gallons/day
Alarm level
common)
ommon .
(conditio of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_v
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of boa,etc.) F�
PUMP C BER:_
(locate on plan)
Pumps in ]ring order-.(yes or no)
Commen
(note oo Won of pump chamber,condition of pumps and appurtenances,etc.)
AL
(revised 11/03/95) 7
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�
// SYSTEM INFORMATION(continued)
Property Address:� // /�/'/►I'1 j D/ ) 4CS'/ (2 d /-44
Owner. A 19,,-r�l
Date of Inspeotion: 2.
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,a' of hydraulic failure, level of ponding,condition of vegetation,etc.) I b h 6 c;o J G��4%;c.a 1 1
CESS LS•_
(locate o site plan)
Number d configuration:
Depth-top of liquid to inlet invert:
Depth;of lids layerDepth f layer:
Dimensie of cesspool:
Mate ' of construction:
Indicatio of groundwater:
inflow(cesspool must be pumped as part of inspection)
Commen :(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVYI
(locate site plan)
Ma of construction: Dimensions:of so
lids:
olids:
Co nts: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: � 7 �(�/��dN��L %3GC cS �j Cc,
Owner. ✓� /9✓'n/ � rS /2 O'
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
� "4'
i
L L1
1
V
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DEPTH TO GROUNDWATER
Depth to groundwater.— feet
method of determination or approximation:
(revised 11/03/95) 9
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to6�
22 .
zzsia f
0
n
14d
-d
OSPA4Q1-4OA3 USH PR "
�J PLAN SHOWtNO
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FOUNDATION .LOCATlN
VC dTUy
EOTUIT, 'MAS.SACHUSETTS 0��m
OWNED 8 Y GGNd'T Q z
SCALE J "=.4Q DATE
NORIIAN 6ROSS`fdAN -- =RE61S.40ED X} 10 SUR. R
C9 W:
f HEREBY CERTIFY THAT .THfS. FQUNDATI4 N ;� LDCATEb
Z.
�4� „_ '
' r z.
ON T1HE. LOT AS.. SHOWN AND CONFORAOS TO O1E TOYVNr. z ti F�
OF BARNSTABLE ZONING REGULAVONS REGARDIN4 - ? ' �' JLfl�'l`
o ,
5ErBQ.GKS FR'OAf :STREET LINES ANO LOT FINS ya i�a
NQR�GfAN GROSShiAN
i•_ -�? (. d ' .r,: ..'N 1,. . '. r,1,'- - - ti.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town Barnstable
........... .........OF..........................---...........------...........................................
Appliration for Di"os al Works Tnnitrurtiun Frrutit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
Lot 23 , Bramblebush Dr. , Cotuit, Ma.
................_............................................................................... --....-----................................----------------••---------------------------------••-.
Theo Constructionnd'od:e;s Inc. 24 Great PoncTr LTtrN°; S. Yarmouth, Ma.
----•................._....---..............--••----•--------........-----.....-•----............ ----.....---•-------------•._..._..-•----......-----------••-•------------------............-----•
W Theo Cons tructionowffo. , Inc. 24 Great Pond`drs. , S. Yarmouth, Ma.
...............................•-•--------------....--------.---•-- ---.........--•.......----...•--...............---------.................._........--•-.........--
14
Installer Address
d Type of Building Size Lot----22,5,1Z.......Sq. feet
Dwelling—No. of Bedrooms.----.----- ...............................Expansion Attic ( ) Garbage Grinder ( )
`PL4� Other—T e of BuildingNo. of persons..:......................... Showers — Cafeteria
Pa Other fixtures ..............................................
w Design Flow...........55...........................gallons per person per day. Total daily flow........3.3.0............................gallons.
WSeptic Tank—Liquid capacityJ.O aO-ga]lons 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 ( )
Percolation Test Results Performed byN-orm an...Gr.o-ssman...P_I I.................. Date...9./R2..........................
1.4 Test Pit No. 1.....2........minutes per inch Depth of Test Pit...12............ Depth to ground water.11A.T).e.........--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ .....................-•-------- .....................•------------.-------•-----•------•---•------.---------.----.....--------•-------•----------.-----
O Description of Soil.....0.."--fi"..__loam,--.!G-'.'-.-3.0_ suhs i1_t._.3.0- 1-44"----s.az7-d______________________________________________
x
w
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 iITi.;.;. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isWd by the boy of - Ith.
/��......
Signed.`. . . -- -----•----- . .-- ........ _....
Da
Application.Approved By------------- .......-- t.... . -- ----•---------------------- ----�-1.
Date
Application Disapproved for the following reasons-------------------------•--...--•-------------------•---------•-----------------------------•---------..........
..-----•--•----------------------•----••-------------------.......--------•------.....--•--------...------•---•----•-••-•--••----•------••-----------------•---•-----------------•----------------_.....
Date
PermitNo......................................................... Issued--•--------------•-•--................................
Date
y
N......�� 7 Fimim ...` _J............
..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
own.........OF........Barns table
......... .. .................................................................
Appliration for Uispoii al Works Tontrnrtion ramit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
Lot 23, Bramblebush Dr. , Cotuit, Ma.
................_........-•--............------------.....-•---...--•-•-...------•--.......-•-- ..._........•-•----••-•-•-----•-•-•-•---------....._..-•--•--•--------..................•••.......
Theo Construct zn Co e, Inc. 24 Great Ponc r �3r:°', S. Yarmouth, Ma.
W Theo Constructional o. , Inc. 24 Great PondA`� 5: ' S. Yarmouth, Ma.
............... .................... ------•-----------------•-•.........-.............._...._...................
