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HomeMy WebLinkAbout0096 CRYSTAL RIDGE ROAD - Health a a 6 Crystal Ridge 90/) D Cotuit P -� -� - - 056 002X18 l IST ECOJECH MAP pARCE , ® Environmental www.eco-tech.us LOT ° THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/1512000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 96 Crystal Ridge Road RECEIVED Cotuit._ Owner's Name: Carole&Leonard Julius Owner's Address: 96 Crystal Ridge Road MAY 2 5 2004 Cotuit ,MA 02635 Date of Inspection: May 12,2004 TOWN OF BARNSTABLE WEALTH DEPT. Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails 4LInspector's Signatureziz- k5- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority'(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note=> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected.No estimate or guarantee of system longevity is made or implied by a passing determination. ****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 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 Crustal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no,or not determined(Y,N,or ND).in the_for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not),is structurally unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 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 and 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 **This system passes if the well water analysis,performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3)OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12, 2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described 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. 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 1/2 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 X Any portion of the SAS,cesspool or privy is below high groundwater 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 l 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 by 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) No (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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in section D above the large system has failed.The owner or operator of any large system considered a significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? Y _ Were all system components,excluding the SAS.located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information For example,Plan at the Board of Health. Y _ 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: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents 2 Does the 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): n/a Seasonal use(yes or no):no Water meter readings,if available past two year's usage(gpd): 440 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sqft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings,if available: Last date of occupancy/use:- OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System last pumped in October 2002(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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/Alternate 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) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age: 6+years Certificate of Compliance issued 11/6/97(BOH permit#97-503) I Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:—cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments:(on condition of joints,venting,evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_ SEPTIC TANK:Yes (locate on site plan) Depth below grade: 12 inches Material of construction: X concrete_metal_fiberglass_polyethylene other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 3 in Distance from top of sludge to bottom of outlet tee or baffle: 31 in Scum thickness: 0 in