Loading...
HomeMy WebLinkAbout0510 MAIN STREET (COTUIT) - Health 51 I Main Street, Cotuit A= 022 - 019 A TOWN OF BARNSTAB_LE G , LOCATION 5"ID Ae 111 vT 0et,fl-ey*9 SEWAGE # VILLAGE /,�ft l�T ASSESSOR'S MAP & LOT 77�64' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /5—eP lra/L LEACHING FACILITY: (type) �fOr (size) NO.OF BEDROOMS -3 / BUILDER OR t PERMITDATE: X1,747 COMPLIANCE DATE: Separation Distance Between the: _ '',"Maximum Adjusted Groundwater Table and Bottom of Leaching Facility F 74- Feet Private Water Supply Well and Leaching Facility (If any wells exist e '! on site or within 200 feet of leaching facility) ,y Feet Edge;of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t i� �.i �. 'A" No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - - V PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for ioogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System. ❑Individual Components Location Address or Lot No. �p e, n� Ow er's Name,Ad ress d el.No. 7.7. _0)3 Assessor's Map/Parcel �� 0 /�� � � , M'a� �' sia MRi� (� Aar "412 y� Installe- e dd s,and Tel.No. Al77 0 Tr— signer's ame,A ess and Tel.No. P0.r&4 �v� �" 3 SK k#1 U6 7 Type of Building: /, Dwelling No.of Bedrooms �'- Lot Size%7sq.ft. Garbage Grinder QJV) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow � gallons. Plan Date -IG 0- -S N ber of heets Re 'sion Date /D- 7 Title S i G et.� L � h, Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti o the nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue s o of Health. / Signed Date �/—0 Application Approved by Date /I —07 Application Disapproved for the following reasons Permit No. Date Issued 7 - A1 6_F`Vk No.- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE., MASSACHUSETTS YeV ZIppricatiou for ]Di!6po!6,ar *potem Corigtruction Permit Application for a Permit to_Construct(/)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A e Owner's Name,Address and Tel.No. y 14119� QW 10, Cc r�, Assessor's Map/Parcel Installer'' e�(�dd e, s,and Tel.No. �� (Dsigner's Name,Add cess and Tel.No. !Jc- ►/3c. iI�a�. rU.oc4 &()k , ) Type of Building: - / / Dwelling No.of Bedrooms Lot Sizeq 2s b sq.ft. Garbage Grinder(/00) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow IMP I gallons per day. Calculated daily flow � gallons. Plan Date 10-)GXr) t Nu(' her of sheets Revision Date Title $IT etle- Ed(- UJ / Size of Septic Tank Ml) Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-,site sewage disposal system in accordance with the provisions of Ti o the nvironrnental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue s o of Health. I Signed ` Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued -- ——--——— ——————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS = Certificate of Compliance `t THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) 5 Abandoned( )by at !s> as been constructed in accordance with the provisions of Title 5 d the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the syste w'll functip aS designed. Date 107- /9— 7 7 Inspector No. ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migolear &pMen! Construction Vermit Permission is hereby'g ad to Cone )Repair( Upgrade( )Aban on System located at ,./� - —��/�' �^ll i 4:/, , Z 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 becompleted within three years of the date of thi it. Date: -7 Approved by BARN � t ,, .TOWN OF STABLE CJ LOCATION L U f Cy O e�✓aY 401W SE AGE # �� y 1!;ILLAGE C UI'��l� ASSESSOR'S MAP& LOT 0 ZL O/9 STALLER'S NAME 8t PHONE NO. y5 ekJACD ?SEPTIC TANK CAPACITY 3.EACHING FACILITY: (type) .O OF BEDROOMS_ _ `} B�D� R OWNER ?;PfiltbiTTDATE: COMPLIANCE DATE: - : Separation Distance Between the: .Ma�tiirtum 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 .:.F.lgg.of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility) Feet .`•Ffitiiiished by I TOWN OF BARNSTABLE G q.. LOCATION J'`/O A AI 467' 6-0--U eS)*9 SEWAGE # � VELLAG-E_� 7�Gll" ASSESSOR'S MAP & LOT 9? —Z'::V� INSTALLER'S NAME&PHONE N0. 1`d�} ) Gt9fi'c5f 77/-�3�1r' SEPTIC TANK CAPACITY A L LEACHING FACIL=: (type) f� 7b►"S (size) -D 1,30 aC,-�2 ` NO.OF BEDROOMS / BUILDER OR '`"1. / PERMITDATE:' 6/��97 COMPLIANCE DATED Separation Distance Between the: _ 'Maximum Adjusted Groundwater Table and Bottom of Leaching Facility F7C 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 0 �Sio.B r; 3s 0 13 b i O 1 ' '17 2-9 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ! es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mioogal *pztem Cottgtructiou Vertu Application for a Permit to Construct( )Repair(VIIU/pgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. p ego Owner's Name,Address and Tel.No. Assessor's Map/Parcel /A '� G"�v/i// e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1601W Olyi eetf15 r 1' Type of Building: Dwelling No.of Bedrooms 3: Lot Size sq.ft. Garbage Grinder(-Cie, Other Type of Building S E? 