Installer Address
Type of Building 3 Size Lot....22-,.510-------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T e of Building ..._ No. of persons............................ Showers
YP g ------------------------ P � ( ) — Cafeteria.(---->-
dOther fixtures -----------•--•---•------------------------------------------
W Design Flow............5.S..........................gallons per person per day. Total daily flow._._....aaa...........................gallons.
WSeptic Tank—Liquid capacity.l.0.0.0p1lons 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 ( )
'" Percolation Test Results Performed by.N,0rman..GruSman.P_.E,._
W s. . ............... Date...�./..$2...................=......
W Test Pit No. I...... ........minutes per inch Depth of Test Pit...12.1......... Depth to ground water.11PA9...........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
----•-------------•--- ---....................-•----..........••..---- -• ---•----............_.........._............_......-•••••-------••--•-•-•
O Description of Soil...... "r'�n._.1QAIt1,. 6.."..W3�1.'.'.---sub8ail,-- Q':-14.4_11...mand.............................................
W
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"L'?TL: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ..........................
Date
Application Approved BY --�' -------------------
Application Disapproved for the following reasons:. _._.._.__ �/ G'+`-
-•••......................••---•--------•---•-•-•---••••......---------•-.....•••---•--------•--....---...-••--••-------•-••---•-•----------............................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..........................OF............................. . .............
(9prtifiratr of Tomphanrr
THIS IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
r
by.................... : af.. >� ....... Installer.....................................I •--•--------....•-•..._.._..-••---------•-----•-•--••-------•-----•-•-...---..........._......._..._.
at................ , ------ r^ r C.e: i; - ns - - - - ----..._........
has been installed in accordance with the provisions of ate Sanitary e a tary Cods es rib the
r�
... / .. Gg�
application for Disposal Works Construction Permit No......................................... dated------------------- b ._.._.... _.
THE ISSU CE F THIS CERTIFICATE SHALL NOT BE CONSTR , AS A GUARANTEE THAT THE
SYSTEI�eI 1Al FU T ON SATISFACTORY.
DATE..........�1 ...�1�...........................•--------•---------•---- Inspector... ... ----•---•-•-......--------------------•---------.........----•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i-v
�ry T Barnstable ""
No......................... FEE........................
Disposal orkn Taontrnrtion ermit
Permissions hereby granted........hg!0-_Construct on Co..,__-Tnc._______________________________
.........................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No......Lot..21,....Br.amb1ghAgh__.Dr. 0 Cotu t. -
Street
as shown on the application for Disposal Works Construction Permit No. ...'..' c+.. Dated..........................................
1------------------•-----------•--------
oar of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
L.0-EA� ION [ WAGE PERMIT NO.
® c423 '&a— e7ay
VILLAGE
v j
INSTALLER'S NAME iDDRESS
S e -o Neo �,qklt
S. lgrmov7l
BUILDERR OR OWN ER
DATE PERMIT ISSUED
oDATE COMPLIANCE ISSUED .. zli
_7_ T
0
1
O
o
Z
ASSESSORS MAP : ��
TEST HOLE LOGS
PARCEL: - l) The installation shall cornpl� with Title V and Town of�i�W Board oi. ,
FLOOD ZONE: ftl� ,�,t�G/G g SOIL EVALUATOR: �� L Health Regulations.
- — WITNESS : l "4 A0 0 2) The installer shall verify the location of utilities, sewer inverts and septic
REFERENCE: e j �C�E DATE: cip 1 components prior to installation and setting base elevations.
2v 7v
----—___ ------ -- - - .�. 2 "
PERCOLATION RATE: .�, 2. YUI1 l , 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" pe,r foot. The first
G � ZO� two feet out of the d-box to the leaching
, g shall be level.
TH 4) This plan is not to be utilized for property line determination nor an other
1 6 TH jj� Y
purpose other than the proposed system installation. j
5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H 10 septic components. �
`,7 7) The property is bounded by property corners and property lines.
�b� 2�� ,� (0 f4� �� 8) The property owner shall review design considerations to approve of total
LOCATION MAP /1� design flow and number of bedrooms to be considered for design. Receipt
of payment for the plan and installation based on the plan shall be deemed j
G� �,5 A19 G ED,5�v approval of the design flow by the owner, f
/ 9) The existing leaching or cesspools shall be pumped and filled with material I
�7 (0- 7 per Title V abandonment procedures. Those within the proposed SAS shall
1 ��
� ___ e � " be removed along with contaminated soil and replaced with clean sand per C
yea u10.W o t��� w►�,� 3�
Title V specs.
q I lb �N� 1 J 10)System components to be 10 feet from water line. Sewer Lines crossing the
water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if I
- applicable. The proposed SAS is being pp p p g installed below the water service
O O O / line. The line is to be sleeved as aforementioned and maintained in place. i
SEPT I C SYSTEM DES I GN 11) If a garbage grinder exists it is to be removed and is the responsibility of the i
owner to ensure such.
FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
1
exists.
'— ` _ ``�� �— 4 `3 BEDROOMS AT ( � GAL/DAY/BEDROOM GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
-�_ / /� ✓_�"141►J I lines exiting the dwelling"rior to the installation.
SEPT I)C fiANK—� o "�' � 3 14)This plan is representative only that a system can fit on a property meeting
Title V requirements. j
GAL/DAY x 2 DAYS lG�� GAL
USE GALLON SEPTIC TANK4_11_111�1
1�•�(�N -
SOIL ABSORPTION- SYSTEM
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Cy SIDE AREA: 2X C 1 -t, IZ� �� XZx11 / 67 bAVID
BOTTOM AREA: -z ?j V 17 = �I MASON m'
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SEPTIC SYSTEM SECTION '
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( 508 ) 833 2177
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to s O A•LL 'SEPTOC TA,-IL5, ��STetg�rr��.J s�,o><, AND
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SCPTIC TANK
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