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HomeMy WebLinkAbout0048 CAP'N ISIAH'S ROAD - Health 48 Cap'n Isiah's.Road , l Cotuit .l,F/R A = 038 063 a 1 No. 4210 1/3 ESSELTE 10% i I • t :,� � �1 � �. `! 11 I "O>A / 5 4 { TOWN OF BARNSTABLE k LOCATION `� ��.d!�• ZS 1 f?Li �� SEWAGE # Y,LAGE ASSESSOR'S MAP & LOT-38-'�3 INSTALLER'S NAME&PHONE NO. 8 c/6.S c0,;edc SEPTIC TANK CAPACITY '/oob C' LEACHING FACILITY: (type) 2,�'0o r�Gr��bi:�s (size) USX %3 NO.OF BEDROOMS 3 BUILDER OR OWNER fi97"/vG i!4Gl�/-'HSOh PERMTTDATE: R 2S=05 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet Furnished by i a m No. '� , V f Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Mizpogal *p!5tem Congtruction Permit Application for a Permit to Construct( )Repair(z,,,,1fGpgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. en c,p�q I 4`j I Owner's Name,Address and Tel.No. � Assessor's Map/Parcel Installer's Name,Address,and Tel.No.j o$—41249—c7'1 38 Design s Name,Addresy and Tel.No. . g� _e, n lwwesly,,�,s owAIr nr Type of Building: Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ,Ct P929 Type of S.A.S. Description of Soil Nature of Repairs or Alterations;(Answerhen applicable) Jea4T.V// 9—3—aa 41A/ 4!2^!V Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board f Health. Signe4 Date Application Approved by Date d Application Disapproved for the following reaso s Permit No. o° + 3—`}t © Date Issued a 5 No. rJ .V I �'� Fee O ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered"m computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Ztgoml *pgtem Con!6truction 3permit Application for a Permit to Construct( )Repair('Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C/T C�� /,t��j /Z Owner's Name,Address and Tel.No. P carver �►r,^�c�, ti, ,����-sa Assessor's Map/Parcel ` 8- 63 Installer's Name,Address,and Tel.No.5 O$-el t V 7 38 Design is Name,Addres and Tel.No. . 8 ZZ nal IWwe15-rvws �W,�f Type of Building: Dwelling No.of Bedrooms i Lot Size sq..ft.­­ Garbage Grinder( ) Other Type of Building No.of Persons Sho er's( ),jCafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets ..Revision Date Title Size of Septic Tank -1006 Type of S.A.S. - Description of Soil 1 Nature of Repairs or Alterations(Answer hen' applicable) ro57-14 4',,0 f i^c,i �ii Tf., 4/ `�rb.��: �4H�ay�-,,- s1 ,• _A5r 3 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 Code and not to place system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. ` Signed Date Application Approved by Date `l� Application Disapproved for the following reasons o Permit No. �� � t ® Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(-Upgraded( ) Abandoned( )by .1GSriD/ ,_ ,-,V3 �/ ralat ,�v7-41 ,1" hates been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 3' w dated - Z s�13 Installer iJn s r Pli /,L d e"'.®S Designer 68.ki IO> 6= l/,� '!?�vG.TLj The issuance of this perlfiit shall not be construed as a guarantee that the system wil�,Etto s Date 7 Inspector I No. ty'�''� �..- �� ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS f 'Wi5po5al *p!tem Con5trurtton Permit Permission is hereby granted to Construct( )Repair.( 4)tJ grade(,/)Abandon( ) System located at . �/d "� w 6-arvi T 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 conditiioons.-� Provided:Construction must be completed within three years of the date of/ this p it. Date:_ r � �. Approved by I TOWN OF BARNSTABLE LOCATION SEWAGE # 2003� S'/D 1 VILLAGE �'aTy1 T _ASSESSOR'S MAP &LOT 3 L'_ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY oob LEACHING FACILITY: (type) 2,5'00 � sb, �S (size). USX �3 NO.OF BEDROOMS ✓� BUILDER OR OWNER PERMTF DATE: D s=b�j _COMPLIANCE ATE: Separation Distance Between the: , Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility I wells exist , Private Water Supply Well and Leeching Facility•(If any Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility Furnished by I Ily i I i ' ' � IiH3 RECEIVED J U L 2 9 2003 COMMONWEALTH OF MASSACHUSETT gAy�NSTABLE EXECUTIVE OFFICE OF ENVIRONMLN'I'AL AFFAI To LT P . DEPARTMENT OF ENVIRONMENTAL PROTECT z � e 1 d e FAILED INSPECTION 4�M s+ v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUN'i'ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address: 48 CAPN ISIAHS RD.COTUIT,MA 02635 ��� �►,(� Owner's Name: NICKERSON v� Owner's Address: 48 CAPN ISIAHS RD. COTUIT, MA 02635 Date of Inspection: 7/l/03 Name of Inspector: (please print) JOHN GRACI, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICI{ET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address ar;i that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was perfor;ned based an 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 _ Conditionall sses _ Needs Furt valuation by the Local Approving Authority X Fails Inspector's Signature: Dzti: 7/. ` 3 The system inspector shall submit copy of this inspection report to the Approving A,::hority(Board of Health or DEP)within 30 days of completing this inspecti n. If the system is a shared system or has a design .",o\w of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional off of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and tine approving authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION. D-BOX IS STRUCTURALLY UNSOUND AND NEEDS TO BE REPLACED. STAIN LINES INDICATE LIQUID LEVEL IN LEACH PIT HAS BEEN FULL OVER PIPE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. I i Titlr 5 Imnwortinn Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM FAILED TITLE V INSPECTION.D-BOX IS STRUCTURALLY UNSOUND AND NEEDS TO BE REPLACED. STAIN LINES INDICATE LIQUID LEVEL IN LEACH PIT HAS BEEN FULL OVER PIPE. 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. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks _ X Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ 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 ? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)):+tea Sump pump(yes or no): NO CA' 0300 0 t Last date of occupancy: n/a ®, COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: I 1979 PER AGENT Were sewage odors detected when arriving at the site(yes or no): NO F Page7of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CAPN ISIAHS RD.COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 8" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a I - Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY UNSOUND AND NEEDS TO BE REPLACED. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): , n/a I R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): STAIN LINES INDICATE LIQUID LEVEL IN LEACH PIT HAS BEEN FULL OVER PIPE INDICATING HYDRAULIC FAILURE. SAS NEEDS TO BE REPLACED. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a A Page 10 of I I r OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CAPN 1SIAHS RD. COTUIT, MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 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. w � Pti�� II � peck. A I on AEI ►0 � 34 0 0 a> Aage I l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continu d) Property Address: 48 CAPN ISIAHS RD. COTUIT,MA 02635 Owner: NICKERSON Date of Inspection: 7/1/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from systel-l-design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. II 629f �2 d 3 .. Fizz No----------------_....... _.....-" THE COMMONWEALTH OF MASSACHUSETTS BOAR® 9F HEALTH dOF...... .......a414...:......---------------......._._.-_..__................... ApplirFa#iou for Dispaii al Workii Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............................ R........--- • ation- ress T • Lot No. Owne ddress a .....-- �4k�'dal..... iva..r c lAV. ....ca t..... ........a��.��kr.�'��. ..� �......................... 