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HomeMy WebLinkAbout0015 EATON COURT - Health 15 EATON COURT Cotuit A = 055 — 014 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: /Vf key to move your cursor-do not Matthew Gllfoy use the return Name of Inspector key. B&B Excavation, Inc. reb Company Name 14 Teaberry Lane It Company Address Forestdale MA 02644 Cityfrown State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/5/14 In ctor's Signatur Date The system i 'Spector 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. ****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 Lthe same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Sub a ewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: i 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4114 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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 at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Eaton Court M Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Eaton Court i 7M Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ E 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? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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): 550 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: August 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I Type of System: ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1987 Were sewage odors.detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in working condition No sign of leakage Septic Tank(locate on site plan): Depth below grade: 61- feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gallon Sludge depth: 3„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, ,M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" 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 16" — How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of leakage. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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.per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to be structurally sound. No sign of solid carryover or leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching was dry and appears to be in working order. No signs of hydraulic failure. 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 ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. Cityrrown State Zip Code Date o Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I' C rAf act A3-:- 39 ' �i2= 35 ` 733 - 't3 r6 t, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: > 168" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/27/87 Date ❑ 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: plan on file at BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Eaton Court Property Address Estate of Robert A. Parlow Owner Owner's Name information is required for every Cotuit MA 02635 6/4/14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION ZO'l rr SEWAGE # _ `�L15 VILLAGE O v ASSESSOR'S MAP & LOT o _ INSTALLER'S NAME & PHONE NO. oki #10 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) A ` (size) /00o y« NO. OF BEDROOMS ' 3 PRIVATE WELL OR PUBLIC WATER pZ.,4, BUILDER OR OWNER Ac 5A ei-e •nP) DATE PERMIT ISSUED: e, - a — g - DATE COLIPLIANCE ISSUED: / VARIANCE GRANTED: Yes No Ilk JIL F>s.. si ......... THE COMMONWEALTH OF MASSACHUSETTS D BOARD OF HEALTH � 1 ®����0 ...TOWN................OF.....5At w-5TAat------------------------------------------ Applirtatiun for Uiiipaa al Warks Tonstrur#'tun ramit Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: o Lam-_ 5---•-..EATC)".....G o-uiz.T-. fJdT. ............-----------------•...--------------..........._...._...............------ MM •• ocation-Address .......•.._----.•.