HomeMy WebLinkAbout0699 MAIN STREET (COTUIT) - Health 699 Main Street, Cotuit _
f � `
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i
TOWN OF BARNSTABLE
LOCATION -S 0.��r SEWAGE# AO('l o 5
VILLAGE `..C T C:t i ASSESSOR'S MAP&PARCEL 0--3 0( `-
INSTALLER'S NAME&PHONE NO.C,40C- - E06 6QT(5XPe4-tS& - 1 l
SEPTIC TANK CAPACITY 1 SpC� C;K-�.��► �L � u�w�1'zt�tT�
LEACHING FACILITY.(type 3)5-005i U-310 COM"S(size) 3;Z,5 � 'K U, �
NO.OF BEDROOMS
OWNER KEV I O C.14d4,S4E �d-4A0,L A�t<(W PY
PERMIT DATE: 9'X-)--,COI J COMPLIANCE DATE: 9. 1 - Q l-7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N 1A 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 . {JA
300 feet of leachhiing facility) b�► Feet
FURNISHED BY \AVCLOI D E
cn
17
iz
- 'life
i 1l �012 .
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No. d"�` � ° `'' � Fee
THE COMMONWEALTH OFMASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for Disposal bpstem Construction Permit
Application for a Permit to Construct( ) Repair(* Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. (D OJ9 MA IyJ S`r LG%T u tT Owner's Name,Addres&and Tel.No.
Assessor's Map/Parcel 3(p a (oct It MAW 5-z- 4-ru l-
-Installer's Name,Address,and Tel.No.S®2-4 zZ-!9 V-71 Designer's Name,Address,and Tel.No. 5 D 8-��3-0 317
C,m4�E�cD� EidrQ0,<1S--_S Te_ GNa1ldC;6Xt&VC Xtie;,
1 S e C-0 4JL0414 0t& WJY C. cis AE44 4 y!
Type of Building: zer?4QE �
Dwelling No.of Bedrooms 3 Lot Size &5f sq.ft. Garbage Grinder( )
0
Other Type of Building R6:9 1kg9Jr(4-(_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33 D gpd Design flow provided A4{ S:7 gpd
Plan Date I- Number of sheets ' Revision Date
Title / ST C)tT
Size of Septic Tank 1S00 C.hC a 400f T Type of S!A.S. _o - --,-WWAe P;
tl
Description of Soil A4 EP S/OWII � [, �S P(. �
Nature of Repairs or Alterations(Answer when applicable) _TAQS'7 G-L_ a Gcaarc� 7'
67/T-LC, mule- mo 'rV (3 ca2Fwb�J'
Date last inspected:
,i
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
- accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of�Healt �g
Signed Date
Application Approved by —_ Date 1
Application Disapproved by Date
for the following reasons
Permit No. go Date Issued
-------------------------------------------------------------------------- --
.•. vtiti.r,....�� ti .'^pi-.'`t'1.a•*a-'i .. ^s.....:.. ..,..:"'i.-..,�� �e��*al�,a � ••'~,'°:;,,••:ti _ .. .. _ t ._
No. t / ,= Fee
THE COMMON,
WEALT OF MASSACHUSETTS Entered in computer: t/
PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for MisposaY 6pstem Construction permit
Application for a Permit to Construct( ) Repair(x Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. (0014 IM 10 S- 7"4V*U t r Owner's Name Address and Tel.No. .
.t ' KEvtN
Assessor's Map/Parcel 3(.11.), MAIU S-r (',p'f u t v,
Installer's Name,Address,and Tel.No..5O 2-43Z"2 VI T Designer's Name,Address,and Tel.No.