Distance from top of scum to top of outlet tee or baffle: 10 in Distance from bottom of scum to bottom of outlet tee or baffle: 14 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping not required at this time but maintenance pumping is recommended every 2 years Liquid level at outlet invert Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out. GREASE TRAP: none (locate on site plan) Depth below grade: " Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 TIGHT OR HOLDING TANK: none (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):_ Alarm level: _ Alarm in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert. No solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no)T Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: _leaching pits,number _leaching chambers,number X leaching galleries,number 1 _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above leachinggallery appeared unsaturated No evidence of surface ponding,breakout,lush vegetation,or other evidence of hydraulic failure was observed. CESSPOOLS: none (cesspool must be pumped at time 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:none (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.): ro 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 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'(Locate where public water supply enters the building) LOCATIONS A B 1 14 ft 19 ft 2 17 ft 16 ft 3 21 ft 15 ft 1 4 38 ,ft 36 ft A SEPTIC EXISTING 0 TP�K DWELLING 2 B 313 D-BOX o 4 O W LEACHING z GALLERY J w W H QI CRYSTAL RIDGE ROAD NOT TO SCALE 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: 96 Crystal Ridge Road Cotuit Owner: Carole&Leonard Julius Date of Inspection: May 12,2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: l l+ feet Please indicate(check)all methods used to determine high ground water elevation: X Obtained from system design plans on record-If checked.date of design plan reviewed 11/6/97(C.O.C) Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators,installers-attach documentation) Accessed USGS database You must describe how you established the high ground water elevation. Design plan shows bottom of system to be 5 feet above the bottom of a test pit in which no water was encountered. 11 No. t� FeeTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS s 2pplication for Zigpozar 6potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete Systems vidvidual Components Location Address or Lot No. quo w R�s' 19 I q Owner's Name,Address and Tel.No. Assessor's Map/Parcel j Lct-rt— t X IF, Installer's Name,Address,and Tel.No.f G S^V-f 0— 97 3uP Designer's N e,Address and Tel.No. Sig" 77 0%3u5 cl 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicablp) ,(�� /- /1//'Gf/ S-Od T© 'Jc/S t/tip -Z -l7r u 46,1 � y '�-d h� e�.�v a�-W' - 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 He 1. / �O Signe Date Application Approved by Date . DL 0`—� Application Disapproved for the following reasons Permit No. �;M 3 3 Date Issued �— ., -----------------:1-_-_-----.--------._- _. ------- No. 7 3 - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ± +� Yes PUBLIC HEALTHIRIVISION -TOWN OF BAR STABLES MASSACHUSETTS ZIpprication for Mi�pozar p'g ems (tonttruction 39ermit' Application for a Permit to Construct(!. )Repair( )Upgrade( )Abandon( ) D Complete System tv dual Components Location Address or Lot No. 76 /?�S / f l: R Owner's Name,Address and Tel.No. Lordly Lf 0t'1�4r� ✓C/l/uS Assessor's Map/Parcel S-;, Arlo-� 0G a x I? ZI ?" Installer's Name,Address,and Tel.No. !O SAP Designer's N e,Address and Tel.No. �06-cr,6 O, t3����s GvrLLrfa ss�C114 rt-s �/7-` / %ls !lam 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) W"41 / N/_'"GCS 5', ly 'w1:11 C-!