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HomeMy WebLinkAbout0072 CONSTANT LANE - Health F.72, Constant L-a:n�, C'otuit A= 039 052 No.. c (� / (Y Fee _ THE_COMMONWEALTH OF MASSAC,HUSE dTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 01pprication for Migool 6p.5tem Construction Verna Application for a Permit to Construct( ) Repair(V( Upgrade( ) Abandon( ) ❑ Complete System 2 Individual Components Location Address or Lot No. ��/f, Owner's,Name,Address,and Tel.No. 03Q- O;S-� 7Z C-00 / Assessor's Map/parcel COIu/ / n�i Installer's Name,Address,and Tel.No. Designer's Name,Address and�l.No. 6. Type of Building: Dwelling No.of Bedrooms Lot Size w ` sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requirLiv_ gpd Design flow provided Lz;l gpd Plan Date Number of sheets / Revision Date Title $ M Z 5 df l Size of Septic Tank C__9 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 of Heal h. f Signed i Date y Application Approved by - Date O �9 Application Disapproved by: ! Date for the following reasons Permit No. Z� l Date Issued & No.. V f# Fee _ ff 1 Entered in computer: / . -THE COMMONWEALTH OF MASSAC�.WSETTS s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Mi5pogaY �§p$tpm Con5trUCtion Permit Application for a Permit to Construct O Repair(�Upgrade O Abandon O 0 Complete System U Individual Components Location Address or Lot No. T Z ��y�qff r� Owner's Name,Address,and Tel.No. 43Q- 05-Z-- y— Lance G lC7i�e uSC Assessor's Map/Parcel cola I Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Z S `15 �. 3L D Y"l� i -mil Type of Building: a Dwelling No.of Bedrooms Lot Size do?'- / sq. ft. Garbage Grinder (� Other Type of Building X(05/0Y*(eec"eO No.of Persons Showers(, ) Cafeteria( ) i Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date ��/� Number of sheets / Revision Date Title 7 Z rn o 5 c"Ow ` A4/'!� Size of Septic Tank Z�iY/S /�'y Type of S.A.S. i Description of Soil Nature of Repairs or Alterations(Answer when applicable) f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in- accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of HHeeaallth. Signed _—�—�—/= G¢ Date 3 2O/ aft Application Approved by // 7 Date 0 6 Application Disapproved by: Date for the following reasons �Permit No. 0 � Date Issued O (o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by (d� lD at 7 7 171--00/Y- 45X11 h been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. cam"' /^ dated ri . Installer �4/�D�C��% 6LeL_5/ , �{_.�- Designer e9ow #bedrooms `[ Approved design flow S gpd r The issuance of this permit shall not be-/c'nstru ld s a guaranteee t he system willll'functio�n a d signed. Date / �7 Inspector -------------------------------------------- No. o 3 Fee f �b THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Mi$tJOgat,,*p$tem CDngtruction Permit Permission is hereby granted to Construct (�r ) Repair ( ) Upgrade ( ) Abandon ( ) System located at 7 Z C. ���/ mil�` �� e CG)1> /a ; 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. 'l Provided: Construction must be completed within three years of the date of t�permit. Date .Q LOG Approved lzy i FROM :down cape engineering inc PAX NO.. :15083629880 Apr. 07 2006 07:10AM P1 Town of Barns table Regulatory Services i Thomas F. Geiler,Director HAM 16394 Public .Health Division Thomas McKean,Director 200 Mahn Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: "l A/O„ Sewage Permit# �D�fd3 � ,.� Assessor s Map\Parcel y �- 1 Designer: W o VJ V : �e � Instalter:r-t-,-j- o C / a /;,- o l t C�G� Address: _ raw•, �T Addreq , x 'f' 01( On / e7lw �©/` �p 61� was issued amit to ins permit (date) (installed) P tall a. septic system at �°� ►ter ,.,,� G.4-,,.,k based on a design drawn - D_ (address) - 6 by �K: dated l� (desi r) I certify that the septic system referenced above was in substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system. referenced above was installed with major changes (i.e. greater than I W lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. H OF A44 9 o ARNE H �yC•� ___ (Installer Signature) OJALA CIVIL Cn No, 30792 (Designer's Signature) (Affix Designer's-Stamp Here) - PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCY WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BV THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK VO 1. V: I leallh/Septic/Designer Certification.Form 3-26-04.doc Town of Barnstable � .o Regulatory Services Thomas F.Geiler,Director • ,nnrsria�, , 9 MASS � Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: p��ZZ�O(v Designer: t LUTES nstaller: J, A� //a Address: 42 CANTERBURY LANE Address: EMT--- 0.A- ITN eneSSACW''SETTS02536 �Q i�Y 33/t� 508/540-2534 On /-,g 7-Owl J.4 A, /f" was issued a permit to install a (date) (installer) septic system at � \," ►..fit based on a design drawn by (address) 7 4 e-w t- , dated . i o (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical-relocation of any component of.the septic system) but in accordance with State&Local Regulations.. Plan revision or certified as-built by designer to follow. HOfMgssq O� CHRISTINE G =®cP�j�Or h1 SSA d�® J� o FAIR NENY �, `�� ��&1S'Eq�v o�`r t4o. 926 Q y oc STEPHEN staller s Signature) J, FGIST 6� DOYLE j ITAPVP�� igne 's Signa (Affix Designer's Stamp Here) °® PLEASE RETURN TO BARNSTABLE PUBLIC_HFALTH:DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED ;UNTIL, BOTH THIS-.FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNS'I'A 1 PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF BA.RNSTA.BLE LOCATION 7.2 hSTe:n Lake SEWAGE # Z"" Ae .VILLAGE ���✓a ASSESSOR'S MAP & LOT -L? INSTALLER'S NAME&PHONE NO. =�b/dJE71i �t��J7`ir�e 1�,�.✓ �/ b' ��>� SEPTIC TANK CAPACITY i 00® e�I LEACHING FACILITY: (type) JOo Gul 44oi 6•-j 6,0 (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: ao-OG COMPLIANCE DATE: 5 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 D6&4 laD� L%•��� ri-�v�s i .rya �ecrr 7T f TOWN OF BARNSTABLE LOCATION '72 e!�27d7jlean Zane SEWAGE #v r. VILLAGE �� �% ASSESSOR'S MAP & LOT 6 INSTALLER'S NAME&PHONE-NO.� ��d , �cJ�tJ7��c-1�,,arl �aZ SEPTIC .TANK CAPACITY 6" GEC LEACHING FACILITY: (type) 3�'d fF! Cis. 6,20 (size) NO. OF BEDROOMS 73 BUILDER OR OWN)ER PERMITDATE` COMPLIANCE DATE: 5 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 Feet within 300 feet of leaching facility) Furnished by L r �•���r i y7, `7y, C S•b 79' YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$40.00 for 4 years]. A business certificate ONLY REGISTERS YOUR NAME in town [which you must do by M.G.L.-it does not give you permission to operate.] You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form tb the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. ' 4k� 3 ' ' 'r: . DATE: t7�` ��L� Fill in please: �. 1t1 � APPLICANT'S YOUR NAME/S: 6f4 V, G-�iPzU ' BUSINESS YOUR HOME ADDRESS: TELEPHONE # Home Telephone Number 14 q L/- UZ5-3 NAME I ..CORPORATION �4 e ,�i yes D NAME O NEW BUSIIUESS '1' '2 TYPE OF.'--USINESS J Re Pv� Nc,yC' ce.J ' IS THIS A HOME QCCUPq IpN? YE5 �10 ADDRESS OF;BUSINESS i F . ..Op. MAP PARCEL fVUMBE. -C Assessln 9} When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSIO ER's OFFICE p/� ST COMPLY WITH HOME OCCUPATION This indivi al h s d info [red f a y ermit re uirements that pertain to this type of busingS . �J R LES AND REGULATIONS. FAILURE TO A on S' not ** COMPLY MAY RESULT IN FINES. MENTS: r 2. BOARD OF HEALTH This individual he be i prrq of the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL Authorized Signature** HAZARDOUS MATERIALS REOULATION$_ COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual he e for d of the licensing requirements that pertain to this type of business. A hors 5' nature* COMMENTS: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI)1 AFFAW9—` ` ' DEPARTMENT OF ENVIRONMENTAL PRO ETION ►.2, � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR yOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM;, PART A CERTIFICATION {. Property Address: sk Owner's Name: .✓ sCa �j�2 Owner's Address: 40�4,A Date of Inspection. I Name of Inspect please print) (1' Company Nam Mailing Address: b Telephone Number: 501K-Z-7/< �� 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 18.000). The system: Passes i Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: j0 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 is ****This report only describes conditions at.the time of inspection.and under the conditions?of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 p Pg Page 2 of 11 OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A: CERTIFICATION (continued) Property Address: 50 A Owner: Date of Inspection: 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: k it 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 jor 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 sou unnd„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: Observation.of.sewage.backup or break out or high static water 1'evel it the distribution box due to broken or obstructed pipes)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: . I :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 a. F - ND explain: r 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS } SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner:-- Date of Inspection: / P 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'environmeiW 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 i 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 surface water supply 1 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. j _ 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 arid.SAS and the SAS is less than 106 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: i 3 , Page 4 of 11 OFFICIAL INSPECTION.FORM—NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; ` PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes or"no,"to each of the following for all inspections: Ye No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 7 Disch arge or ponding of effluent to.the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool - Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . / Liquid depth in cesspool is less than_6"below invert or available volume is less than'/Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water.supply. ' V Any portion of a cesspool or privy is within a Zone'1 of a public well _ Any portion of a cesspool or privy is within 50 feet of a.private water supply well. Any portion of a cesspool or.privy is less than 100 feet but`greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] i 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. . i E. Large Systems: . To be considered a large system.the system must serve a facility*ith 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'I1 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: kho' Date of In ection:Ov &ZAvi l Check if the following have been done You must indicate"yes"or"no"as to each of the following: - Yes �—o Pumping.information was provided by the owner,.occupant,or Board of Health Were:any of the system components pumped out in.the previous two weeks? — Has the system received normal flows in the previous two week period Have large volumes of water been introduced to the system recently or as part of this inspection? — I 1/ _ 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?. v i — Were all system components;excluding the SAS; located on site _V _ Were the septic tan:c 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. j v _ 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)] L 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: joq . ]FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):__3 Number of bedrooms(actual): DESIGN flow!based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms). ' Number of current residents: Does residence have a garbage grinder(yes or no): t Is laundry on a separate sewage system(yes or no):j7 .f if yes separate inspection required] Laundry system inspected(y,e�,or no):,L(, Seasonal use:(yes or no): Water;meter readings; if aviila ble(last 2 years usage(gpd))` i�,©�� ©✓ �7���� LJ sun pP PumP(yes or no):NCO ` Last date of occupancy CO'MMERCIAL/INDUSTRIALA/0 Type of establishment: Design flow(based on 310 CMR 15.203); gpd Basis of design flow(seats/persons/sqf,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste dischazged to the Title 5 system(yes or no) Water;meter readings;if available: Last date of occupancy/use: i OTHER(describe): GENERAL INFORMATION Pumpiing Records Source of information: Was system pumped as part of the 4nspection(yes or,no):ao If yes,;volume pumped: gallons-7 How was quantity determined? Reason for pumping < . y p - - - . TYP OF SYSTEM eptic tank,distribution box,soil absorption system Sutgle cesspool ,OVerflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative%Alternative technology.Attach a copy of ahe current operation and maintenance contract(to be obtained from system owner) _;Tight tank' Attach a copy of the DEP'approval Other(describe):. Appr imat age of a 1 compgaynts,date installed(if known)and source of information- Were sewage odors.detected when arriving at the site(yes or no): 6 i 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: J006P BUILDING SEWER(locate on site plan) v Depth below grade: 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:—Zoo cate on site plan) N,Q 4p i l Depth below grade: Material of construction: �Concrete metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , Dimensions: Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto f outlet tee m baffle: �. How were dimensions determined: a2(_ABf." �� Comments(on pumping recommen ations, ' et and outlet tee or baffle condition,structural integrity,liquid levels related to outlet�invert,evide of leaka e,etc.): Y (� I 190 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.): f 7 Page 8'of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -6)rV.A Z�IA Ix Owner: ` Date of Inspection: /Q, TIGHT or HOLDING TANK:/(tank must be pumped at time of inspection)(locate on site plan) Depth.below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity:, gallons Design Flow: gallons/day Alarm-.present.