14 Installer Addfss r�� Type of Building Size Lot.C=4 VZ..Sq. feet U Dwelling—No. of Bedrooms............. .........Expansion Attic ( ) Garbage Grinder 06.) `4 Other—Type of Building No. of persons............................ Showers — Cafeteria A4 Other fixtures ................................ . W Design Flow.................��..................gallons per person per day. Total daily flow.__............_ca.3.-...__-.-_-_.gallons.` WSeptic Tank—Liquid capacity/,"....gallons Length_,5fr..6.••.. Width.._ _!�__.. Diameter................ Depth...S•-.(r_. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.____.____`____.___. Diameter.......... Depth bel9w�inlet........�....... Total leaching area....` ? '..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ )we'2ft �4L^N CMN65 Fei Percolation Test Results Performed by...... U tz _.. �".....-•................... Date_._...•....•.•.....3_1--,17 7 y Test Pit No. I_-__-- ---- per inch Depth of Test Pit.......1 4.._--- Depth to ground water...../_Y�.. �4zE�Z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------•---•-••----••-•----....--•--....--•--------............---•--...•........--•--•--------•------••--•-•-.....•--•...........--••-- O Description of Soil.......... s6'AV.0.. ....... W U ••••---•••••-•--•••••••..........••--••--••-••-----••------•-••-------•--•----------------•••••••-------....--------••••••-••----•--••••------.......--••••-••----•....------.........---•••......•••... 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is by the oard iealth. Si ••---• -•-.... .. .. ........................... ..... Date Application Approved By-- f.� d��. . . ....................•---•-. ......... Date Application Disapproved for the following reasons:............................................................................................................... ....................•----•--•--...------....----....----------------.........----••-------.....-----.-_.... ------••-Date Permit No......................................................... Issued... ..� - ----•- ------ Date 67 No.._........a3....... Fms....,2.r�..--r-. . THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ............ .............OF....... .-4 o'n........---...--........-----...------.....---.......------ Appliration,.f n Bi pos al Worko Tanstrurtiuu Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage- Disposal System at: t 17 H t t t•. ; ......... .. ....... ..................................... .... ............................................................._. TM.... .. Location-Address _ or Lot No - .... •'•••' S--r *f a�' '.. .:.. .................................... .... . .. ..../ .... "� ✓f r •--t #r / r G'. a �at'K� i`i Ownr- Address fe Installer Address r� t.*...... ` UType of Building t Size Lot.Z_7 2:=...........Sq. feet .-� Dwelling—No. of Bedrooms............ .........Expansion Attic ( ) Garbage Grinder `4 Other—Type of Building ...............�_.._,,........ No, of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures.x. -- '= - -------------------------•------- W Design Flow------------------`'9>,...... �:gallons per person per day. Total daily flow................. ............gallons. p q p y gallons Length Width................ Diameter................ W Septic Tank—Liquid ca acit �.�t'."' �.. _�'_:. eI F"� xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.::.:_..........:...sq. ft. Seepage Pit No..._-_____I___ Diameter........._.. Depth..below inlet.........:....... Total leaching . P..sq. ft. � ------ -- g area.._. �'°, Z O�her Distribution box ( ) Dosing tank ( ) 10"ZI «� �f Fl"r, '-' Percolation Test Results Performed by...... "?``...�::.:...... t.-.......................... I,f� a Date--------------- `~ Test Pit No. 1------.�___.miriutes per inch Depth of Test Pit........ Depth to ground water ... 1, (T4 Test Pit No. 2................minutes per inch Depth.•of Test Pit.................... Depth to ground water........................ Ri ... .. .-- .........................--c ........................--------•-•-•---•••---•---.............................. O Description of Soil........ Ytr__`__t' ;~` xt � V .....................................••---••----•...----••--------------------•----•-------- 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 TiTiE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss by the boar d of iealth Plication Approved B ... Date AP ••--•----_--_-_-•--------- Application Disapproved for the following reasons:............. ........ ...•--•-------•--._........._.___._....................-----_..._ Date....... J a ................................................................................ Date PermitNo...................... Issued.-------•------•----•.........................••-•--•-- Date y THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH .................. ......... ::OF........:. .........A; ' ✓? .......................................... (Irrtifiratr of- Tautpli attrr TH IS T9,CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by .....------•--.•. / .......... w- -------------- ................ ... .--•- . Installer has been installed in accorda e with the provisions of T 5 of The State Sanitary Code-.as described in Zie application for Disposal Works Construction Permit No. . .:..`. ! ,:+..-__._..... dated__.. 4 Z__.:..7ZA _...�....1 t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A,GUARANTEE TT THE SYSTEM WILL JUNCTI. N SATISFACTORY. mot`DATE .- •-----------•--•--•--•---- Inspector =_ -------•--fix==- ,�;..,-.�.:,., ...._....-- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ......OF........ ry N ....�����.... -�.............................................. FEE....r.. ..:" Roposal gar o m5ouutrudivit prrmft Permission is hereby granted....-- ._. ---•-•-.-------._.....-----•--------------•......---•------•--•--.....--•--......---......... ..-----•-- to Cons t 4 �" r air an Indiv-du Sewag ispofal S, em at No. 1y _ '� > -- ....... ... . Street as shown on the application for Disposal Works Construction Perm o.___._...... 'Dated....... ...... Alth ...........................o ?ndb DATEV 7� e , FORM 12521 1I013BS 11 WARREN, INC.. PUBLISHERS Ao i r � Ftf ye Tc;'I%t-t_ 'C:> G.P.D. i r,. t {`��1f'Y{ ,6 :13:1 10 4., To? 1=.+u =icao.o t- Afu ��� "�� I o0o tuv. Su+ 4 2 tuv. I T—AkK. 1_EaG� '•° 'T met" 4- 1• ES. NII t-c� y i �.1 ot, � I wAs�e u C7--1) })Lc,'T- PL- 4,y-j � c.t.t<�;It•- �( T►-!,�.`r TNC= �ut�t►.!� St-lc:u�►J �='t_ Ls.tJ I ,tt- DE. t_I 7 3 A>JL> "Ll e •.(:t-. t-'CId:��C:;�A,1�::►—lT'� G.�� Fit; S ir, its c►-rr BA P-K AEft.� LAAJ'D LevueT i'U 0 �3dV4-: �k t:;cf V l_jC,'I' Ut -o F►J C.'; rLt'Vil_lc.� c, ti���Si. ,t-t• 1 .'_ Fjt'Tt ( :n.t- s ';' L'fi. C, ATION 1�" SEWAGE PERMIT NO. VfLLAGE INSTA LL R'S NAME 6 ADDRESS Y'C B UIIDE/R OR OWNER _ d -P y T _P Y"V S 7 1 _ DATE PERMIT ISSUED _ J2- 7-9 DATE COMPLIANCE ISSUED f Q� �, � ', o � �� �� N � � ,�_ . ,- J ¢¢ .�.� � 7,1 -CM, t r Ali �tr Y a T n 7 x t t , a !s y ax r 4D 144 r. 71 rFr,�.. -... _....x+aai'�• � .,' _..,.:;t.. ,-,,: ,;- ..�• :,�,�•..._.-.-, t 4-,,.. ,+,. n ,� ,,:v,� v,±Fu "s` .�,'�'. '�"ti�-w ��r*' x � - •'.'$•nvo,�iK'.. :..`,,' _'� k�.R�3..-,.+, �" 4 ,w�'`'7 y#:`..� .s•+ro.-r';�`� <� a'�. ��c r S.v v.d .mot' �* CM `s�tR` a t` �- .,���' �i' ;�; ' "• .