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HomeMy WebLinkAbout0054 FURLONG WAY - Health 54 Furlong Way Cotuit P i No. Fee- -=-- ` ETTS THE COMMONWEALTH OF MASSACHUS T T , PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS �� J ���Yication for �i�po�a� �pgren� c�or��tructco��,�petn�it Application is hereby ma a for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. L 1 Owner' Name,Address and e,1.No. D O T r-J40 A.15 Installer's Name,Addres,and Tel No Designer's game,Address Tel.No. t �o a�S � L$t 6 1 � 6D Z�- Type of Building: Dwelling No.of Bedrooms-_--_ - 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 Description of Soil Nature of itepairs.or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensurelhe c uction and maintenan of the afore described on-site sewage disposal system in accordance with the prov' ions of Title S of th ental C ` e and not to place the system in operation un 'I a Ce cate of Compliance has een S. e r Sign � Date _ o Application Approved by a `' Application Disapproved for the following reasons Permit No. R Uo '23 Date Issued Fee 0 No. ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS . �f Yicafiot� for-Zig;paal orac rY Conquuction,Permit fzc Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at, Location Address or Lot No � r I Owner's Name,Address and Tel.N . 0 ,J, Installers Name,Addres ,and Tel -�- Designer's ame,Address Tel.No. �Y ��orv7 v c��6u�11^� C /1��A� �RN Sv'r '� Type of Building: Dwelling No.of Bedrooms_ Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �/ j y __ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs.or Alterations(Answer when applicable) , Date last inspected: Agreement: The undersigned agrees to ensure action and maintenan of the afore described on-site sewage disposal system in accordance with the prbv' ' ns of Title 5 of th ental C e and not to place the system in operatiAunilCe 'fi- cate of Compliance has een i s. e Sign �/> Date NS Application Approved by Application Disapproved for the following reasons Permit No. a Uo '3.3J— Date Issued a� 3 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the n-site,-Sewage Disposal System installed( )or repaired/replaced( )on �r o n. by �� 0,0 Z r v c ,o w • L;u C- for 14W has been constructeld.in 4ccordance as with the provisions of Tide 5 and the for Disposal System Construction Permit No.2 00 3—3 7 S- dated a o Use of this system is condition on compliance with the provisions set fo _ below: -ivj� ?5- Fee No. a U0 3 —3 3 � �---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS �tg;poghY bpgtem QCou1truction Permit. Permission is hereby granted to �r oc to construct( )repair( )an On-site Sewage System located at 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. All Gotistructi n mu t be completed within two years of the date below. Date: a 3 (J Approved by �� TOWN OF BARNSTABLE LOCATION SEWAGE # 2-06 3" 3 3� VILLAGE tf ASSESSOR'S MAP & LOT OL-0$ INSTALLER'S NAME&PHONE NO. Ak �_ >�� YLY.•1�G� 5/ SEPTIC TANK CAPACITY /000, LEACHING FACILITY:(type) 4-C- (size) �� S"� t 401 N6.OF BEDROOMS BUII.D OWNE � N,ZC�K�do�► PERMTTDATE: � 2 2 U 3 COMPLIANCE DATE: . � �� d 3 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 c 3,v rx s ,ED f=-0 7.3 . G 6 GAa,4� k Se 2 f,. . f'r R E �1 t��1Z 43 s✓T . R y ' p 4 ® TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map '�' 'Parcel IF t Permit# Health Division �� ► �� ®� 5 E Date Issued Conservation Division Pig 12: ` Application Fee Tax Collector r /�Iel 6Vew M Permit Fee Treasurer ; SYSTEM MUST SE � �'�� INSTALLED IN COMPLIANCE Planning Dept. VIM WLE rb Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address Village C° O 77 Owner . =RAA Jam' K 1 =D zJF'F Address vr'zl t112 z©� G Telephone Permit Request .