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 51�059,01 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _. 50✓�4�/ �a4�1'g®��d�L��.� —Zt —46Y14- I/- Jre /�q71�pi' ��i9'/ra9l�e�s 3o/-X Z p 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 Bo of ealth. Signed Date Application Approved by — Date 7 Application Disapproved for the ollowing reasons Permit No. Date Issued .41 c77c> No. �� Fee w , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer- Yes i PUBLIC�HEALTH DIVISION -TOWN OF.BARNSTABLES MASSACHUSETTS Zlpprication for Migotar *pztenf Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components I Location Address or Lot No. lri� J/)Owner's Name,Address and Tel.No. ell Ass essor'sMap/Parcel ,�',R9,¢-�j"�-- r!C'i1 � 77/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /�al�pLo�`i CG�57; 7 71- W i Type of Building: i Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( � Other Type of Building lt'�'eAlCK ' No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 7Jf gallons per day. Calculated daily flow gallons. ( s 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) /el 4/ ✓3D G X Z r� f Date last inspected: +Y. Agreement: 'r 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 Boat. of ealth. / Signed Date _Application Approved b`y Date 7 Application Disapproved for the following reasons i Permit No. ''' Date Issued .---.- - THE COMMONWEALTH OF MASSACHUSETTS Q Z-Z ©/OF BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-sit Sewage Disposal System Constructed( ) Repaired( VI"Upgraded( ) Abandoned( )by at / T�GI has pe constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ) dated Installer Designer / ✓ ., The issuance of this pe s all n It be construed as a guarantee that the syste"Lwil1 function as dreeserd�rn� ign ) Date /�l Inspector a(r0 ---------------------------- ------ No Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS =i0po.5ar *pttem (Construction Permit Permission is hereby granted to Construct( )Re air( )Upgrade( )Abandon( ) System located at �d_�yr�� G'G AV—17'` 444 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. j ! Provided:Construction must be completed within three years of the date of this permit.: l � c} Date: r�/7 7 Approved by t " �v 01 c c 12-A .Si o t. v �!QL v m. a -k NOTICE: This Form Is �'o Be Used For the ReparOf Failed a x Septic Systems Only, CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED P ANCI hereby certify that the application for disposal works construction permit signed by me dated �a�b/y T concernins the property located at ✓`r/D Aple0/,-��_�y�id. GBf�1� meets all of the foilowing criteria: There are no wetlands within 3,00 feet of the proposed septic system r /—,,Ie,,e are no private wells within i^v --et of the proposed septic system V/17ne observed•groundwater table is i 1 �eet or zreaIer below the bottom of he ieachina_ _..c%ir,, aere is -to increase n now andior caarse in use proposed �' bier - ,o var ances Guest d or:ze d. a SIGNED : DATE: l� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the'licensed installer posesses a certified plot plan, this plan sliou' d'lie submitted]: ARM~a Y - J y .r _t, S E Oa o� 3, 7a o - ►n lo4, 91,9 BORTOLOTTI CONSTRUCTION, INC. ' y�o 'oaT�g<F 9,. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 N 508-771-9399 508-428-8926 FAX: 508-428-9399 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION Property Address: VrQ Date of Inspection:f5 Inspector's Name: — nees Nam nd Address: CERTIFICATION TAT .MENT•. I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the.proper function and maintenance of on-site sewage disposal "MS. The System: Passes Conditionally Passes Needs Further Evayylon By the ocal Aproving Authority Fails Inspector's Signature: Date:_ G109� The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: A)SY�STEPASSES: I have no t found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any.failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed 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 The Board of Health): - 1 - ' � .• �1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) l Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced. 