- /5 Gur i;ii 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 of H,e/a1th �/a l. ,/ �/ Signe '� ;E> 1t2/ Date Application Approved by Date Application Disapproved for the following reasons Permit No. �;M '3 3 �-�, Date Issued '7 �- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIPY that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by ✓a5>/41 Z !-r at Z6, / e/ 41 a; 2 6! " T/��?!�i'% has been corst..ructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�2 o D It "3 32 dated L/ Installer �o5 r, Designer The issuance of this hermit shall not be construed as a g uarantee that the sy stmywill�wnction a de ' ed. Date -7 /'0 Inspector �i -----LL4---------------------------------- No. 24!-O 4 3 73 'a, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mig;po.5at *potent Con5tructiou Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon System located at y� �r u</r"�/ / ua and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru tion/mus`t be completed within three years of the dat ooff"ftthis p t: Date: �aG d 7 Approved by ' -/�----� TOWN OF BARNSTABLE - auu -33' LOCATION �0-Y5T9L dGe -Q SEWAGE # q-1-<- 03 VILLAGE .�i�r°�� ASSESSOR'S MAPr LOTS p®r m ht INSTALLER'S NAME&PHONE NO. a 32! SEPTIC TANK CAPACITY. V20 GAL � LEACHING FACILITY: (type) f �� La#Gk size) 13X� �_ NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: tA to q7 Separation Distance Bet n e: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 ooa Iq 1� I2I 1 Is 3 1-1 Ito Od" ,v., o ,5�0 �jca //w� C/n H w, v^ 2 u o Y-33 2 I Town of Barnstable WE rqy, Regulatory Services Thomas F. Geiler,Director * 3ARNSTABLE, 9 MASS' Public Health Division s6q. ♦0 AIFD ,I,, Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: ��� Designer: Installer: clasY.d� ,Oe 5 Address: t� / j� ��� Address: `Z- On,--I -O yD� 15,5t1wes was issued a permit to install a (date) (installer) G= O septic system at ro/ 1412 based on a design dra . n' by �'• (addres ) c ' r.. dated designer) o -0 79 I certify that the septic system referenced above was installed substantially accords tom the design, which may include minor approved changes such as lateral relo ation if the distribution box and/or septic tank. kD M 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. -�H of�Ssgc o� DANIEL E. .tiGN o BRAMAN (Installer's Signature) Q CIVIL Cn No. 32686c Q(A✓Lc �SS/ONAL �av (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OFBARNSTABLE - 2Uu =33- LOCATION Lot IcJ,,0 &4§L "1�(A�rt'- 4A, SEWAGE# q-1'<'O VILLAGE ASSESSOR'S MAP & LOT,SG A©z Am- INSTALLER'S NAME&PHONE NO.`DC' 'Z8 "�30n- TA x+� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) sX ekoL ►. size) 1 1 NO.OF BEDROOMS r BUILDER OR OWNER Ax- la- 1 lcke(t,'- PERMITDATE: COMPLIANCE DATE: U I r 97: Separation Distance Bet n4hhe: A Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of.Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � p✓ oo® Iq t� Z I$ 1 Ito a 21 15' fo 45 yw 2uoLl-332 A y Fee No. �" �� THE COMMONWEALTH OF MASSACHUS S Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABL . MASSACHUSETTS Apphration for �Digogar *pgtem Con.5tructton Vermtt Application for a Permit to Construct( L Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Addressor Lot No. t 9 k CgY5%i�L R I Pd E M Owner's Name,Address and Tel.No. 77 40 V20 Assessor's Map/Parcel 5" Q,0 Q 1 x /c p , f Installer's Name,Address,and Tel.No. 1— �Q �S Designer's Name,Address and Tel.No. 7 7 5-- 07-3 57 J0 15:- 'D I C l A/00 Type of Building: Dwelling No.of Bedrooms Lot Size qY,717 sq. ft. Garbage Grinder(AW Other Type of Building U)jQQ> IVAAE No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow O gallons per day. Calculated daily flow 3 3D gallons. Plan Date Number of sheets Revision Date Title &,Lf N eAY5741— Rlb6te Ab Size of Septic Tank Type of S.A.S. Description of Soil PO4 PO Al ,r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to'ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm al Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by oard o(Hea Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued Z�9/ �' � s x r �,�7 � 4 •awiWy«..'