�L?>) �� ���� — ° C�tJSE •� D .� i��/ jQ DG vr� .�s✓o7 12 Igo Q-rl.O ►) ©F 01 'Square feet: 1st floor: existing 1141 proposed _ 2nd floor: existing 0 _ proposed Total new I 1 Wing District Flood Plain Groundwater Overlay AVO g�Q Construction Type /._o0 roject Valuation YP 12 �t Size S"O- Aq Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. 'telling Type: Single Family Two Family ❑ Multi-Family(#units) 'I of Existing Structure Historic House: ❑Yes EW0_ On Old King's Highway: ❑Yes 9<0 `-,ment Type: ull ❑Crawl ❑Walkout ❑Other ment Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) _ ier of Baths: Full: existing _new Half:existing hew 11r of Bedrooms: existing , new oom Count(not including baths):existing new 9 First Floor Room Count -� )e and Fuel: �as ❑Oil ❑Electric ❑Other / I sir: ❑Yes No Fireplaces: Existing _ New Existing wood/coal stove: El Yes r No ®' garage:❑existing ❑new size Pool:❑existing Ellnew size Barn:❑existing El new size .1arage:®'existing ❑new size 4t2 q Shed:Ellexisting ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes B'IGo If yes,site plan review# Current Use y IFL i—1 o Proposed Use 121aC '4 /'rJ G TOWN OF BARNSTABLE LOCATION ��� �•/+!� SEWAGE # 2-00 3_ 3 3� VILLAGE Ca )4V.rnf aw ASSESSOR'S MAP & LOT D21'"0g�- INSTALLER'S NAME&PHONE NO. � ['.�lEi+sLY-2�GZ1 y SEPTIC TANK CAPACITY lDOD LEACHING FACILITY: (type) 4 C- (size) fi' u4= S-0/ N6. OF BEDROOMS BUII.DE OWNEN — PERMITDATE: 2 2 0 3 COMPLIANCE DATE: V4 d 3 Se on Between1he: 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 t, Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by • p r 0 O A - D /9•a .Zmi -� 63.0 cq COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR VD '(O`NHALIH DEPT g�E TITLE 5 OFFICIAL INSPECTION.FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION r�. Property Address:. 5 Owner's Name: Owner's Addre ZL [t� &4&t4IU, iL1,4 (1,)3YL3 Date of Inspection: s 0� � Name of Inspector: lease print) a J-- " `' IC;P4 Company Name , i� �, °. Mailing Address: .6). o V Telephone Number: �;G3 .`� "7 f• `i �� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported f below is true, accurate and complete as of the time of the inspection. The inspection.was performed based on nay 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 /I� eds urther Evaluation by the Local Approving Authority. / ails g Inspector's Signature: 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 ****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. • t Title 5 Inspection Form 6/15/2000 page I f Page 2 of 11 + " , :OFFICIAL INSPECTION FORM N . T FOR VOLUNTARY ASSESSMENTS _'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART A CERTIFICATION(continued) Property Address: 16 V Owner:. , Date of Inspection: (./ Inspection Summary: Check A,B,C,D or E/All I S complete all of Section A. (System Passes: 1-have not'found'any'information which.indicates fliat any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria n t evaluated are indicated below.. Comments: B. System Conditionally Passes: One or more system components as described in tl e"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacemen or repair,as approved by,.the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or he 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.H.ealth.. *A metal septic tank will pass inspection if it is structural,y 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 