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKLIST Check if the following have been done: (/Pumping information was.requested of the owner,occupant, and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _.&!�'As-built plans have been obtained and examined.. Note if they are not available with N/A. , _The facility or dwelling was inspected for signs of sewage back-up. _yGThe system does not receive non-sanitary or industrial waste flow. I/The site was inspected for signs of breakout. /All system components,excluding the Soil Absorption System, have been located on site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum: I/ The size and location of the Soil Absorption System on the site has been determined based on ; existing information or approximated by non-intrusive methods. _3 L SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST(continued) VThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RV%H)ENTLAL: Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected'I'o System: Seasonal Use: A O Water Meter Rea ings, if a ailable: Last Date of Occupancy: 1_91L atl K, COMMERCLALIINDUSTRIAL: /J0 Type of Establishment:. Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERA INFORMATION PUMPING RECORDS and source of information: Ap System Pumped as part of inspection:A) If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(I es,attach previous inspection records, if any) Other(explain): -� , A� APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors d ected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART.C GENERAL INFORMATION (continued). SEPTIC TANK: U Depth below grade: Material of Construction: concrete metal FRP Other (explain) — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee of baffle: � Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) GREASE TRAP: /IJ o Depth Below Grade: Material of Construction: - concrete_metal—FRP— Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Ak . Depth Below Grade: Material of Construction: concrete_metal__FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition'of inlet lee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:NU Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:/-Aj Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- t A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: Leaching pits, number: l Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydr ulic f 'lure level f ponding,condition of vegetation, CESSPOOLS:__v Number and configuration: Depth-top of liquid to inlet.invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: l �GJ Materials of construction o4 6116"Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: no condition of soilk, signs of hydraulic failure, 1 el of ponding,condition of vegetation, A. .co ,P�h. �Qf�j,C�iT• , PRIVY:A&) Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. LAP 51 53' DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Approximation: , -7- �� I/ a r BORTOLOTTI CONSTRUCTION,INC. ►n rowN 9 19 765 W' 9 8 �F KEBYROAD,MARSTONS MILLS,MA 02648 H�°y�FpSTgB 9, Ake 428-8926 FAX: 508-428-9399 j N SUBSURF CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Z CERTIFICATION ess: �U w Date of Inspection: Inspector's Name: ees Nam d Address: _CERTIFICATION STATEMENT• I certify that I have personally inspected the sewage disposal system at.this address and that the informa- - tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- ' formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further Evalua" n By the at Aproving Authority Fails / • Inspeetor's'Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: f A)SYSTEM PASSES: 41 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,not,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,stnicturally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by.The Board of Health. Sewage backkup or breakout or high static water level observed 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 The Board of Health): SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A •t CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced 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 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 the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. Z)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUN CTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below in or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year IYOT due to clogged or obstructed pipe(s). Number of times pumped 2- SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART A - CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow ofa system is 10,000 