� N6. !` �J Fee THE COMMONWEALTH OF MASSACHUS T S Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABL MASSACHUSETTS Ye`� Application for Mi5pozal Apg/tens (Cori.5tructiou Permit Application for a Permit to Construct( 4Repair( )Upgrade( )Abandon( ) O Complete System D Individual Components Location Address or Lot No. #9 4, C `y5 JrO I ;e 06 F Owner's Name,Address and Tel.No. 7 — 40(la GOTO /T b6YS iD� &be IA16 Assessor's Map/Parcel_- QQ a' x / 'i r / Installer's Name,Address, d Tel.No. Designer's Name,Address and Tel.No. 7 7 7 — tr/7-3 Type of Building: ` Dwelling No.of Bedrooms .3 Lot Size t���'? sq.ft. Garbage Grinder -- Other Type of Building 9)00-> 77KAOic-No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 666 gallons per day. Calculated daily flow 330 gallons. Plan Date G 3 q7 Number of sheets Revision Date Title 1U T /'( C(t.Y s,41- /2/D6,9 fib Size of Septic Tank Type of S.A.S. - Description of Soil ®r4 P L-14/ 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 Environme al Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by i oard o1 Hea Signed Date* /(/7 15; Application Approved by ' Date `' Application Disapproved for the following reasons l Permit No. Date Issued 0ov �-- 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 J _D 1 C/ij A-I& at (D C 12Y 57¢I L A (b 6F RD C 0 U l T been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No p" 7.7dated 15;'''—, ' Installer JUr— Z)/ G/oq A"o Designer The issuance of this permit shall not be construed as a guarantee that the syst w'll fun o s -esigned. . Date //—7" / 7 Inspector , ��� ------------------------ No. 9/ °"_ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Migaar *p.5tem (Construction Permit Permission is hereby ranted to Construct( V�Repair( )Upgrade( )Abandon( ) System located at 9� C9 YS Tf1L- X /666 A CJ7U /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 conditions. Provided:Construction must be completed within three years of the date of this e Date: r Approved by c, TOWN OF BARNSTABLE LOCATION � I�-I CaYSTAL 'Qid ���. SEWAGE # q�'sC3 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.` eC[> SEP,n. TANK CAPACITY ISCO �RL LEACHING FACII.]TY: (type) (Z) Sae 6ipL bk4cn&C iraert5�'[size) 13X Zr NO :OFBEDROOMS 3 BUILDER OR OWNER �1 PYS;A T1 v►k0kettS PERMTTDATE: COMPLIANCE DATE: U (s q 7 Sep,'qon Distance Between the: Max vin,Adjusted Groundwater Table and Bottom of Leaching Facility P&MeVater Supply Well and Leaching Facility (If any wells exist ,.::. ontsi(e:br within 200 feet of leaching facility) Feet Edgeof Wetland and Leaching Facility(If any wetlands exist wthin`300 feet of leaching facility) Feet i Furnished by f SI Iz h o all L. Ii U SI Z ` .. l hl / o00 h TEST HOLE LOG DATE:- SEp T. /3 /98� P— )fro� SOIL EVALUATOR: WITNESS: - / cJ/�CT- PERC RATE: Apl 1/NC s� 4 .I o k:> GZ r ,c16D/vN SA�4� GZ �l0 I�JAT� ��tJ�'ou.J�E/ZE� G� DESIGN DATA DAILY FLOW: (3)BDRMS. a 110 GPD= 33o GPD SEPTIC TANK: 3 3oGPD z 200% GPD �D O USE: /Sd C>GALLON PRECAST SEPTIC TANK ►��Y j LEACHING FACILITY: Zo USE. Cz� � l c� y o� sT••� - �- 1 (-A're _� M , CAPACITY: SIDEWALL: 76, a'Z 1 a� BOTTOM: /3,X ZS xo, )y Z�/a.S \ ( TOTAL: i \ �- OTES: �\ 1. ALL PIPE TO BE 4"DIA.SCII 40 PVC. BRAMAN �TEVEN l 1. CIVIL 2. PIPE TO BE LAID LEVEL FOR V OUT OF DISTRIBUTION pUAA8,1 v No.32686C BOX. 35790 ,p O 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE 8,y> 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A StlA�t GARBAGE DISPOSAL. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE 2•LAYER OF 313"FEASTONE OVER 3/4•-1 UP WASHED STONE ALL AROUND TOP OF FOUND. @ EL. to y o o 10• 14" Goo \ (oo,ofl\5983 S�.So f o �oD so - SEPTIC SYSTEM PROFILE SITE ^r SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR 6. ����E' TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR IS.00:TITLE V. 3. TNiS PLAN 1S NOT TO BE USED FOR PROPERTY LINE DETERMINATION. G DATE: SCALE: �/ i 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. �.c� 3 /` r 7 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLER & ASSOCIATES 1645 FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508)77M735 FAX: (508)77M754 APPROVED BY: TEST HOLE LOG DATE: - j;-Ea?7 /33 SOIL EVALUATOR: ,OOP-Jt�JE r. WITNESS: _ J�vti N/ACT PERC RATE: �J o �` GZ•S °- Co•�w we / G.O Q Go,o r ME'Diu.�/ 6`i► v �Z �` GZ /S(o l�J Ai� �.tJ�•ou�E2E•a O G`I / �• DESIGN DATA �o� G DAILY FLOW: (3)BDRMS.a 110 GPD= 33 o GPD �O SEPTIC TANK: 3-1-GPD:200%= &G n GPD �O O USE: /56 oGALLON PRECAST SEPTIC TANK LEACHING FACILITY: �� USE: Cz�S3,SxZ'�s�) 19c. Drryw�c�s ff zo�� CAPACITY: o 1� SIDEWALL: 7G 1 BOTTOM: /3 "X ZS no, >y Z�•S TOTAL: -OF IF c oTEs: r O BRAML // 1. ALL PIPE TO BE 4"DIA.SCII 40 PVC. ^� BR CIVIL s 2. PIPE TO BE LAID LEVEL FOR V OUT OF DISTRIBUTION 1V 1! o .326 BOX. •, � I'+ v No.32686C y 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 'O-AFC 6"OF FINISH GRADE. fs O 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A sunvi 1 �D GARBAGE DISPOSAL. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2•LAYER OF"'PEASTONE OVER 314"-1 1/2•WASHED STONE ALL - AROUND TOP OF FOUND. G�b \ lv0,o�\Sy.83 lvo. so fo o, Z S S8, So SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR [[DATE: 10 %.4 L �j� E v, TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 1&00:TITLE V. 3, THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. SCALE: - yv S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. _ I WELLER & ASSOCIATES 1645 FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508)775-0735 FAX: (508)775-0754 APPROVED BY: ro Lo��s PROI=ILE: NOT TO SCALE ONE 1`E5T f—fOLE LOCH MR5r PIPE LENGTH OV LAYER ,Va'POLOLE � O 70P P`011 A7't4N 45`Or PINIstm 6;/Am rOR MIN. Z' WASFIED51'OrE TEST f�Y:�O�u a/ pc� 9 GiMRS TO WIT11N TO De SET LEVEL Ot ,1c i EL- �v S 1 m9l 6RME WFNE56:- ✓ Duv r IIL - Gz PERGRATE: a a' FPNNV�o rap EL srn ao -,r�-� p. DorTaM 0 EL G. > .0 M Ad A7 F �,�", I e.e �E'(� S 4S n+am rr rm DIST. J�ii/33o i L sEPrla 6TAM Nj A" STONE DAIX C i 3�0 N VcIC EL E v ' -50 'rTi�i G tiere.., O. 'Y<.e Z2_. -- 1 jZ sus ti DE510N DATA Go 7 �� �, ` PA LY FLOW: (z/)MPROOMS x I b 6PD= y5�o C�PD '/ 5Er 1"ANK: V7o eep x2001-88o c-;PD F USE: A56 o GALLON PRECAST SEPTC TANK LEAGHINC-7 FACILfrY: �e USE: C3) .5'x-R. 5 i<2'--- Socy O.a�Y�cJELGS •- 7d CAPACITY: SIDEWAL..: �3 e z'Xe_,251 _ /37l� 3, 3 ��x�.,y . .3 ZZ, 3 GENERAL NOTES __ x/s Tiy� f30TTOM 10 TOTAL:_ yS9.9 c x I CONTRACTOR TO M RESPONS13LE FOR THE LOCATbNOF ALL Ui Ur ES, ADOVE AND UNDER6ROUND,PR0R TO ANY EXCAVArON OR 60N57RXTON. 2. SEPTL SYSTEM TO bE NSTALLED N GOMrLANCE WFH 39 GMR P00:TfrLE V 3. THS PLAN S NOT TO pE USED FOR PROPERTY LNE DETERMNATt2N .�`� ✓ v v A. ALL P! eEf� M p 5, CONTRACTOR TO PROVPE 7-4 HOUR NOT6E FOK ANY REQURED N:;PEGTONS �vl �iyyo. rx►�13oc,,� _. _ .,s'r-�s ,�E-1-,9 /L - , ioc / �o u � I 517F eff-\/\/AaF- FLAN 1 LOCATION: /_ of M� PREPARED FOfZ:_ G viyR2.o c�v G_ v� SCALE: DRAWN f3Y: DANIEL IAR ; STEVEN W _. q � ' S7RUCTUFiAl CD UMBA a Gc� GtJ JOf3 NJMMR: PATE: : L � 1� f1 St1EET: el ?OFFSSIO�P ���S�Difk1 E 9�p SURV cn� __�7 -c WELLER & A5506 I ATES I645 FALMOUTH RP - SUITE 46 CENTERVILLE, 'MA OU?a TEL.: (505) 775-0735 N FAX: (508) T75-0754 PROFESSIONAL ENGINEERS & LAND SURVEYORS