big,I static water level in the distribution box due to broken or obstructed%pipe(s)'or due to a broken,settled or uneven di.tribution'box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box isle y eled or replaced ND explain: The system required pumping more than 4 times a year due to broken or,obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l'l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: rf try Q Owner:." -� ' Date of Inspection:.' / _ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation.by,Ibe Board of Health in orderto determine-if the system is failing to protect public health, safety or the environment. 1. " System 01,oass unless`Board of14ealth determines in•accordance with3i0•CMR 15.303(i)(u) hat.ilke. 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 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: 3 f Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:6r e�'..�'i, A1/ 1 y� Owner: ` I 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: Yes No _ V7 Backup of sewage into-facility or system component due to overloaded or clogged SAS or cesspool t�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 7, Liquid depth in cesspool is less than V below invert or available volume is less than %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. _ Any portion of a cesspool or privy is within a Zone l 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 fhat 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 thCanalysis must be attached to this form.] (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 i.s within 400 feet of a surface drinking water supply the system is within NO feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn 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 I Page 5ofl.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'F.ORM PART B CIIECKLIST Property Address: ��' >✓� 1 y A Owner: Date of spection: Check if the following have been done.You must indicate"yes"or"ilo"as to each of the following; Yes No Pumping.information.was provided b the'owner;occupant,or.Board of Health t' p Y � p. � . _,Z�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? Nave large..voluntes.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 uricovered,.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).pro.vided with information on the proper maintenance of subsurface sewage disposal systems? The size and locatiowof 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. _ Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable) [310 CMR 15302(3)(b)] s 5 Page 6 of I] OFFICIAL INSPECTION•FORM—NOT FOR VOLUNTARY;ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: ' Date of,., spection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)°a: Number of bedrooms(actual): . DESIGN flow based on 310 C*MRA Y5.203(for example: 11:0 gpd x#of bedrooms): 7?;l,3 G -Number of current residents:. Does residence have.a garbage grinder(yes or nob Is laundry on a separate sewage system(yes or rio�if yes separate inspection required] Laundry system inspected(yes or no)�,/)- Seasonal use: (yes or no): 0 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no).,/ ,t Last date of occupancy: WAX,-,/1.�n"i / IIVI.,ZI&Altt COMMERCIAL/INDUSTRIAL Type of establishment: Design flow.(based on 3 10 CMR.15.203): gpd Basis of design-flow('seats/persons/sgft,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 n Source of informafion:, �/ p = �i Wass stem.pumped as art of the ins ec .(' P o y P P. p P ..ton ,y�s.,r.no)� �,�` If yes,volume pumped: gallons--How was uantit pumped determined? q yp P Reason•for.pumping: . 