gpd.or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner,or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _f�As-built plans have been obtained.and examined. Note if they are not available with N/A. __L,Zfhe facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. jZAll system components,excluding the Soil Absorption System, have been located on site. jLThe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. _ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTLA_L:_ Design Flow: gallons Number of Bedrooms: Number of Current Residents:_a� Garbage Grinder:1C)n _ Laundry Connected To System:,0 U Seasonal Use: AA Water Meter Readings, if available: Last Date of Occupancy: CO MERCLALANDUSTRIALLOO Type of Establishment: . Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informatiofi,�, `7 �a. System Pumped as part of inspection:AJO If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes, tach previous inspection records, if any) Other(explain): Ly APPROXIMATE AGE of all components,date installed(if known)and source of information: i� Sewage odor etected when arriving at the site: 6jo -4- SUBSURFACE SEWAGE•DISPOSAL SYSTEM INSPECTION.FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: /-)U Depth below grade: Material of Construction: concrete metal FRP• Other (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) GREASE TRAP: w Depth Below Grade: Material of Construction:—concrete—metal FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.) TIGHT OR HOLDING TANK:/J0 Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:/l)d Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:A')b Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure level of pond* condition of vegetation, etc. JOY) 'Ply CESSPOOLS: ► Number and configuration:/ (a xS Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:(o p Y P Materials of construction• "6'►81oc6ndication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level o ponding,condition of vegetation, etc.�2'Q Q ��./ex)G 5 (/�,c i, - 9- 1,Q .aZ plea, PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cunlinncd) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within IPq Feet. Tr DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Approximation: -7- TOWN OF BARNSTABLE 4 LOCATIONS SEWA E # VILLAGE ASSESSOR' MAP& LOT�/� 3. 70 NSPLT�i2'SNAME&PHONE NO. SEPTIC#ITANK CAPACITY LEACHING FACILITY: (type) Oki]�.c.� �C/�c- k—e)�2eA IOC 5 � NO.OF BEDROOMS BUILDER OWNE� ' PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: 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) y� Feet Furnished by �� t� ua V 6' S4' 3q ►u' tou a 3' 0/9 3, 70 y _JUN <` 4 1997 BORTOLOTTI CONSTRUCTION,INC.. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A.. .:.. CERTIFICATION Property Address. 510 Date of Inspection:e/.11iVq7 Inspector's Name: ees N and Address:O'T Ad CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informs lion reported,below Wtrue,'accurate and complete as of the time of inspection.The inspection was per formed baseed on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: E Passes Conditionally Passes �V Needs'Further Eval on By the oval Aproving Authority ` 4 Fails , - Inspeotor's Signature: Date: The�System'iInspector sliA lubmit a copy of this inspection report to the Approving authority within thir- ty(3.0)days of completing this inspection. 'If the system is a shared system or has a design now of 10,000 gpd or`greater,'1he`inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental.Protection. The,original should be sent to the system owner, and copies,sent to the buyer, if applicable and the approving authority. r INSPECTION SUMMARY: r rail<e� �h F A)SYSTEM PASSES: : 'I have,not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated, below. B)`SYSTEM CONDITIONALLY PASSES; One or more system:components need to be replaced or repaired. The,system,upon comple- tion of the replacement or repair;passes inspection. t - Indicate yes;nor,'or not determined(Y,N,OR ND).Describe basis of determination in all instances. If . not determined",explain why not. >The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or. exfiltration,or tank failure is imminent. The system will pass inspection if he existing sep ' ?".J!" tic tank is replaced with a conforming septic tank as approved by The Board of Health. `4 Sewage backkup or breakout or high static water level observed 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 The Board of Health): ' - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced a, The System required pumping more