•..........................Lot No. Owner Address W Installer Address 2 Type of Building Size Lot.ACa ..r, 5.7...Sq. feet Dwelling—No. of Bedrooms.................___......._..._______.Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons......... -............. Showers ( ) — Cafeteria ( ) GaOther fixtures -------------------------------- - -- ---- ---------------------------------------------•------------------------------------------- Desi n Flow..............15.5.................... allons er erson er da Total daily flow.._......_ W gg P P P M Y• � Y � �-- --• --.................gallons. WSeptic Tank—Liquid"capacity_I�gallons Length.�t'G... WidtA__'�Q_. Diameter................ Depth..�.-.4_. x Disposal Trench—No......... ..... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I------_---- Diameter.A.Q'-o~ Depth below inlet......Q........ Total leaching area.•2OP-7.1.....sq. ft. Z Other Distribution box (✓) Dosing ank ( ) Percolation Test Results Performed by..VAL -------------- as Test Pit No. I........Z...minutes per inch Depth of Test Pit----t6P6"... Depth to ground water--------e.......... f? Test Pit No. 2_..._._Z-_-_minutes per inch Depth of Test Pit.....;Nl t>_.. Depth to ground water.------507........ a' -----•-------- --------------..----•--- . ..... -----•---------------------------------------•-------- O Description of Soil �� M Q 4 , CJToN------------------------------•---------------. x 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 be n iss d by the board of health. Signed-------• ... ...........�'� . •------------•-----•--. _,�..`-'... ` F Date ApplicationApproved BY....A7.0...- ----- - ....................._.......................................... ........................................ Date Application Disapproved for the following reasons:................................................................................................ -------- easons:................................................................................................ ......... 8 7—3 /� Date PermitNo------------------------ ------------------------------- Issuecl-....................................................... Date •��� Y,j I tT" ( �'"t�� No......................... Fzes............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ©1r�1N................OF.... ,IN..-'TAIL. ------•---•............................. ApplirFa#ion for Disposal Works Tontrurtion Frrmit Application is hereby made for a Permit to Construct ( r) or Repair ( ) an Individual Sewage Disposal System at N ....... - "tmQ�.._. cT...CQTJ ......................................... : . u . ot .-- - ......_........----- oaionA ®J rNo AIMT)- -•-•........ .......•_••----------------•_•••••-•--••-•--••-------.........._-••-••-•-•--•••-•------........_.. Owner Address W Installer Address UType of Building ��, Size Lot.............�_____�_._Sq. feet Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons.........a__............. Showers — Cafeteria Q' Other fixtures -------------------------------•-----______-•---------------------------------------------------------- Y- d - Design Flow.............. per person per day. Total daily � � W.. ; ow to s WSeptic Tank—Liquid capacitylgallons Length!�'. ... Width' Diameter________________ Depth... x Disposal Trench—No..................... Width.................... Total Length......._ ._,....... Total leaching area____ _____ .....sq. ft. Seepage Pit No.... _._________Diameter... Y"�__ Depth below inlet_._._�..._..__ Total leaching area._C............. ft. Z Other Distribution box (� Dosing ank ) Percolation Test Results Performed b ..4 �-T�:(Z____�_•. LDMAN Date. .T.__..`...j_f�� ' y •---- ,� 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........................ a -- ---- O Description of Soil.....__.�'�IU --- �- __/ TJ..I.° x W --••-----•-•-----•------------•••••-••--------•-•---•--•••---•-••••--•------•••-••••.............