(yes or no): AlarmAevel: Alarm in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Lam- Depth of liquid level above outlet invert:=�� /Zb .. " Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,.any evidence of agee into on out o box,et .): J PUMP CHAMBER: (locate on site plan) i Pumps in working order(yes or.no): Alarms in working order(yes or no): - . Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):. 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Owner: ��/;, Date of Inspection: / oK !�,CO SOIL ABSORPTION SYSTEM(SAS): V(locate on site plan,excavation not required) If SAS not located explain why: Type/ pileachin ts,.number: —b�-; j leachmg 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, 02 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid.to inlet,invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction- , Indication of groundwater inflow(yes 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.): i 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART C SYSTEM INFORMATION(continued). Property Address: Owner: Date of Inspection: Id, O(p 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 ° �a S �G a b , 1 i I 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: C Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Z4eet Please indicate(check)all metiods 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: l�iY l�JC�' lO�l { it Permit Number: Date: Completed by: , HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Z �oe5- le� Lot No.�� e Own Address: Address: Contractor: k° Address: � 1l Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ............ .. Date Z ln4 . month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: O Appropriate index well.............................................. Z✓�3 ... OB Water-level range zone ................................................ G STEP 3 Using monthly report "Current Water.Resources"Conditions." determine current depth to rr0 w �l d water level for'n � a7 7�index well ........................... ` . month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) . determine water-level adjustment ............:.................... � I STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured at site STEPpth to water 1) ........................................................ ........................................ � red de a . t I Figure 13.-Reproducible computation form. 15 i F � f i i i I�N N :. THE COMMONWEALTH OF MASSACHUSETTS BOAR® E HEA TH .� ............OF....... .. . �• ...................... Appliratinn for Uwvosal Works Tonstrnrtinn ramit - Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................-.. .............. .Ji� .. ' __Location Address o o. Ow� --------------•--- Address a •.. .............. .................. ......................... staIIer Address / Type of Building Size Lot........ Sq. fe;t U / Dwelling—No. of Bedrooms........ .................................Expansion Attic ( ) Garbage Grinder '4 Other—Type e of Building No. of ersons.......... ....._..... Showers — Cafeteria Ga YP g P ( ) ( ) Otherfixtures .._r;.__......-•-----•.........................................•-----------•---------.....--------------•--------•----•--------••---•--........ 1QW ._._. W Design Flow.............. ......cr__..gallons per person per day: Total daily flow................ .d?_ .d............._gallons. WSeptic Tank—Liquid capacit; Y_.gallons Length................ Width................ Diameter.... Depth..._..___.:.... x Disposal Trench—No.............. Width.................... Total Length.......... Total leaching area......_--___---•----sq. ft. Seepage Pit No...._:_.-.�.__._..., Diameter......C.d___... De h below ml _....�......... Total leaching area._�� ,sq. ft. Z Other Distribution box ( ) Dosing to -7 Percolation Test Results Performed by.__.:�1 Zted'All .................... Date...l��'_�._rf.'