colov ki t,04E 'Te- et-.11V mic-Z X <
153 Ho(S-+ ViELw I ;ks s-4 d_x41J Owy iv AA&04 r f
Type of Building: 0?7
Dwelling No.of Bedrooms Lot Size j 1� ` sq.ft. Garbage Grinder
Other Type of Building g RCS 1j9DJ7't 4t.,. No.of Persons Showers( Cafeteria( )
t,
Other Fixtures ;
w
Design Flow(min.required) 3,3( gpd Design flow provided L4 I 5,-7 °:j gpd
Plan Date '.� (-' Number of sheets Revision Date
t Title (419 / .57- do-7 0
Size of Septic Tank 1.500 e4L � , 400C 7') Type of S.A.S.(31 Soo 464436t.!r
Description of Soil M e7) 15Alui ca /.'&-r_ p4woj
Nature of Repairs or Alterations(Answer when applicable) .x'tVSTJ&#_ &*'!o.> 11900 QwL GptGtl�i�•'t "7'"
� TiG "f?�1i✓K �7ro 0•010 D, boy ` y raj Koo Gvk , *-do UaE,�At xf
Date last inspected:
.. Agreement: �.
The undersigned agrees to ensure tonstruction and aintenance o he c f the afore described on-site sewage disposal"system in Yl'
accordance with the provisions of Title 5 of the,Environmental Code-di not to.place the/system�in operation until a Certificate of
",✓ �`•Compliance has been issued by this Board of Heal
'Signed Date -
Application Approved by Date 2
Application Disapproved by Date
for the following reasons
_ ,
� Permit No. C Date Issued .--
4
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded
Abandoned( )by �d� I'D �"�►a9rZ' et:t '
at (bq ll M4 E j ST dZ TL P t'7""* has been constructed in accordance
z-
with the provisions of Title 5 and the for Disposal System Construction Permit No.AID/ ���r 5 dated
Installer lit Q&AjI &.7'E P,t.!$'t--c Designer
#bedrooms 3 Approved design flow gpd
The issuance of this permit shall not beconstrued as a guarantee that the system wjI,I'funct o as-desi ed.
Date 9 ( � / Inspector
_ ----ti--- _. ----------------------- -._.
No. 6-Q A J" 2-9 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal &pstem Construction permit
Permission is hereby granted to Construct( ) Repair( y) a Upgrade( ) Abandon( )
System located at 9Fr Ae Aj o-7 tj! -7—
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit�<
Date r Approved by
- r
f
09/11/2017 13:46 5082730367 05654 P. 001/001
Town of Barnstable
Regulatory Services
. Richard V. SCAN, Interim Director
a.sNsrneic t
MAM Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office; 508-862-4644 Fox; 508-790-6304
Installer& Designer Certification Form J
Date: 9'1 H 7 Sewage Permit# o1oC7"a Assessor's Map\parcel 3(a 112
Designer: S-G E�n�(�nezc��n� T.nc._ Installer: Gae luf4e. l AVc-(fc(seS
Address: 2b51 C4'aA em% Nialnwa� _ Address: ► 53 Cc*, fxctpl Webf
East war 6gv"W , 11 A 07.55S M a s4+ eel It A 0 2 iO L 9
on 17 Cppzw(de. was issued a permit to install a
(date) (installer)
septic system at (oil a iv, S-tr pe based on a design drawn by.
(address)
" C 618(0eErtn.c� art . dated ��9 • 2d17
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced :above was constructed ' e with the terms
of the M approval letters(if applicable) �"°r"'As�
JOHN L '
CHURCHILL
Inst r' Sign r NOI1807
s ner's a (Affix Des, er amp Here)
P ASE RE TO BARNSTABLE :PUBLIC HEALTI DI SION. CERTIFICATE
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARX RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q;\Scptio\t)esigner Certification Forth Rev 8-I4-I3.doe
TRANS. NO.:
CITY/TOWN: Cotuit
APPLICANT: Capewide Enterprises
ADDRESS: 699 Main Street, Cotuit, MA
DESIGN FLOW: 330 gpd
REVIEWED BY: DATE:
N/A OK NO
GENERAL
Legal boundaries denoted 310 CMR 15.220(4)(a) X
Street, Lot,tax parcel number and lot number noted on plan [310
CMR 15.220 4 u) X
Locus Provided 310 CMR 15.2204 t X
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for
components) 310 CMR 15.220(4)] X
Easements shown 310 CMR'15.220 4 (b) X
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- i not, a variance is required 310 CMR 15.412(4) X
Location of impervious surfaces (driveways,parking areas etc.)