than four times a year due to broken or obstructed pipe(s). t The system will pass inspection if(with approval of The Board of Health): �e 'Broken pipes)are replaced ;g Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: n Conditions exist which require further evaluation by The Board of Health in,order to determine i�, nY{;:the system is failing to protect the public health, safety and the environment.,.:, + 1)SYSTEM-WH L PASS UNLESS BOARD OF HEALTH DETERMINES,THAT THE —SYSTEM 4S`NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE : {v. PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THEm ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100.Feet to a surface;? water supply or tributary to a surface water supply. } � The'system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. o The system has a septic tank and soil absorption system and is within 50 Feet of a private.,stt water supply well. The system has a septic tank and soil absorption system and is less thanf100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fromN ' the facility and the presence of ammonia nitrogen and nitrate nitrogen,isequal to or less 1 than-5 ppm. D)SY$'I'EM FAILS: ✓ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Healthr.s should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of efluent 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 clog- y ¢+ ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is,less than 1/2 } day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool,or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed. to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: c The following 'criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significantf threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply r ° The system is within 200 Feet of a tributary to a surface drinking water,supply F 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. , The owner or operator of any such system shall bring the system and facility into full-compliance with the, groundwater treatment program requirements of 314 CMR 5.00 and 6.00..Please consult the:local< ,tr regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check rf,the following have been done: , _Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and;the system has f: been receiving normal flow rates during that period. Large volumes of water,have not been introduced into the system recently.or as part of this inspection. 4/' As-built plans have been obtained and examined. Note if they are not available with N/A. r/The facility or dwelling was inspected for signs of sewage back-up. V/The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. ✓All system components,excluding the Soil Absorption System, have been located.on site. : _LThe septic.tank manholes were:uncovered,.opened,and the interior of the sepgd tank was.in s .Pect ed for condition of baffles or tees material of construction dimensions,depth of liquid, P 9 d, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART B CHECKLIST(continued) 4/'The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , _ SYSTEM INFORMATION " FLOW CONDITIONS RYSMENTIAL! Design Flow: gallons Number of Bedrooms: Nu'mmbcr of Current Residents: Garbage Grinder: iV0 Laundry Connected To System;/�(GI/I✓Sc onal Use: O Water Meter Readings, if available: e Cu'`+`�g�?�� Last Date of Occupancy:rLG �-Q�- �-�' -n rnMMF.Rr[ALANDUSTRIAL, Type of Establishi lint: Design Flow: _ gallons/day Grease Trap Present: (yes or.no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available Last Date of Occupancy: ' OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: -)/x) System Pumped as part of inspection: /(JCS If yes,volume pumped: gallonst4 Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If ,attach p evious ins coon records, if any) es 0 r(explain). -� PROXIMATE AGE of all components,date installed(if known)and source of information: Sewage,odors detected w9en arriving at the site: -4- f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .GENERAL INFORMATION (continued) SEPTIC TANK- Depth below grade:" Material of Construction: concrete metal FRP ' Other (explain) Dimisions: Sludge Depth:. Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments:,(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) ' TM GREASE TRAP:_ - Dep&Below Grade: ' Material of Construction:_concrete_metal FRP Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or battle: Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid''" level-in relation to outlet invert,structural integrity;evidence of leakage;etc.) ;TIGHT OR HOLDING TANK: ,Depth Below Grade: Material of Construction:_concrete_metal FRP Other(explain),,,' , Dimensions: Capacity: f;allons Design Flow: aallons/day Alarm Level: Comments:.