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) —Tight tank _Attach a copy'of the DEP.approval Other' describe : I Appro imate age of all components,date installed(if known)and source of information: Were-sewage odors-defected when arriving.at the site(yes-or no): (�- fi Page 7 of 1 I A OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f , Owner: ° Date of spection: 911a 16 1 BUILDING SEWER(locate on site plan) �rj— ' Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): ev - Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: —L/-�(locate on site plan) Depth below Qrade:422!� 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: Distance fi-om 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 bottom of outlet tee or baffle: �I How were dimensions determined• o U Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): ;a 0. loor-) Zo X -, 161j,�(A'al SA�Z— GREASE TRAP/ ('Ibcate 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 Page 8 of I I OFFICIAL INSPECTION-FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• 5 )X1 4 Owner: �a% Date of pection: 0 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_polyethy zne_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 alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER locate on site plan) 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 SYSTEMINSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of SOIL ABSORPTION SYSTEM(SAS):—&Alocate on site plan,excavation not required) If SAS not located explain why: Type aching,pits,number: 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 pou�nding, damp soil;condition of vegetation, a ^ r fvJkd ' pumped as art of ins ection locate on site plan) CESSPOOL(cesspool must be pump p p )( p ) 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(y s 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFO.ZMATION'(continued) Property Address:. ( C j$ Cal M— A i Owner: �( Date of I pection: SKETCH Or SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includi g ties to at-least two permanent reference landmarks or benchmarks. Locate all w0ls within 100 feet. Urate wl ere public water supply enters the building. ayt L 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: - 1;7�1 ? r Owner. A fir Date o spection: �f SITE EXAM Slope Surface water Check cellar. Shallow wells - ,.r4 •�;,.. _ >�: - =r a' .< �a.: ► <, `psi .. Estimated depth to ground water 23 feet Please indicate(check)all methods 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: :]/hecked with local excavators, installers-(attach.documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ,1-1 t Jyy� � ^i 11,11, Permit Number: Date: Completed by: Al "`R F- HIGH GROUND WATER LEVEL COMPUTATION �.. , . ' / qe Lot No.�+-��` Site Location: ,rrY Owner: Address: l>l/ T; Contractor: �� �/1/il ��?�'y��"� Address: ���fUSSJ��Y Notes: STEP 1 _ Measure depth to water table to nearest 1/10 ft. ... ....................................................................... . ate month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................................... OB Water-level range zone ...................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to ,�®� water level for index well ........................... month/year F 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 2B) >�? determine water-level adjustment ..............:........................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) Figure 13.