310 CMR 15.220 4 d X
Location all buildings existing and proposed 310 CMR
15.220 4 c X
Location and dimensions of system components and reserve
areas. 310 CMR 15.220 4 e X
System Calculations 310 CMR 15.220(4)( X .
daily flow X
septic tank capacity(required andprovided) X
soil absorption system(required andprovided) X
whether system designed for garbage grinder X
North arrow 310 CMR 15.220 4 g X
Existing and ro osed contours 310 CMR 15.220(4)(g)]. X
Location and log of deep observation holes (existing grade el. on
each test) 310 CMR 15.220(4) h X
Names of soil evaluator and BOH representative [310 CMR
15.220 4 h and i X
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i) X
Percolation test results match loading rate? 310 CMR 15.242 X
Certification statement by Soil Evaluator 310 CMR 15.220(4)0)] X
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR"
15.220 4 n X
Address 699 Main Street, Cotuit,MA Sheet 1 of 7
f
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220 4 k X
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water suppI X
within 250 feet of the proposed system location in the case X
within 150 feet of the proposed system location in the case
of private water supply wells X
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. 310 CMR 15.220(4)(1)] X
Water lines and other subsurface utilities located [310 CMR
15.220 4 m if waterline cross see 310 CMR 15.211 1 1 X
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR15.220(4)(o)] X
Stamp of designer 310 CMR 15.220(1) and 310 CMR 15.220(2)] X
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)] X
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405 1 k X
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103(4)] X
Test Holes adequate to confirm adequate groundwater separation?
310 CMR 15.103(3) X
Benchmark within 50-75' of system 310 CMR 15.220(4)( X
Materials specifications noted? [various sections of 310 CMR
15.000] X
System components not> 36" deep(unless Local Upgrade
Approval or LUA requested) 310 CMR 15.405 l(b) X
I
Address 699 Main Street, Cotuit, MA Sheet 2 of 7
N/A OK NO
SEPT�IQTANK ;$ � �.
Size OK? 310 CMR 15.223(1) X
Inlet tee located ten inches below flow line 310 CMR 15.227(6) X
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6)] X
Outlet tee with gas baffle or approved filter 310 CMR. 15.227(4)] X
Note regarding installation on stable compacted base [310 CMR
15.228 1 X
Separation between inlet and outlet tees (no less than liquid
depth) 310 CMR 15.227(2)] X
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA 310 CMR•15.405(1)(k X
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR. 15.2228(1) and 310
CMR 15.232(3)(f)] X
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" b 7/07 310 CMR 15.228(2)] X
Access to within 6 " of grade - one port for systems<I000gpd,
two fors stems>1000 gpd 310 CMR 15.228(2)] X
All at-grade covers secured to unauthorized access? [310 CMR -
15.228 2 X
> 10 ft from building foundation 310 CMR 15.211 1 X
Buoyancy calculation Required/Done 310 CMR. 15.221(8) X
H-20 Where appropriate? 310 CMR 15.226(3)] X
Setbacks from resources 310 CMR 15.211 X
1VIUlt1=COni artlment^*Tank3! 3ta i"TTNIMM " xw +: M
Required when other than single-family dwelling or flow>1000
d 310 CMR 15.223 1 b X
First compartment 200% daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2) and 3) X
"U" pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15.224(4) X >
Address 699 Main Street, Cotuit,MA Sheet 3 of 7
N/A OK NO
5 v as y e ! h^ek w^ ti agr '' r
BUILDING.'SEWE-R,', 70mwPIPING� �`�M � ., � _' 11,
Located at least ten feet from any water line? [310 CMR
15.222(2)] X
Disposal piping at least 18" below water line (when water and
sewer cross, see 310 CMR 15.211 1 1 X
Cleanouts required/provided ? 310 CMR 15.222(8)] X
Thrust blocks specified in force mains? 310 CMR 15.221(6) c X
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
310 CMR 15.222(6)] X