(condition of inlet lee,condition of alarm and float switches,etc.) DISTRIBUTION.BOX: Depth of liquid level above outlet invert: Comments;,,(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out'of box;etc.)' :. PUMP CHAMBER: Y , Pump is in working order: r Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5 ' .. - V�,.:,rr t£ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):�(o�� (L.ocate,on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: ry Type: iL,eaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure level of ponding,co tion of vegetation, et u - Qd CESSPOOLS: Number and configuration: a- Depth-top of liquid to inlet invert: Depth of solids layer: DeP1,h pf scum layer: Dimensions,of Cesspool: .'b Materials of construcdon,C�/ "Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level f ponding,condition of vegetation, etc.) GJ 'Giz.yi-A COP PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) 4� . cz /OOO C) )( �Caitls- G� ao vL•� ti/(X�-r, -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (co wfimcd) SKETCH OF SEWAGE DISPOSAL SYSTEM:' Include ties to atteast two permanent references, landmarks or liek imarks. Locate all wells within 100 Feet. -39 53 . r CP r DEPTH TO GROUNDWATER. Depth to groundwater: /5 Feet C Meth of Determination or Approxynad n. A, /�,R'�/LPIl �/'D� ✓ �� lti��R�r�r9`D5 -7- q No...-L-0........... Fx$..c ..... THECOMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ...........t w ------------OF......,c l9�rasr � ------- ................ Applira#ion for Difilimal Works Tom ion amit Application is hereby made for a Permit to Construct ( ) or Repair (U-7"an. Individual Sewage Disposal System at: ......_..�... ~��.. .. /.. L..o.c'/a..t.'/ i "4 / .1 V.. V:4 As y ..� ._.: .. .......... O _�ic�s.................. ....... .............. A dr t otNo. ........ ......... ... E/� � ..r ........ Own Address .................................Y.. ....W ... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) � Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pq Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.....------..--. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..............--..-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.---................ Depth to ground water.........------..--.--.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..........---........... P4 .................................................. -...... -....... -------------- -------- •----•------•---.......................... .............. --------- 0 Description of Soil........................................................................................................................................................................ x U ..........................••-•---••-•-•••-•••-••.............•••--••••---•-•---••------•-••••-----•••-••••••-•-•••---•--•------•---•---.............---..........-•-•-•-•-•-•......•-•-•••-•.........•-- W -----------------------•--------•----•----•••-------•--•--------•-••------•-••-------•-•............-----•----•-. --- ...............<-----------••----•••••----- .....-.....................-------- A / UNature of Repairs or Alterations—Answer when pplicable...... ter. -�--t ----- =.- +-�� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee ssue by t board f health. 0, Signed.__...... .--. ..'._.....-.,---���•dA�l................................ ` Date Application Approved By-•••-•------•-••••--••-•-•••---•----•-•-•••--•••••-•-•-••••-••-•-•-•--••-•--•-•---... -.......... ......•••..........•- ------------------ Date Application Disapproved for the following reasons:.. ......-••••••-•-•-•-•-•-•---•---•••-•---••-•---•-••---•-••••...... .............•-----••---••--•----...-•------.......-•----------------------------......--------------.....------....-----............----'=-------------------------------------------------•------•...... / Date Permit No. i................................................ Issued... l Date No....bo_..... :..... Y` Fic$ .�.... ......... THE COMMONWEALTH OF MASSACHUSETTS rw BOARD OF HEALTH Application r 'Rimosal Works C�onst• tton anfit ,Application is hereby made for a Permit to Construct ( ) or.Repair Oo<an Individual Sewage Dispos 1 System at .......... ... ....... "�1 ............................