—Reproducible computation form. _ o III J f 3/Q FL.YWO�r -�-•i.VE AIL JSTS/Z' l. ! B!p_ h'-O ? W AEL OVE NUS d 24v66 -— ; _ �____ F7ZPD �F t �D P_ri Q F�2 JJ k -- d°x6� yle-r i rl \� 3` a _.�\ 3°FZLVL 2WJ1�Y6lIs wN O li hl-(-f e'ELOo r C.,66-,eLrT I hdl ID 1 is k(/r� r a-26xdb J' b"i�YIFE�d. Sjhi 1 GZ&r=Lcwl 1 OTE% Liu. F}mv%' vkipow/5, -fo MATcH E�4S?_�NYL lo',tw-ro gar F" 71cv", AaOV6 (a o - 1L q-6"P a lbw >�+aTcuxlsT DI t�t1�G 3°KML _O � lll gA7N`erah �o axd v�-r mk Fm M-GW6 Vi 31. y NSW GiTd!¢h hT QED eM I tj �GL�Ef'=�I FJ7vaG�.. L-1 � Erna zi'2"o/o � 13 h100 _ 1 Gil, NEW vs' (off' d'- p 2 v/ALLS lv I GAQAIE II� I'!.S _ GIV11J(,f;D•'1 II ��f D_U,?i_�.Y�f, 1. N f �Dvyt�r0&RDOuv dQ=o ��IN NSE NE'1Y/ ;�z AeoviO 11 I,:b`on Ex)yrn�� I 3-6 cG Pi, FF AL NOTES rw+9Yq�L a4S aAfYyE misToy OG PCUw 0Auf1o►.. Q-10.04IG s PLAN IS Fa7 THE OESICN AAD 14 owaf-r TB� SOIL TEST PIT DA'i-,\ Srg7-y INL of TTIE sENAGE orsgzsA( INVERT ELEVATIONS'• - e1-.100.00 ILITY OMY. - (A SSUMtirJ� T.P.-1 INVERT AT BUILDING 6.6-► GgND. ELEV. 96•ls T.P,.ASMA E FORM y ss-S NSrSAS CS ALL - rNVfRT IN AT SEPTIC TAAor 96. o_ �w3-r r.�C G.Y. ELEY. GRND. ECEV,N7ENANCE FOR DLE SEPTIC SYSTEM SfLA(C -- G.W. ECEV. FORM TO MASS. O.E.O.E. rr7LE 5 ANO LOCAL. lNVERr OUT AT SEPTIC TARDY G-1 TO RD OF HEAL IH RECl2ATIONS. �� REMq)uACCESS COYFJIS MUST BE MI7HIN G'OFINISH GRADE,INYEHr ou A OISL BOX -9� P1u)g)j®stjyOg ov]R SEPTIC SYSJFJ/.E. LWHTS SUBJECT TO INYERr OUT ATDIST. Bar "�y:a 96•r.7 SAAj EL RG.00 INDICATES LLYE(OAOING /l.E. UNDER ORI-20 L, ETCM' INVERT IN AT S,A,S. PEW'. TESTIL BE DESIGNED TO MIINSTAAD N-20 LOADING. _ 9 '•Z3 3•SEVER PIPE SMALL BESCHEDULE40ORBOTTOV OF S.A,S R• -OO - 96.40 RM. 2.OF ROVED£DUAL. OBSERVED GlNA'MfONAIFR 14'MIN' bQ IMA /2'DIA. LIQUID SrONf INDICATESOq£STARTING L)7 TRWrION CALL OIG SAFE GAOUNOMAIEA 10' ^OEPIH 1 SZOBSERVEDnFv- 0-322-4844 FOR LOCAIfON OF GIST. 4., GR011MYATER B Low UNDERGROUND OTICITIES. l000 GAL. BOX W3/4'-1 J/2'OIA . SEPTIC TAAOC ii-)p MASHED STONE - pp B. OAlU,V IS FlSSUMp-D Egg SEPTIC rAh9C(C GAD-BQY'TO BE SEl OVA . EX)$7)uG 43•60 INDICATES CYIVIAIC)�717� 7FA TEST O.80siaw X A7i YO"W"O w1 - - TE 7. NO H AEM RESM'HAS BEENNAVEAS TO COMPLIANCE �I h'ITHOEta RESTRICTIONSOR S RESG NSIB TIONS lSGI9�LEk,�C/.1<SS,_IT SHALL REMAIN IT/E Dh7YEA'SRESPONSIBILITY TV OB7AIN ALL REOOIRED PERRITS, SPECIAL.PERMIT.,^ bVARIANCE$ ETC. FOR THIS PROJECT `,/ B. IT SHALL RE.YAIN THE ONNER'S RESPONSIBILITY DATE• 11 S 0� TO HAVE RV PROPOSED O,?p,,E_FOLD G GR,N � CA aA L LA"V � up. E' AAv-50EO TO ACCOUNT FOq Ifg EXISTING Gq,)OF TEST BY.' U.NAMLEI,y l 90)- F,dr A 0 SOIL COaDITIONS AT RTE COCATlON OF R1E 0^P1h Irom Surince SoB HoAaon y PROPOSfL.,[LING. Soil Tamture Soil Color h'ITNESSEO BK+ _LE6. MCCO"GL{, 9. •»+)9 LOT )8 A,nT r_oca�o ,u .\ _ (lnche.l .. - . . T (U50NI IMuneelll L zau2- of cov�.oc'L"? TO n ! PERC. RATE _�MlN./IN. 1,-+ Cl 9TRA-rq } 9Ub L1G wAvC�P. 9U:�L`{ y,A�tL. } 0-b„ 1911- sl?L1'41 1,)19 14 17.67YR.q1zL A ` DESIGN CRITERIA: .I C6 ,L / �( �f�•Tri FiNC' / cS/�id/7 �`5 6/b DESIGN FBEV _S- BfOg00H OMfLLING @ IIO GAL/OAy pER BEDgOON YOh� b-Box�L�1 y, . 4'=LS 440 GALS. PER DAY. L L' LOAM /7 S �/ �a SR,Ta� /• Y� N � s£PrrC TA.UK RfOUIREZF ' 440 GPO X 200i- RAo GAL. - Ci( l?,fVe1L1 NX 1 4' 1 SEPTIC rA PROYlDaa - 10 GA(ITo • - AASE'�1'A11J to Y� ! .. .D� 46viJv,ft) t � tyre SIZE OF LEACN.ING FACILITY REQUIRED; \ L; DESIGN PERC. RATE < RINU7ES/INCH N \ 11�' N'( l�v•( L pp__NLA C� j •4 4 0' GACLO.YS PER OAY�/ i--�--A SIZE OF LEACN.ivG FACILITYPROPI�OE7k 1_ THRFg_SOO G4LLOr-+ C.4 Grr4Cps Ls�A �'6 Sst�uCTUR�B w/4L STouEE� ��S.F, X 0,7') 01 a6 ex)°rn.6 L eotrON 43�s.F. xOn TOTALS ro2'L —�'322 Gp0 0. 