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] X
Siphonproblem/ leachfield below pump chamber) X
Endca s or vent manifoldspecified? X
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2) h X
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed) X
DISTRIBUTION BOX °+
[t.�
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232 2 a X
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323 3 a) X
Riser if deeper than 9" 310 CMR 15.232 3 X
Inside minimum dimension 12" 310 CMR 15.232(2)(b X
Minimum sum 6" 310 CMR15.232 3 e X
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
310 CMR 15.232(3)(d)] X
PiUMP'!CHAIVIBERS�$ s
Capacity(emergency storage above working=design flow)? [310
CMR 231 2 X
Proper setbacks 310 CMR 15.211 same as septic tanks)] X
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE 310 CMR 15.231(5)] X
Service components accessible (not too deep with piping,
disconnects accessible) X
Alarm floats - alarm on circuit'se arate from pumps specified? X
Exceeds two units must have two pumps operating in lead-lag
mode. 310 CMR 15.231(6) and 8 X
Stable Compacted Base 310 CMR 15.221(2)] X
Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)fX
Address 699 Main Street, Cotuit, MA Sheet 4 of 7
�F%
N/A OK NO
SOIL ABSORPTION�SYSTEIVIS SAS
Calculations correct? X
4 feet of naturally occurring material demonstrated? [310 CMR
15.240 1 X
Required separation togroundwater? 310 CMR 15.212 X
Aggregate specified as double washed 310 CMR 15.247(2)] X
System Venting required/provided? (system under driveway or
>36" deep) 310 CMR 15.241] X
Inspection ports specified and within 3"final grade? [310 CMR
15.240 13 X
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document X
GAILERIESPITS CHAMBERS;�31;0'C1VIR°15253°
> > �
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. 310 CMR 15.253(6)] X
Each structure with one inspection manhole (if>2000 gpd must
be tograde) 310 CMR 15.253(2)] X
Aggregate 1 minimum-4'maximum. 310 CMR 15.253(1) b X
2' sidewall credit maximum 310 CMR 15.253(1)(a) X
In bed configuration, inlet every 40 s . ft. 310 CMR 15.253(6)] X
Width 2'minimum 3' maximum 310 CMR 15.251(1`)(b)] X
100 feet-maximum length 310 CMR 15.251 1 a) X
Minimum separation 2x effective depth or width whichever
greater 3x if reserve between trenches 310 CMR 251 1 d) X
Situated along contours 310 CMR 15.251(2)] X
Breakout OK? 310 CMR 15.211(1) 4 and Guidance Document X
BED;SAS,` aximum size of tiedorfield5000 � d
M:
minimum 2 distribution lines 310 CMR 15.252 2 (a)] X
Maximum separation between lines 6' 310 CM R15.252(2)(d)] X
Maximum separation between lines and outside of bed 4' [310
CMR 15.252 2 (e)] X
Aggregate depth below discharge pipes 6" minimum; 12" .
maximum. 310 CMR 15.252 2 ( X
Separation between beds 10' minimum. 310 CMR 15.252(2)( X
Bottom area used in calculations only 310 CMR 15.252(2)(i)] X
A
Address 699 Main Street, Cotuit,MA Sheet 5 of 7
N/A OK NO
DID�THE;PLAMINV,,01 y , n
.Ei F1ProrsG�i +s'x�'m' 1Y M r�rzw,a'+
Pressure Dosed System ? Provided pump and piping
calculations as required 310 CMR 15.220(4)(r) X
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals] X
If used in gravelless system- make sure jet is directed as not to
scour soil interface Guidance Document X
Inspections once per year(systems<2000 gpd) or quarterly
>2000 dgood to note on plan 310 CMR 15.254(2)(d) X
Construction in fill - Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)? X
Impervious barrier and/or retaining wall ? Guidance Document X
Impervious barrier installation must be supervised by
designer 310 CMR 15.255(2)(b) X
Retaining g Y g
wall must be designed b Registered Professional
Engineer 310 CMR 15.255(2)(a)]
gX
Side slope not exceed 3:1 ? 310 CMR 15.255(2)] X
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document] X
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) 310 CMR 15.255 2 (e)] X
°GravellesstSysfem[I/AA" rovalLeAN
fters
Check DEP Approval letters for credits and design conditions X.