•••---•••-•-...•-•-•---•---•.----••-•----•-•••-•------••--..._....----•--_.._..___...•••••----•_-••-•- VNature 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 TITiZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be iss d by the board of health. Signed........ . ......... L� ..`..__ 1��2� - �7 ............... Date Application Approved By _.. .• .............••--......................_..- Date Application Disapproved for the following reasons-............................................................................................................... ---------------------------------------------------------------•-........-----------.._......._......•---•--•-•-••••_•-•••••-•--...••-•-------•-----••...._____....••••-•--••-•---•-----._...---•--___-- -f Date -•• Permit No.._• •-..I... ........I............................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Intifiratr of TontpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by•••••••••..............•------.....•••---•--••-•••--•-••-••---•••••--•-•...-•--•••----•-•-•--.._..••-••--••••••••-••_......•••-•--._.........._..........................•••-•........-••-•••._... Installer at...................................................................................................................................................................................................... has been installed in accordance with the provisions of T TI f 5 of Tl�State Sanitary Code-a described in the application for Disposal Works Construction Permit No________________ y'._ ............ dated.....!.....__..__ /_.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... c/ _r -� ...._... .. Inspector --•--•-••--••-•--- ... t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH FE Disposal Works Ton#r ion rrntit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street ,� as shown on the application for Disposal Works Construction P�rmit N8...___::J ,____ Dat d.__ _.._Z:_...............-------- ----- Board -- FI----- DATE---- 7 FORM 1255 HOBBS & WARREN, INC., PUBLISHERS AsBuilt Page 1 of 1 /T/ AS TOWN OF BARNSTABLE LOCATION ,C01 F*�v� Comer SEWAGE # � 7� S ys VILLAGE fig COT�f ASSESSOR'S MAP Sz LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY_ /000 LEACHING FACILITY:(type) �, /" _ (sue) /000y` NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER P✓I/ BUILDER OR OWNER 1146 54.,l f Coax S rY�✓Gf. �`� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ) VARIANCE GRANTED: Yes No f" i �o✓SP ► i \ `ram i�ul 1 f is http://issgl2/intranet/propdata/prebuilt.aspx?mappar=055014&seq=1 6/4/2014 IITEM II'NOT ' TO -SCALE"TOP. nm.''� 'FINISH �GRADE FINIS141 GRADE OVER GPA DE D VER 'GRADE -OV�EL ' -FINrSH DIST.: BOX ER IHL EA CHTNG PI T 44-,�Z�-SEPTIC TANK4 Z I..........\\\\7 VARIES old* 12 MAX P RECAST' 'CO)Vd. _OR SHED PEASTONE BRICK, 49 MORTAR ,�OUTLET PIPE 19 LEVEL BEL O GRA DE FOR FT., MIN 01-0 6 4 6 -56 6 0'.6 .0.4 C. I,. OR PVC TEES-6.h Ift A 8SMT. :FLR 1000 UALLON DIS TRIBU TIOM, BOX EL.-5s'.2.15 vQ tINS TA L L ON LEVEL, BASE �314 �j 1�12 6 RECA S 7'PRECAST CONCRETE 'NA SHED CRUSHED H-7, 0 CONCRETE TONE , 10 SEPTIC TANK TE TO EL E V. OR 411 INSTALL ON LEVEL BASE NOTE: EXCA VA L OYER TO REMOVE ALL' IMPERVIOUS MA TERIA L ; BENEATH THE L EA CHING AREA -0 2 Ay REPLACE EXCA VA 6 ',-O TED MA TERIA L WI TH CL EA N, CLA Y FREE SAND fop Oil EFFECTIVE DIAMETER,4r,G f7 rT EACHING NOTES GENERAL 1�vs TA L L ON, L E VEL BA SE.1000 GALLON -1 ALL EL E VA TIONS SH01vN A PE BA SED ON A SSUMED PRECAST CONCRE I I 2. ALL PIPES Iff'THE SYSTEM MUST BE CA S T IRON SFFTXC TANK T OR SCHEDUL E 40 PVC. prT IOSSERVA TIO/V THE BOARD OF HEAL TH MUST BE NOTIFIED PIA L TER 'P. OLDHAM WHEN �CONSTRUCTION IS COMPLETE PRIOR PECOLA TION TE*TO BA CKFL L ING MIN'11N.wo.I 44 4. ANY CHANGES INTHIS PLAN MUST BE APPROVED WITNESSED PRECAST CONCRETE SURVEYING