�' MITI? # , I y � +i TOP OF ' FO UNDATIoON GRO UND SURFACE E1,2 S 1 1`i N.1J�`i R D NO T�'S� GROUND SURFACE .6L__�)_1 I__ " MIN 1) THIS PLAN IS FOR THE I11rSTALLA TION OF A SEPTIC SYSTEM. OUTLET PIPE LEVEL 0) ALL INSTALLATION PROCEDURES AND MATERM4LS SHALL CONFORM TO 310 CMR 15.000, TdE STArF FNKRONMENTAL CODE, Tr_ ^-� FIRST TWO FEET z ,Z A)o VENT REQUIRED 5 5 TOP EL TITLE 5, AND THE TOWN OF _ A��^/S TA/aG L __ SUBSURFACE DISPOSAL REGULATIONS. LIQUID bFVFL v MIN 2' LAYER DOUBLE WASHED 3) NO DETERMINATION HAS BEEN MADE' AS TO COMPLIANCE' OF AVAILABLE PROPERTY INFORMATION WITH RECORDED DEEDS Q ld —BOX ve'- 1/2' STONE OR ZONING REGULATIONS. INVERT EL 10 14" EFFECTIVE 4) TOWN WATER SERVICES THIS PROPERTY. GAS BAFFLE AT OUTLET / IN EL SIDEWALL 5 THERE ARE NO KNOWN PRIVATE WELLS ON THIS PROPERTY OR WITHIN 100' OF THE PROPOSED SOIL ABSORPTION SYSTEM. t B" SMNE BAs INVERT EL ) INVERT EL 6) ALL COVERS OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 12" OF FINISHED GRADE, WITH ONE COVER OF THE 5 , D - Box e 1�j. �j ?w o Z'{ 27 r E/' Co N c.rar r 3/4'- 1 1/2' DOUBLE SEPTIC TANK BROUGHT WITHIN 6" OF GRADE. INVERT EL (Typical) CII AM T t(1'_: w��/ jToN t WASHED STONE 7) ALL SYSTEM COMPONENTS SHALL REMAIN ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY 6" STONE BASE INVERT EL 1 .3 3 .a UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTERFERE WITH THE PERFORMANCE, ACCESS, INSPECTION /00V Gal Septic Tank BOTTOM EL � 4- (Typical) PUMPING OR REPAIR. I I I 3 + I 0 EL 5 S 'r7 8) NO DRIVEWAY, PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION BOTT M OF TEST HOLE SYSTEM, EXCEPT WHEN VENTING HAS BEEN PROVIDED. 9) SEPTIC TANKS; GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE PLACED ON A 6" S7ONE BASE I Z 5 I TO ENSURE STABILITY AND PREVENT SETTLING. 10) OUTLET DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST TWO FEET OF THEIR LENGTH. 11) ALL SYSTEM COMPONENTS SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' OF DRIVEWA IS OR PARUNG OR TURNING AREAS, IN WHICH CASE H-20 COMPONENTS SHALL BE USED. 12) ALL BUILDING SEWER LINES SHALL HAVE AN INNER'DIAMETER OF 4" AND SHALL BE CAST-IRON OR SCHEDULE 40 PVC. 13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS SHALL NOT EXCEED 36" UNLESS VENTING HAS BEEN PROVIDED, 14) IN THE AREAS OF EXCAVATION, EXISTING GRADES SHALL BE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS. 15) IF SOILS ARE ENCOUNTERED DURING THE EXCAVATION OF THE SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM Wooded THE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDING. Area PROPOSED LEA CHING FA CILIT Y 16) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTILITIES. Test Pit 0 � Two 4. 6' x 8. 5' x 24 " deep concrete chambers (or similar) Prop ��� .'..: . . 25' with 4 ' stone D Box (Total Area — 25' x 12. 6) Pump fill and remove 1 cr DESI DA TA existing pit as required �,, � DEEP OBSERVATION Exist 1, 000 Gal :'tip` Number of Bedrooms: 3 HOLE LOG Septic Tank � � Garbage Grinder: A10 Test Hole #1 (EL =,> , f) ( Design Flow: 2� ev soil son son 6� o 0 U� (110 Gal/BR/Day x Number of BR) /d °T�n�jl` �et) Horizon Texture color (USDA) (Mansell) gto:7 IY o�ir LoA�+ �o o �s� 4�3 .0 0 01' U°' i Septic Tank: �OQ 00 l i ` i (Minimum = Design Flow x 200%) C��Cy�1'tr�r i 5 5.S E5 CoAr^�"+i � -7,5 yp- EL d US.1 CAAot L', 9 I0Yk te(L, TB� � � � Leaching Area: C Top of Fn � � lQ'bo � /( a� Sidewa'11: ' nr , r T �1`'p Z Sidewalls x 2 5 _Ft X !___Ft) + Deep Obs Hole Date: -1 f 2 51a 3 •F 0 / Soil Evaluator. &0/ 5TO"Cl' EL I C 2 Endwalls x ( Z l' Ft x 2—Ft) Witnessed By: -2J Pero Rate: C__ f r,a Soil Survey Desori tion: CARVER Bottom: T Geologic Material• p OUTWASH ( 2 /2 , (,, r`✓ ? Depth to Standing Water.. NA — X — -- � Depth to Weeping Water. NA I Depth to Mottling(Color): NA Long Term Acceptance Rate (LTAR): 0. 74 High GW: NA W t x 1 Est Seasonal S \ j � USG3 Observation Well: NA \ Leaching Area Design Capacity. 3 '� `( Date of last Meaeuremeut: NA Comments: (Sidewall Area + Bottom Area) x LTAR - .J l I 1 1 i Wooded i l Area �l l' R = 620.00' y� L = 84.88' '" } 6 ry 10 CIO 1r'+'v PROJECT LOCATION �f c ',� r 0)4 � T , r`" (I 3 8 O (fl ASSESSORS MAP L T R. c A(T 6A(sLC 1 APPLICANT.• iEz f.,A•,ej L 0, , ( Laws G0'TV I rt 1� M - Y PREPARED BY A & M Land ,Services 15 Sunset Drive South Yarmouth, AM 02664 (508) 394-2723 ?' SCALE I = 'Z�' DATE.- REV. LOCUS MAP -1 .� d 0 ol ,-1;c DWG. 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