__ 7............... Test Pit No. 1---�,?...minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ W' - / Description of Soil.. . �! ••--•....-f �~ / - - - x 7 .. 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 LITLL 5 of the State Sanitary Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the boar4,pef health. Signe ......-- ----•----------•.................. - LJ Date Application Approved By..... --�... . .. . ...... z "�_ -...... Date Application Disapproved for the following reasons:.........................-------------------.......... .............................•.............................-••........................................................................................................................................... Date ra Permit No. Issued ---- r 1 NL2..2 THE COMMONWEALTH OF MASSACHUSETTS BOARD !7 F HEq TH/ ` .............OF...... I t � ., /� ! . ....................... Appliratiou for Disposal Works Tomitror#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..................—.................. .. .........................._........... ........... ........ . .. .. —Location Address or Lot No. /t ...... ... ............... ` ow;.=2 Address ,1 �...J.:. ll..,. ..................•.....•.......... ....---...............--•--....-•........... -- 74 staller Address L,� d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._.__..,?.................................Expansion Attic ( ) Garbage Grinder Other—Type T e of Building .............. No. of persons p� yp g .............. p 3............. Showers ( ) — Cafeteria ( ) Q+ Other fixtures --------------------------------------------------- -... W Design Flow.............. ' ......5...5........gallons per person per day. Total daily flow................. _..3_ ?..........._..gallons. WSeptic Tank—Liquid capacit}� '�t`_gallons Length.............•.. Width................ Diameter..2,r. . Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.._........_.../....sq. ft. �y Seepage Pit No.......... ..__..... Diameter....../_1...... Depth below inlet....... Total leaching area._2.-j�--,�l..sq. ft. Z Other Distribution box ( ) Dosing tank( ) ,' `/- �i `-7 `J W Percolation Test Results Performed by.. :� �f�.,d/ rl.................... Date._.��:_�..,`�.:_._ ��........._.. a Test Pit No. I.... ...minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil:-----------1----Q-�---- ........ ..... . . _ . / ...-•-•...........................�•-•-----••-------•------•----- ..... . W UNature of Repairs or Alterations—Answer when applicable................................................................................................ --------------•----------------....................-----•-•-----------------•-•----------•--•-•--•------•--------------............t................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT;-;::. 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'.....!... '---------------------------------•-------------------............-- GI /JJ Date Application Approved By.....=�= ,l �l �..................... -•�_•2-••Z -----7y ...... Date Application Disapproved for the following reasons:........................................................................................ .. .----•----•••... --------•-•---••-••---•-•---•-•-----•--•-----•-•-•-----•.....................•------•--••......---••----•--•........-•-•-••-----...•------••----•-•••--••••--•--•---•--•----•-•---•---••----•--•-••••-•- ate PermitNo......................................................... Issued........ 1 --.--------•- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD �=.- H f ..OF...... .......................... Trr#'firtt� of Tompliatta T, IS TO CERTIF l That � ndividual Sewage Disposal System constructed �r Repaired ( ) by �,1'_LEz ... a ..... ..................................... . = ...--------�-- — , , nst er } _ at.. �` �t� C . :/J..... P�W': ' ....., '.(-�L-� l/ `� `�` :`- . G :�"19.�'vr� • --f has been installed in accordance with the provisions of TI/'_ P 5 of The State Sanitary Code as described in the 7�1 application for Disposal Works Construction Permit �r o�.,......�...y.�.:.............. dated------- -.. ---l.--._7_7............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 'WILL FUNCTION SATISFACTORY. A DATE............... .... Inspector........... ----- ....... r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH •1, ��, .................e`'::.. :'..::i..........OF....... ............Y.k•1:%,I� :.......Z�::%::........................ ,_ NO:�..................... 1 FEE......... ............. Disposal ,Works (goats#rutiotv .ernti# f Permission is herb anted..... ;.!`'_. :%�! = �s "r!::: _: y to Constru,5tr pr Repair ( ) �Individual wage Dis9 1 SystSt at No.,%//t_, i- LC, t iJ.. ...L-- ........ - Street _ •_ as shown on the application for Disposal Works Construction PerrA No.,.-................ Dated..... .......................... .... _r.. _"------------ 7 Board of Health DATE------------- ---•-•-----------........--------................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS �,� _ ,��v, .•��t.` off: ', `•� � ilk 000 111 `IV cQ° ' [�. N _ i • Oct go11.0 a� . .nA UAI ZQ K.�•r. 3 ��.' r - � e�Y•^I.F xy v5+, r y, ,i p irt. 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AT EL. 66.24' SYSTEM PROFILE NOTES ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT M SCALE) 1. DATUM IS APPROXIMATE NGVD •" (ADD IF NECESSARY) ACCESS COVER (WATERTIGHT) TO MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2X SLOPE REQUIRED OVER SYSTEM 2. MUNICIPAL WATER IS AVAILABLE �_ RT• 28 . 62.00' � ' TOP OF S.T. AT EL 63.56' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. /—FOR FIRST 2' — IXISTING 1000 // 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST .UNITS TO BE AASHO _ H 10 0 • GALLON SEPTIC 61 1'±* 60.18' � y TANK (H- 10 AS BAFFLE 59.60' S9.43 a a a o O O 0 a 0 5. PIPE JOINTS TO BE MADE WATERTIGHT. CpNSTANT BAN r9.35' p p O 0 O 0 ED E3 c3 z 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 6" CRUSHED STONE OR MECHANICAL 0 0 D O Q D t`IE MASS. ENVIRONMENTAL CODE TITLE V. ENCE LA COMPACTION. (15.221 (21) 2' 0 0 0 0 a o o a o 0 57.35' pRUp DEPTH OF FLOW 4' (6.5 X SLOPE) ( 1 X SLOPE) 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED 'T�ZR BE USED FOR LOT LINE STAKING. INLET DEPTH = 10= LOCUS MAP OUTLET DEPTH = 14" 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. NOT TO SCALE FOUNDATION EXISTING SEPTIC TANK 35' D' BOX 10' LEACHING 5.85' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION ASSESSORS MAP 39 PARCEL 52 OBTAINED FROM BOARD OF HEALTH. LEGEND LOCUS IS WITHIN FEMA FLOOD ZONE *THE INSTALLER SHALL CONFIRM MIN. SEPTIC TANK 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING "C" AS SHOWN SIZE AT 1000 GALLONS AND ITS SUITABIUTY FOR DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ON COMMUNITY PANEL #250001 0018 D 100.0 PROPOSED SPOT ELEVATION RE-USE. BOTTOM TH-1 EL. 51.50' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO DATED 7/2/1992 • COMMENCEMENT OF WORK. +100.00 EXISTING SPOT ELEVATION 100 PROPOSED CONTOUR � � 11.PUMP AND REMOVE (OR FILL WITH CLEAN SAND) EXISTING 0`� / �, LEACH PIT. 100 EXISTING CONTOUR ' SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) DESIGN FLOW: _3 BEDROOMS ( 110 GPD) = 330 GPD USE A 330 GPD DESIGN FLOW SEPTIC TANK: 330 GPD ( 2 ) = 660 *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL / ;' ` / PAVED 'Q� St �op C� USE A 1000 GALLON SEPTIC TANK (RE—USE EXISTING) BUILDING SEWER OUTLETS AND ELEVATIONS -.� DRIVE `90• G� '�q `�1s LEACHING: PRIOR TO INSTALLING ANY PORTION OF %� SEPTIC SYSTEM. SIDES: 2(30 + 9.83) 2 (.74) = 118 30 x 9.83 (.74) = 218 BOTTOM: TOTAL: 454 S.F. 336 GPD USE -(2) 500 GAL. LEACHING CHAMBERS (ACME OR 6�� �fO�� // j \ �•` EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND TEST HOLE LOGS / / - BETWEEN UNITS c�� EXISTING DWELLING / < ENGINEER:• DAVID FLAHERTY, RS / / ,.- o�UG EL LINE OF FNDN=66.2wl WITNESS: DON DESMARAIS, IRS LPIT -.I- -- - '\ o �, �I MA DATE• MARCH 6; 2006 ` '�> ; �; I Box APPROVED DATE BOARD OF HEALTH • < 2 MIN/INCH Al 2 GAS METER ( /, PERC. RATE _ _ I I ' ~ ,' TITLE 5 SITE PLAN CLASS i SOILS P#11233 / / ?H-1 i '-- ' DECK / OF ELEV. ELEV. TI]NEI WALKOUT , � on 1 / - == 72 CONSTANT LANE 0 A - 5" 61.58' LS / TH-2 �— .- i 6 LOT 66 `V 20,049 SFt COTUIT MA A 1OYR 4/1Q- LS 4" 61.67" \\ /; \ \\ I ' PREPARED FOR 11" 10YR 4/ / \ , 61.08' LS / a� . \ �� BENCHMARK TOP Q� B 10YR 5/6 , \ OF WALL AT EL. < �� % �'` BORTOLOTTI CONSTRJ LS ��'� ti� \� \�) 64.7' 31" 1OYR 5/6 27" CLAIRE FUSCO 59.42 59.75' C C PERC PERC `,, DATE: MARCH 9, 2006 M S M S ' /Ihoff 508-362-4541 / fox 508-362-9880 10YR 7/4 10YR 7/4 T / �HOFs 6f down cape engineering, inc. 20' ARNE H. G� oJAiA CIVIL ENGINEERS 126" 1 151.50' 122" 1 51.83' i/ OJALA N CIVIL No.26348 No. 36791X LAND SURVEYORS NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' TEL RISER , ' ° E S S °�s No 939 main st. yarmouthport, ma 02675 ELEC Box ; DATE H. OJALA, P. .L.S. DCE #06-030 0 10 20 30 40 50 FEET / XXXXX.DWG