9,hP•LL BE vV,n vg.v F�,�• : )• �C(),.:.:•': S.F. 6 0 CPO EXIST EX TIN a a9 ryL-b-r.r A�e-V 6AC.L¢.1LL2.D e, w)TH 6/ro.i ly To eL1N'11/1PTf_ m Lam Q- ::' �,'��/ :.) :'i•� �� k`A I��l�;; 'aocos � REVISIONS. o �7(-�ni / ' '1�' %.of !�- IjR i`S..•l. NO. GATE REVlSIQY - L.=ter=✓ `_r .� .aTC-2 r L_EL,=f00 00 AS UM o4 PAUL � Nu.3NA8 \ PLAN SHOWING .4 PROPOSED REPAIR TO'AN F 1 EXISTING SUBSURFACE SEPTIC OISOPOSAL LOT J9 FURLONG JYAY (COTUIT) BAfU/S STEM MA F \ ' PROF AOJ C g R Y�OR SCALET SY I'=30' NOVEMSER B, 2001 CANAL LAND SU91IFYING 4 306 OLD PL YMOUTH ROAD, 5,46AMO/7F BEACH,' d1A - r OAT- PROJECT NUMBER OI-092. e • tz, No........ d..--- Fiziic ............... THE COMMONWEALTH OF MASSACHUSETTS W, BOARD OF EALTH D - -- _ ..... OF............. : .. .............. . ...:......... ............................ Appliration -for Ui ipwial Works Totwtrurtion Vrrmtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .............................. Lo ti .Address or Lot Ivo. ..-��„�r�v.C'.---�-1%-�....1----------------------------------------------- W Owner Address Installer Address Q Type of Building Size Lot.............................Sq. feet Dwelling-L;*`No. of Bedrooms_.__�.....................................Expansion Attic ( ) Garbage Grinder (IVO aOther—Type of Building ............................ No. of persons..________________-____-___- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- -- W Design F - per person per day. Total daily flow._.._....._�� .___._._......_._gallons. WSeptic Tank--L Liquid capacity_/0e0.gall6ns Length---------------- Width_.............. Diameter-----.---------- Depth--_._-___.--._. x Disposal Trench—No..................... Width-------------------- Total Length____-__-____--__._ Total leaching area--------------------sq. ft. Seepage Pit No----I--------------- Diameter.LP5?q....SO'. Depth below inlet...._ ........... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) -O,lj-✓� + `?_7, aPercolation Test Results Performed by........................................................... .. Date........................................ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ .............- Description of Soil------------------L --•e-yea c._. - ib" _ _ .�... r� �� f ,p ..e -- ------------------ -----------------------------------Y----------------------------------------------------------------------------------------------------------- --------------------------- V Nature of Repairs or Alterations—Answer when applicable_---------_____________________________-------------------------------------_f'---------------- -------------- ----••--•----•---•-•---------- -----•-------•............................................................................................................ ......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI 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 boar of health. / ��7 ? Signed •(•--P�rcG_ ------------------------------------------ ------..._.. ..... _. . Date Application Approved B � =PP PP Y ------------- --. ?.......7-6----- Date Application Disapproved for the following reasons:............................. ` -•••-••••--••-••-•••-•----------•----•••-•••••---•--••--••---------------•••--•-•--•---------••••-•--•--•.....-•--•-•-••••--...--••-•-----•------••--------•-••--•---------------------•••--------------- Date PermitNo......................................................... Issued........................................................ Date No.-...... Fps............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ... ........ .. :OF............ �F. Appliratiun -fur Ui,ipuual Vorko Towstrurtion V.rrmtit ' Application is hereby*made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: } L u T .... �. j....... t.. ! ._.. - E .....•.... / / La at}on-Address ------------------ -------•--........... or Lot No. t I/1/✓f lr + ! tl T --•• ••-•---•---•--------•.........•---^ ---.....--•-------•--••••-•--•-•-•••-•--•---•-•---••. -••-••-•----•-•-----------•••--••••-•............................................................ Owner Address Installer Address Q Type of Building Size Lot____________________________Sq. feet 21 Dwelling ''�No. of Bedrooms._- '_____________________________________Expansion Attic ( ;1 Garbage Grinder (IV6 pa, Other—Type of Building ............................ No. of pet-soils._._..__.___________________ Showers ( ) — Cafeteria ( ) a' Other fixtures ________________________________ _ Design Flow_. .........---••-......• gallons P P P Y Y d-� ._.. g`... . W ............. 111on� per arson per day. Total daily flow........... gallons. fyi Septic Tank-L Liquid capacityLC� __gallons Length................ Width................ Diameter................ Depth..._____._..... w Disposal Trench—Nb.�;A.................. Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. x _ z Other Pit box ( ) /Dosing I7 Depth below inlet____________________ Total leaching area_____.__._______-sq. ft. Seepage Pit No._hJ..:.. .......... Diameter..__.___._____ Distri tank ( )-G,D-/JG - 3 ' - 7(, aPercolation Test Results Performed bY------- ------------------------------------------------------------------ Date------------------------------------ ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit.-.-_______________- Depth to ground water........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__.__.______________.... Ix -------- -- -----•............•• =------- ---- -- ----------------------I Description of Soil Q �.G..... rJ s!. ., .......................� "C'* ✓�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 Article \I 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. S f Signed.'` ,Y F� �'�, � � 7 7 (� •---- /� _--. Date Application Approved BY---------- r- -- f ....7- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- ------------------------------••-••--•--•_------------....--•••--------------------•-••----••••-•••.•-- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE L H jam..........oF......... . r-�-� z-;!....-...... Trrtifiratr of Taautpliattrr T IS IS TO CER" I 'Y, That"h "Individual ewage Disp sal System c structed ( ) or Repaired ( ) Y G� f . iIn alter e has been installed in accordance with the p visions of ' _ ice I of The State Sanitary Code as described in the application for Disposal Works Construction Permit N -- _ _________________ dated...- -'__---___!1�_ 7_(. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... - Inspector ...............................----------------------------------------------- THE' COMMONWEALTH OF MASSACHUSETTS �G BOARD O/F HEALTH _ ......... .... r?. �i2...........OF........ ........G �� N..••• -••--•• FE tau l urk Qlan Curti ;rrmit Permissio i herebyranted_._.__ _._. ._.... ( '___ ________ _______________ z_� +E!� .. g c..:._. .. - to Con /'cV( or 'epai ' ( ) ndividual�wa efD' 'posaI tam / at Nods'--`_-/--- I f = .'n'? . ---- --- r----6 as shown on the application for Disposal Works Construction P nil o._._ ____._ Dated .-7_... • Board of ealth DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .2U } 41 Fti�A iV 10e;l All,�� -I . g1�. 