- .............. ----- ............... - ......... Loca Addr s I o of No 3» W Ow��� �,,� Address a ................................. .............................................................. ....................----..................... _7.......... InstallerAddress d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ............................ No. of persons............................ Showers (. ) — Cafeteria ( ) Q' Other fixtures ------ ------•------------------------------------•------•-•-•••••....... Design Flow............................................gallons per person per day._Total Bail >flow.....__..._...._.__ W Y ---------------------....gallons. WSeptic Tank—Liquid capacity............gallons Length___-____-__-_- Widtli`,.............. Diameter----------------- Depth................ x Disposal Trench—No..................... Width-------------------- Total'Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter........•------------ Depth below inlet..*.................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth'of� Test Pit.................... Depth to ground water........................ (� Test Pit No. 2................minutes per:inch Depth of Test Pit.................... Depth to ground water.•__...............___. O Descrl •-•...a..... -------•------•--...----•------------••----------•----......................................................... ption of Soil' < ---------- U ....................... __._ --••••-•---•----••••---_. ..................................------------------------------------------------------------------------------------ W •-------------• ...................... a" = ................ Nature of Repairs or Alterations Answer when. ppl>eablet ... -� Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with the provisions of Article:XI of the State Sanitary'Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sue by t board f health. /�� ,j Signed. `••t•. . --• lt bfa/' F Date Application Approved B ...................................................... •' ` PP PP Y Date Application Disapproved for the,following reasons$,. ..---•..............................:......:.....................................•=------------._....... ••••-•-• --•--• .................... ............. Date PermitNo. . ..........................................................•-•------------_.._.. Issued. _/. 71 ._..... ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH lt- "F k.r :� ........OF.. .......... ..... ....:.......................... 'rrtifiratr tit Tom"fiaurr THIS IS TO CERTIF That th� ndividual S wage Disposal System constructed ( ) or Repaired ( by-------------------------------------------- _ .......J���.�' '..............•--•--•---....---•----------•-----------•----------------•--•--•--•-•-----••--•- r taller at---------------------"���----•••• ����.. � --------------------------------- ......................... . has been installed in accordance with the provisions of Artie XI of The State Sanitary Code s d 'cri ed in the application for Disposal Works Construction Permit No.__......_..�?......................... dated.... ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. ' DATE......,--... _ .. . ...... ................................. Inspector..........-- ......................--------------_ ...' THE COMMONWEALTH OF MASSACHUSETTS f BOARD 0 F HEALTH ..... OF. ......................................... Disposal Narks �an��x� t��t �'rrmit Permission is hereby granted, ' ... ...................... to ,Construct ( ) r Repair an in idu S D osal System at No:__ ` _... .. .. ------- ----............................................... Street as shown on the application for,Disposal Works Construction Permit No..................... Dated.:.. . .__✓ ,. ••-•-•...........................•---•-----------------.....-----------....•-•-....................... Board of Health t DATE............................••-•........ �' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SEPTIC PROFILE TEST HOLE LOGS T.O.F. AT EL. ACCESS COVER TO WITHIN fr OF FIN. GRADE (NOT TO SCALES n�� + n ACCESS COVER (WATERTIGHT) TO ENGINEER: VLAW. WITHIN fr OF FIN. GRADE I (� }�o MINIMUM .75 OF COVER OVER PRECAST .S 2X SLOPE REQUIRED OVER SYSTEM 1 a WITNESS: DATE: 5 PIPE LEVEL f DOUBLE WASHED PEASTONE i /_RUN FOR FlRST 2 M I r-ILPRD I Svo 3 MAX. PERC. RATE _ i� SEPTIC s�7 j , CLASS SOILS P#-_ 10 ) GAS , BAFFLE c o �s•� L nJ 0 0 0 0 0 0 0 0 OF c aS SLOPE) —AL!�' CRUSHED STONE OR MECHANICAL 3 ! 