If used with pressure dosing do not allow pressure discharge
to scour soil interface X
Alternative Se tic System[I/A A` rovdl'Letters �i 411RA @M5 #�
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions? X
Is the technology being properly applied and does it meet all
DEP Approval Conditions? X
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement? X
Any alarms involved on separate circuits X
Did the applicant submit an operation and maintenance.
manual? X
Has applicant submitted a copy of a maintenance X
Are the variances listed on the plan ? [310 CMR 15.220
4 ) X
RLS Stamp necessary on plan if a component is within five -
feet of property line 310 CMR.15.412 4 X
New construction or increased flow proposed- [Refer to 310
CMR 15.414]
I
Address 699 Main Street, Cotuit, MA Sheet 6 of 7
N/A OK NO
Nitrogen�Seisitrve Ai easy �� ��%``�'� .�r;��� ` k� ��" ��� •���.' �� °�d. �= '�� .Y :: '�;� "
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems] X
Is the system proposed on the same lot as served by private well?
310 CMR 15.214(2)] X
Are the nitrogen loads proposed in compliance? [310 CMR
15.216 1 X
` �.
.zT�.➢ .. +
Pumping to septic tank? 310 CMR 15.229 X
Shared System 310 CMR 15.290 X
Address 699 Main Street, Cotuit,MA Sheet 7 of 7
i
Town of 13iinisthble P#_ e'
' Departinent of Regulatory Services
;
. i aantr Public Health Division Hate i e, t4 '-.-�
200 Main Stmat,Hyannis MA 026ol
CEO(,11tt I" •
Date Scheduled Time Fee
F
Y _ Pd._ i rCiP r7
Soil SuitabilityAssessment or Se
a 1 is osal r
Performed-By:
_ rA1 � -e� t ezTl C 5 Witnessed By:
LOCATION&.GENERAL INFORMATION
Location Address (oq 1 PiAl Owner's Name Cd(!�
�T Tc� r.
445,
Address (p9'� CIt�T61 T•
Assessor's Map/Parcel ` 03010 Engineer's Name xe. —
NEW CONSTRUMON((�� REPAIR _ Tele hone# j( 5—t{'('t Q 7'7
Land Use 1nG1C. �'q►MIlV i211IYIA Slopes(96) 0-12 Surface Stones
Distancoa firm: Open Water Body ft Possible WetArca ft Drinking Water Well 2400 ft
Drnlhage Way r• ft Property Lino ft Other ft
SI{ETCHI(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands I'n proximity to holes)
See. a4 ched,Ple,vt.
• i Lq
r ,
Parent mate(lal(geologic) t u4i4Qrh Depth to Bedrock 7134�� bas
1 +
Depth to Oraundwater. Standing Water in Hole: 7 13 a.. . �_t Weeping 11'oirt Pit Ran 713 pi' in.
Estimated Seasonal High Oraundwatcr
DETERMINATION FOR SEASONALMIGH WAT.RR TA UM
Method Used: Olfta dos rVAAi� '
Depth Observed standing in obs.hole: -7 1311 In, Depth to soil mottles: ►n,' .
Dooth to weeping from side of obs.hole: y 1 3'?,,,,�,•,- In, Groundwater AdJuslment — ft,
Index Well► — Reading Data: Index Well)oval ,,, Adj.-factor r Adj,arnun watdr•Lovel.�
PERCOLATION ITST bule,...$1, 'T IMIN !L&
Observation
Hole# Tlmn at 4" '~
Dc P th of Pero 36' 4" - _ — Time at 6„ l
Start Pro-soak Time @ AM
End Pro-sank - 3 AM
Rate Mln./Inoh C_ a Y"p;
Site Suitability Assessment: Site Passed U Sitp Failed: i Additional Testing Needed(Y/N)
Original: Public Health Division r Observation Hole Data To Be Completed on Back-- '
***If percolation test is to be conducted within 100' of wetland,you must first notify the,
Barnstable Conseirvation Division at least one(i)week prior to beginning.