2(f 1'Ca 41 .S/�Gu'lcj ,4/E/'G�iOh,l ,_^�.1..ryJ'�f� t;/r:,+� Ti-/� �j��{j`�;:,�, :' �`'� �,. �I•IC. Eel'+ 'tT.��GE GENERAL /VOTES.• a.�,.•o SOIL TEST PIT DA TA . THIS PLAN IS FOR THE DESIGN AND .INVERT ELEVA TIONS.' L. , 100, S / T. -J T.P. -2 1 CONSTRUCTION OF THE SEf►'AGE DISPOSAL _ CA�61SM��� GAPJD. SRND. F_L.E"V. FACILITY OY. INVERT AT BUILDING G,6� G. '. ELEV. G. M. E.`_EV. NL 2. ALL CONSTRUCTION METHODS MATERIALS AND IN IN A T SEPTIC TANK q 6 .4 �.yl'S� r ACCESS COVERS MUST BE WITHIN 6 " OF FINI.jf GRADE. ! ! MAINTENANCE FOR THE SEP7`IC SYSTEM SHALL INVERT OUT AT SEPTIC TANK q6 . '_5 R .7�,3R��+ 10 i CONFORM TO MASS. D.E.C7.E. TITLE 5 AND LOCAL _ T'F'`-' 9 - a v-Av f' pv", INDICATES BOARD OF HEAL TH REGULA TIONS. INVERT IN A T DIST. BOX - q :y ,61r 5 �-L q .7 O PERC. TEST L SEPTIC SYSTEM COMPONENTS SUBJECT TO INVERT OUT A T DIST. BOX 9 � y . q °z 3 " 3�' 3. V I F G E. UNDER ORI VENA YS. ETC.) INVERT IN A T S.A.S. •�� MIN. 2" OF VEHIC_- LOADING (I. -.___ SHALL BE DESIGNED TO VI THSTAND H-20 LOADING. r 1�Q 1/B=EO DIA. � BOTTOM OF S.,4.S• q` •d� �Wo �!' YIN. ' 1 MASHEL' STONE INDICATES o GEPlnI I� �� ` �,� i OBSERVED 4. A�L SEVER PIPE SHALL BE SCHEDULE 40 OR OBSERVED GR000YA TEA `r DIST. ` I GROUNOWA TEP S tiE LO APPROVED EQUAL. ADJUSTED GROUNDMA TER 0 N (�a 3/4 -1 J/2 DIA. v { -'f n• � Pad 0 6AL. BOX W� MASHED STONE =' } 5. BEFORE STARTING CG,^:'STRUCTION CALL DIG SAFE SEPTIC TANK 44- 14� 3. p INDICATES j 1-800-322-4B 14 For? OCA TInN UNDERGROUND UTILITIES. TIC TAW D-6 7X TO BE" ."�T OM A i S7��G �— T� T PIT 6. DATUM IS F�SS UM�� l J`0/�!`� 1 OT a �- �^ 6 BED Of [.YeA�•�-,iC;1=D A9L5h.c.° STC!f -1 a CA WCTA9 1D "TER TFST 4.-13-c i" TO P". S.A.S. 7. NO DETE.RMINA TION HAS BEEN MADE AS TO CONPL LANCE �i / MI TH DEED RESTRICTIONS OR ZONING REGULA TIONS. I 7 �' IT SHALL REMAIN THE OMNER'S PFSPONSIBI!_I TY TO 03TAIN ALL REQUIRED PERMITS, SPECIAL PERNI Tv; (Tow l.1 Y" I E'�/"/� -�J� DA T rE4 — -- --- �' VARIANCES, ETC. FOR THIS P,0L)ECT. C--A A 1_ TEST BY.• -- u. AM`�-�1� B. IT SHALL REMAIN THE Oh'NER'S RESPONSIBILITY TO HA VE THE PROPOSED Oh'EL L ING FOUNDA TION tV TTNESSF_D BY.' DESIGNED TO ACCOUNT FOR Th,E EXISTIN S,q,1"T D-pth from Surface Soil Horizon Soil TextureJ Soil '�;lur _ D OIL CONDI TIONS A T THE L OCA TION CF THE t. AN S G (i nc he�n) - r�RC, r7ti TL •7 MIN./ IN. 1>� C+ t; PROPOSED DWELL IN . (USDA) (Mum All q_ T�YI g l.o"4 IS p b L o G D A 3 i DES-RrW CRITERIA: !Q C %►-�S`i ` I ! DESIGN F!OM• BEDROOM DAELLINS Le 110 GAL/DAY PEP, BEG,-'UOM EDUALS � 1� GALS. PER DAY. - 7-3 gox� � �'`� SEPTIC TA;Y 4' REQUIRED. � ��� Y 4 X �OoX ) . ex,s'-r)r.a r kl R N I� Ai_:v !A A' PRU✓1J' a ��5� GAi���� h I 3�i/ �7Lf yec/ i •I 7E �. L AC.H' Nr FArri _.. f { rry of �cn r� C,' K' L' r 'n I r. ` �, i `' / •( � vL f D �' - ... S 7-1 ZL' Of tEACtI.;Vu FAC'L 'TY .,W)v1.1EG?' !4 SIDEMALL 6 S.F. X OPl._i.. Aw ��� GP.O `}\ .` BOTTOM q 3 S.F. X 0 TOTALS S.F. 6 0 GPD e�tt°.r 1 -S�, L e: . �j'k. $1�•R'1.L 6� PV�n P't'.D EXI •, s on -J' •Do .....-•, ST EX TIN o. a� C,l.�A-r� �b •3 A�cx�l LL�n -- � - - --R��o--` \ '�" �:Cs�ti W� P, ' � f +�•- 1,'JIC'i M -� -� '� t'J \� / •w Locus `:r",� CP 5. J �` ;1 IC ,i - N17. JA TE PF;I-TS10v �', 'A ENGIN R CIV L� __. -H_ ._ a C L ,A G� _ l i✓- LOCUS M Ac T,FAUL , .:�100. oo (, SSUMEQ o . -- lti n L v, r` Ems' 'a^,�,� ' '�'/i /' \ - roJLlll l S�15PIINr A PPOPOSEV P-., TH TO AN F t-T .' .rJvO St 3SURFACE St�:PT-Tr 54'" Si'STEM LOT " , t rrL O ar WAY (COTIJ2-T) 5XPA49 TA9LE, MA 1 C.4,N,r,'L LA O 306 0L OA9J PL YHOUTH F S . ,.�' � �'rACH, AIA 15G. 69 ��_J_ -; _ DA TE PROLIECT NUMPYER 01--092