0 0 0 0 0 0 0 0 0' 1 COMPACTION. (15.221 [21) 3 ELEV. W ELEV. R DEPTH OF FLOW - X SLOPE) �_x SLOPE) �~ y� Cr TEE SIZES: 0 A d INLET DEPTH - . ( '• i ti - h jJ�vd OAS l l A 3/4' TO 1 1/2" DOUBLE WASHED STONE f 3 LOCATION MAP SCALE 1" OUTLET DEPTH - _ 4. LEACHING FOUNDATION 2-3 / SEPTIC TANK 9 D' BOX FACILITY a ASSESSORS MAP ZZ-- PARCEL 141 s �}" o �Q s/� .q-!� ZONING DISTRICT: rzF G � YARD SETBACKS: FRONT = aT ��� ✓. �-�' �i G ✓�/ �,�/ SIDE = I S �l Sr Ld�j REAR 5 Go � PLAN REF. — FIo iCb�iorl m� 6r FLOOD ZONE: '.I,�'ek 011, 5e?+ 4f AIV �. SIGN: (GARBAGEDISPOSER IS Now o.wow�✓�' 1 DATUM IS � ✓� �h�'�"t�'� C'O"(►-1 l"r 9�"� SEPTIC DE wI .. a :�v . �� C' i-un r n�. _ rl' ? k?l P9!,r Al ATF ,- USE A GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE . n N J / / ., 1/8" PER FOOT. SEPTIC TANK: / GPD (v) _ 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H— 10 n0 00 5. PIPE JOINTS TO BE MADE WATERTIGHT. USE A GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 7 LEACHING: ENVIRONMENTAL CODE TITLE V. 4 y S + g ��o• 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE SIDES: - USED FOR LOT LINE STAKING. 53 BOTTOM: ° 'L5 ri �` 8-�3 ['T4) 2 7 � 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40--e PVC. \ \ 30.00 \ s r o — � ' "� TOTAL: �� S.F. GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED K- I tM 12L/L I�-I r1 Z] 5 FROM BOARD OF HEALTH. \ i -� /'�� --`' , ✓� ' I'(� �' h j0ff (, art �OGc��, 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE LOCATION OF ALL UNDERGROUND do OVERHEAD UTILITIES PRIOR o �0-00 TO COMMENCEMENT OF WORK. e�4/ / LOUD- SITE AND SEWAGE PLAN "` 100.0 PROPOSED SPOT ELEVATION OF �' f� 100x0 EXISTING SPOT ELEVATION 0 100 IN THE TOWN OF: PROPOSED CONTOUR C i `� r � �� '— 100 — — EXISTING CONTOUR / PREPARED FOR: M �� 0 { HOAM OF HEALTH ApPROVSD DATE MA SCALE: n� '�0'_ DATE: OG�" V, Igi / off 508-362-+341 for 506 362-OM i'/X I SM Of 'k(p h� down cape engineering, inc. to ofQJALA CIVIL ENGINEERS cCRM Nw OIA _ LAND SURVEYORS ,g JOB# q 1 - o G•7 A, 939 main st. Yarmouth, ma 02675 H. OJ P.L.S. DATA i _ I T.O.F. AT EL. �i3.S SEPTIC PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN Ir OF FIN. GRADE (Nar TO SGLE) ACCESS COVER (WATERTIGHT) TO ENGINEER: WITHIN 6' OF FIN. GRADE � �o MINIMUM .75 OF COVER OVER PRECAST 5 27r SLOPE REQUIRED OVER SYSTEM WITNESS: �� ' �'� '`I '� DATE:/__RUN PIPE �(,5 FOR FIRST 2lEVEL 2' DOUBLE WASHED PEASTONE PROPOSED I Soo 3 MAX. PERC. RATE S GALLON SEPTIC -Ad TANK H- 10 , T CLASS SOILS P r� ?F� ( _) GAS� 'T O O O O O O O O o c t�==� SLOPE) lr CRUSHED STONE OR MECHANICAL 3 ! o a O o 0 0 0 0 o aj�p ELEV. ELEV. COMPACTION. (15.221 (21) DEPTH OF FLOW ( X SLOPE) (Tz SLOPE) 5'y -� A�,O TEE SIZES: 0 A O1A INLET DEPTH 011t1.ET DEPTH OAo 3/4" TO 1 1/T DOUBLE WASHED STONE 1 3 LOCATION MAP SCALE 1" = zovo � - �'.,' FOUNDATION 23 / SEPTIC TANK D' BOX �' LEACHINGFACILITY ASSESSORS MAP Z-z- PARCEL I D '5 `O " �Q s/� 'q'� ZONING DISTRICT: 12r'G YARD SETBACKS: FRONT — 9,p' �T ���✓. .�-�' � �-�( � Y9/ M �,�/ SIDE = REAR a 5 o PLAN REF. - iA-02 1 Fi[ dTioFI mF FLOOD ZONE: (2, � �o ' � //•r r� o l�6_1 NOT S *T d -rvv►0 ✓1 / J SEPTIC DESIGN: (GARBAGE DISPOSER IS No-L o.wow�.� ) 1. DATUM IS �l�fY DESIGN FLOW: BEDROOMS (-UQ-GPD) _ 40GPD 2. MUNICIPAL WATER IS �D1►.+al''��E 0 f - ..,. .GPn nFSIGN1.OW 3. MINIMUM PIPE PITCH TO BE 1/8' PER FOOT. DING FOR ALL PIRE'OA `i UNI I S 10 _ds A r v r;— - \ o0 SEPTIC TANK: � GPD (v) _ 4. DESIGN LOADING (jj /' 52 5. PIPE JOINTS TO BE MADE WATERTIGHT. n o eP USE A GALLON SEPTIC TANK \/ ( � �� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. LEACHING: ENVIRONMENTAL CODE TITLE V. .�+ 8.8� moo. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE �� \ ,� o SIDES: 1 -- USED FOR LOT LINE STAKING. 7. i� k Jf �,- �� / s3 \.. BOTTOM: — A5 x >?J �3 ('74� 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. �= 3� \ a �`' , i 1 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT o �' rl / TOTAL: �_ S.F. �GFD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED o o _ f', % J 1,�1 Jh� �, �fi��c lr✓+I� �� ,• �►-1 -1 r -t`o�5 FROM BOARD OF HEALTH. `/ / -� , , '��--'° �,� , ✓� 1'f L� �' 1,1721 Iti AT 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE LOCATION OF ALL UNDERGROUND do OVERHEAD UTILITIES PRIOR -' TO COMMENCEMENT OF WORK. L N SITE AND SEWAGE PLAN z. 100.0 PROPOSED SPOT ELEVATION OF 0 - 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF: _ r Fl 001 PROPOSED CONTOUR \ � — 100 — — EXISTING CONTOUR PREPARED FOR: I� 0 mho coo 'to I._ BOARD OF MAUR APPROVED DATE MA SCALE: DATE: OG (2-e to- -`i 797 (wv✓E ►+S4 + off 5011-382-484/ fm 5W 30-OM y� down cape engineering, inc. „ BEN Of CIVIL ENGINEERS Cwn. A H. LAND SURVEYORS r 'o /�/r 7 JOB# 939 main st. yarnaouth, ma 02675 H. 0 ` P.L.S. DATE