Q:ISEPTICIPERCFORM.DOC j
• I
I
DEEP.OBSERVATIQTIZOLF,LOG Hole# r $2
Depth from Soil Horizon Sall Texture Shcl Color Soil• Other
Surface(In.) (USDA) (Munsell) Mottling (Stnucture,Stonef;Boulders,
Consistency, Urival)
P .
36•13; G IHS 2-trY 916
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Sol]Color Soil Other
Surface(in.) (USDA) (Munsell) ' ,Mottling (Structure,Stones,Boulders.
Consiste
DEEP OBSERVATION HOLE LOG Hole#
Depth from j Soil Horizon Soil Texture Soil Color Soil Other
Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders..'
DEEP OBSERVATION HOLE LOGS Hole#
Depth from Soil Horizon Solt Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stonee;Boulders.
i .
Flood Insurance Rate Map:
Above 500 year Mood boundary No— Yes
Within 500 year boundary No}Z'_ Yes '
Within 100 year flood boundary No.-)/— Yee
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious mtiterlal exist in all areas observed thrpughout the
area proposed for the soil absorption system? , vex 5
If not,what is the depth of naturally occurring pervious material?r._,._..._._....._._.. i
Certification
o evaluator examination.approved by the
Z date)I have passed the son I certify that on • � (
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise a701cunce described in 4 10 CMR 15.017.
Slgnature Datb h
Q:%AEPT(LVBRCPORM.DOC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI 8
DEPARTMENT OF ENVIRONMENTAL PROT %ION
ONE WINTER STREET, BOSTON, MA 02I08 617-292-5500 QD
4
1 ,d
WILLIAM F.WELDTD �Bg9N9 1`99A1_1DY C XE
Governor yDFpjAg�f �r tan
ARGEO PAUL CELLUCCI DAVIO UHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM gC issioner
PART A ti
CERTIFICATION
Property Address: iogcl� V\P%%K St CO-TV Address of Owner: `/ r (= �C,s�
Date of Inspection �-r- (if different) �►`
Name of Inspector: ��._
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: `C. e- 1L
Mailing Address: a
Telephone Number: •2-2 Tz6kX!j
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the tim of inspection: The inspection was performed based on my training and experience in the proper function and
maintenance of on-site se age disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
oe-
Inspector's Signature: Date: gjafl
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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: Check A, B, C, or D:
A] SYSTT PASSES:
7/ 1 have not found an information which indicates that the system violates an of the failure criteria al defined in 310 CMR 15.303.
Y Y Y
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
A/ One or more system components as described in the "Conditional Pass".section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:Owww.magnet.state-ma.usidep
ej Printed on Recyded Paper
)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: vn l i1 tW%QJ t co- i_t \
Owner:
Date of Inspection: �_ -S7
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup 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). Describe observations:
broken pipe(s) are 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): m
broken pipes) 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (a MCA-,11 5\
Owner:
Date of Inspection:'a-
7
D] SYSTEM FAILS:
You-must indicate ei:i.er "Yes" or"No"as to each of the following:
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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 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_.
YP P
An onion of the Soil Absorption System,stem, 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.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,O00 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:
m
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a
public water supply well)
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.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:LaRO� 'c,,�,vj 5\ cCSZ)v—,
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least 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.
V _ 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.
_ 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 the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected 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:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)J
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property A q dress: 6 ck9 fA,,,,, sz CO'((V`k
Owner:Cc,-,,X ,
Date of Inspecti n:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ttGOV e.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):�[
Laundry connected to system (yes or no):\
Seasonal use (yes or no):�/
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump(yes or no):�
Last date of occupancy: �set`'TTl\M�
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
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:_
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information
(�(/tM )-�06 7 `Q1A�( 0��- ►WSe�iTloYy
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping: yV,w'C iuti.Gwc
TYPE O STEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: S
Sewage odors detected when arriving at the site: (yes or no)inq
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
^' SYSTEM INFORMATION (continued)
Property Adoress: (DR
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade: z�
Material of construction: _cast iron _/40PVC_other (explain)
Distance from private water supply well or suction line
Diameter 1
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_V
(locate on site plan)
.Depth below grade: t
Material of construction: \/Concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
r
Dimensions
Sludge depth:__ LI y
Distance from top po Isludge 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 Qr baffIT W
How dimensions were determined: ( Vy\
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of(liquid dllevel in relation to outlet invert, structural
integrity, evidence of leakage, etc.) L ��"� � , -T—
SEEi 1
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: .—Concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(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.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (a C(Q OW,W, d t v",
Owner:Date of of Inspection:
TIGHT OR HOLDING TANK: 1 (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
i
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:NOyzwm. -
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: IYes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
I
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6Ct ` CU T v ,(\
Owner: G"S e-
Date of Inspection: i -�
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:
Alternative system:
Name of Technology;
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:_
Dimensions of cesspool: .