CO., INC.., R. GIFFORD BY THE BOARD OF HEALTH AND CA PE & ISL A NDS LEACHMS PIT MA TERIA L S A AD INS TA L L A TION SHA L L BE IN COM BARNS LAO-LBRO.; OF 14tA L TH DESI PL JA NCE WI TH THE STATE SANITARY GN DA TA DA TE* T. 8 CODE - TITLE -V - AND LOCAL A PPL ICA BL E 0 ES 42 RUL AND REGULA TIONS NUMBEP OF BEDROOMS 3 0 6. NORTH ARROW IS FROM RECORD PLANS AND No GA R6A GE DISPOSA L IIS NO T TO BE USED FOR SOL A R PURPOSES TOPSOIL IG -330- GAL�.7. FLOOD HA ZA RD ZONE C DAILY FLOW SUBSOIL A TER SUPPL Y TOWN ,WA TER SEPTIC TANK REG ,'D. GA L--.,f3 SEPTIC TA NK PROVIDED 000 GAL 330 GPO.LEACHING REOUIPED f4c), 2 , vi tl 40 MEDIUM SAND'S SMA L L ' S TONE,:, S.F..SIDENALL ; AREA , - 188-F.X ;2.5, :471 GPD JBBS. G/S.0) AL - ' 79 S.F.BOTTOM ARE F.X I _GIS.F. 79 LEGEND S.15 57 t 5F- 'L EA CHING 550GPD PROVIDED 44 Et. Zel.5 168 NO GROUNDYA TER 4 0, ExIs TING c0NTOuR SINGLE ''F' AMIL Y,"PESIDENCE -OBSER VA TION PIT ,LoT 157 ST 0 DISTRIBUTION BOX 'DISPOSAL S'y PROPOSED SEIVA GE,PREPARED FOPm CHING PIT L EA SEPTIC TANK or 0 MCSHANE CONS TPUC'TION !-I58- EA:TON �E.OUR JRPI , RE SERVE T.00 TUI 8APN.5TABL— _,,PIPE IN VERtELEVA 776N ': 'DA,TE,IFc.,U S R VE) IIVG,',,,IIV C DS APE- igj'ISLAN E PLOT,..PLAN SCALE, AS.. NOT D - 34:SCALE- TEA CKET MA SS P I 4 A 41`,�L' 1� 1w, TEM NOT TO SCALE FDN' TOP FINISH GRA DE 0 VER FINISH GRA D�E EL A R -OV FINISH GtqA DE OVE DIST. BOX FINISH DE R, 'A NK SEPTIC 7 LEA CHING PrT: 44.1- VA RIES -,(//A\\ //A\\N 77M I A OF I/ 46 12 MAX 3 12 PRECA S T COIVC. 'OR SHED PEA S TONE, & R K B'91C A O&TLETL PIPE.'LEVEL TO 2 BELOW GRADE FOR .2 FT. MIN. 0 6 C. I. OR PVC TEES 46 F7777 BSMr. 1000 GA LL ON EL 5�2 DIS TRIBU TIO/V BOX 11 To, 1 211 0. INSTALL ON L E VEL BA SE 14 3 R E WASHED , PRECA's PRECAST CONC E T 0 -CRUSHED CONCRETE STONE H 10 REINF TIC A T 40 SEP NK A TE To ELEV 5.Z- INSTALL 01V LEVEL BASE NOTE, EXCAV et OR -A OYER TO REMO VE ALL IMPEVIOUS L 7 2 '_-0 2*-O� L so- 6 0 REPL A CE EXCA VA TED MA TERIA L tjj TH M A TERIA L, BENEATH THELEACHING A REA, AY F D 19EELSAN CL EA N, CLA Y :-10 -0 rVE IAMETER ft EFFECTI 0 m r CHING :T L EA GENERA L )VO TES 1000 GALLON NS TA L L 01V,;L E VEL BASE ALL EL EVA TIONS SHOlYV ARE BASED ASSUMED PRECA S T CONCE ALLL' SE.?TrC TANK 2. PIPESIN THE S YS TEM MUS T BE CAST�IRON PVC OR SCHEDULE 40 019SER VA TION ' PI T, THE BOA RD OF HEAL T14 T BE NOTIFIED TER NA L OLDHAM MHEN TE PRIOR P CONS TRUC TI01V -IS COMPLE TO A CKFIL L ING PERCOLA TlOfV,'RA TE: ANY CHANGES IN THIS PROVED 2,'MIN. 44 4. PLAN MUST BE AP W I TNESS45D, B Y* BY :THE BOARD OF' HEA L TH AND CAPE & ISLANDS SUR VE-YING CO. INC. GIF PRECAST COMCRETE . FORD r RIALS AND INS TA L L A TION SNA L L BE N L EA CHING PI T MAE DA TA aN_.,lj T-4 2L EBAD. OF HEA L TH,: SIGN PLIANCE NTH'LTHE S TA'TE SA'NrARY �DE COM DA TE: SCT 8 CODE TITLE V - ,,AND LOCAL A PPL ICABL E 0 RULESAND REGULATIONS 3 BEDPOOMS ap 6. NORTH ARROMIS FROM RECORD PLANS AIVD , NIUML3ER OF' 0 R PUqpoSES NO GA RBA GE , DISPOSAL IS'NO T TO BE USED FOR SOL A 330,' 'GAL . DA ILL Y :FL ON SUBSOIL 7. FLOOD HAZARD ZONE R PPLY 7, E p 1000 GA L 8. WA TE TOPIN, WA 16 SEP TIC, TANK, REG 'D L .1000 GA SEPTIC TANK PRO VIDED 330 - GPD- LEACHING REGUIRED, t4 0.1 it p DIUM D ME SAIV 40 SMALL STONE SIDEMALL , AREA -f BB S.F. 88S.F.X - 2.5 GIS 'F. - 471 6P0 Bo 770AIi.'AREA 79 S.�F. L ' T 58 LEGEND F�'. 79 &P0 GIS 4G '5 5 7 '5 F� 5,ff 0 GPD 44 LE4CqtNG POVIDED , _Z Z PRO)POSED ELEVA TIO?V f 6,9"1 NO GROUNDXA TER XIST.TNG CONTOU E 40, AMILLY, PESIDENCE 'SINGLE F OBSER VA TION PIT LO'T 57 4G DIS TRIBU TION BOX 0 PROPOSED SEkAGE DISPOSAL YS TEM �j LEACHING PIT PREPARED FOP CONS TPUC TIO/V TANK ro ol 'SEPTIC Pi .- COUPT,EA TON (R RESERVE LOT ASS BARNSTABLE-�' I T U DA COT TI01V -PIPE IN VCR T ELEVA _DALTE Z7, t4�7 ISL A NDS SUP'VEYI/VG,.'.;,1NU� jCA PE. ig I F VA , 2 A TONE PLOT�'PLAN �BOX:,�334L' 4 'No A T H RA S- 8 PCL- SE SCALE SCA LE �,A S NO TED