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:Ll
(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.)
(revised 04/25/97) Page 8 of 10
L
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
[,�3 SYSTEM INFORMATION (continued)
Property Address: -`_` m"'Itu S( CU 1 V l
Owner: G�\C,S—e
Date of Inspection:
g -►� q7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
v
v �
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:Vtct mo ,w 57 ccf—\'V
Owner:
Date of Inspection- �
Pl >,ID c�'K✓
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
-/Check local excavators, installers
` Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
0,1a11 '0 �Vw" c5�'r/W�. fJj! �IT' %S LI-r-
L,%A`i e— Y �3�Stvk►�w��
(revised 04/25/97) Page 10 of 10
L
yTOWN OF BARNSTABLE
LOCATION
/-f
(��%/� � �� �� a ��,.� �( � � EWAGE # (✓
VILLAGErV /7i ASSESSOR'S MAP & LOT 0j o/ �-
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 7— (size) G
NO. OF BEDROOM _PRIVATE WELL O PUBLI WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
W � W %j
` I
v � �
i
L
No.... 0. FRs....... m.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
.......... -0-.1�....N-.......OF............ 45 ../SA.................................
ApplirFatiou for Diopooal igurkii Towitrur#ion Vamit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
...........� 4.4Q. ,----:-------T----Z-----------------------------•-•-------------
• Location.Address or Lot No.
............ -lc� vow S -•-••-•-••--•--•---•-------------- --�.2.q...0 F... .�: ..fz . — ..............
S owner Address
a 46
I i.....c.c .-tea. .le................................ ....................fly..-...V.N-i-C...............................................
J t, '� Installer Address
Type of Building /-� ,�} Size Lot----- ...7'7_.S:-Sq. feet
Dwelling=No. of Bedrooms.-J./..........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .....................:...... No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ................................ .
W Design Flow...............�.5.....................gallons per person per day. Total daily flow..........1!._Q_.........................gallons.
WSeptic Tank—Liquid capacity.IQ�gallons Length.._=. `�Width_. `.:�a"'Diameter-___---_______ Depth_.6 7".
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...........L-------- Diameter.......,._`...... Depth below inlet.......(...:...... Total leaching area.....�17...sq-#t. C71�Q
Z Other Distribution box ( ) Dosing tank ( ) l
'—' Percolation Test results Performed by..._ !/Lta.c ? r�(w�R�[-��''.°..�! - Date------- 1.. 7 " 70
Test Pit No. 1...... ....minutes er inch Depth of Test Pit___,/.�'..._... De th to round water.A.- C...
a P P P g
�Gz•, Test Pit No. 2................minutes per inch Depth of Test Pit__._____--_.____-_-. Depth to ground water........................
^ -------------------------------------------------i•-•.••--•••---••--
O Description of Soil-•-a -. ---•• f �...k-Z:/J1UVn.-
x
W -•••------------------------------------•---•-----------------..__.I....--••- -••---•-•-••••-----••-----•--••-••---------------------------••---•-----.................................................
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 iITLE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar4 of health.
SignedA •/Y'M'�-- V•--••--------................................................ ....• ------
Date
Application Approved By..........
� -_---------------------------
Date
Application Disapproved for the following reasons---------------------------------------------------------------•-----------------•---------.........---•------•-.
--•-•••-••••••••••-••--•••-•-••••----•-•-...•----•••-•---•••----••••--••-----•--••-•----•--•--••••-•••••.•••---•--•--•-•--------------------•---••----------------------•-----------•-•---•••--•........
q Date
PermitNo........ -1. . P.....YI.A....................... Issued_.......................................................
Date
No... A_.' FE$.......,�?. .......
THE COMMONWEALTH OF MASSACHUSETTS `
BOARD F HEALTH
/.��.. ..�.....OF............. 1rL c-?`,.�.. .._...............�.....
ApplirFativat for DhipmFal Works Towitrur#iura tirrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
.... -&-�'- �` �l d i^�:..5�� ........................ .' .T I-- ....
Location-Address . or Lot No.
.....................•--- -----••• C.... _---....._......... ............
�-� Owner Address
1✓/ ��� .. t�'7�t. / �r.!1G! �r...............................................
Installer Address
PQ
" Size Lot----- -_3__. 7__5_._Sq. feet
1�
Type of Building
�-� Dwelling—No. of Bedrooms...............Z...........................Expansion Attic ( ) Garbage Grinder ( )
` 4 Other—Type e Other yp of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
04
04 Other fixtures ----------------•---•---------------._...-------------•--•••......-------•---•----•......
W Design Flow................:�'.5-..................__.gallons per person per day. Total daily flow---------- >.G2_........................gallons.
WSeptic Tank—Liquid capacity.�d�gallons Length__ F_ _G'Width.__ ✓.d_''Diameter------_______ Depth__
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------!-------- Diameter.._............. Depth below inlet....._.C_......... Total leaching area..... ...sq4. t. 6*'r)
z Other Distribution box ( ) Dosing tank ( - ) /
aPercolation Test -Results Performed by.... �c.y _>_P�yt. �'?_t 'v__ � - Date....... 1-.7 ___................
a Test Pit No. 1------_4'__-......minutes per inch Depth of Test Pit..J....Z.......... Depth to ground water. ------
IT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
a . .
QDescription of Soil-••¢ ...... ....... •-- -- .--- .................f v
U -•••--------------••---------•--
......•-------...•---------------•------...----,•----............ •---------------••------•---------------•••-•--- ---------...------.....---••----•...------------
W
-----------------------------.--------------------------------------------------------•-----•-------------------------------------------...-------------------------------------------------------•---
U Nature 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^_ITL-, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar of health.
Signed----•--(/(/- ...... !/ v......
c Date
ApplicationApproved By.......... .........- ----------------------••------ --------------------Da ..............
ate
Application Disapproved for the following reasons---------------•--- --------------------------------•----------•------------------------- .................
...•...............•-•----•--•---•-•----•-------....------........-•------•-------------.....------......._.....--•--•---•------------------------------------------------..........-•-•------••--------
Permit No.-•....Y.6..:•- !f'U Issued.......................................................Date-
Permit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
-�O�F HEALTH f�
...:... ........./44...........OF..... c �s .b✓ 'rz/1! d l�.
01 prtifirFa#r of (dam fiv anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
y1 . -- •-•------------------------•-•••-•-------•--.._...... --------------------------------------
9, Ins Iler
at........ Q 1 .........1Y1--44_1.......57----•-----��c -------------....................................................................
has been installed in accordance with the provisions of TIF E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-_,� ,---- dated__..._-_._.____________________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
DATE ...................................... Inspector............. :-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
At
L 1....:' .�........OF......�Z ;t �-
. ..............................
No.... U FEE....,1
11iopusal Vorkii TDOnotra ivaT ami
Permission is hereby granted.........�.t//........ ------------------------------------------------•-•--......----••-•--•--••---.
to Construct ()%;) or Repair ( ) an Individual Sewage D'sposal System
at No............L c .x .�..a ........-% �l!�..CLc ....... t_x
Street
as shown on the application for Disposal Works Construction Permit No.
X._ zo. Dated................:.........................
...................................... . r- f....._....----•---• ..............................
q qq. Boarrl of Health
DATE............../._. - -r._..?O..----•-.._.::.::_
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOP OF FOUNDATION= 43.81± PROVIDE EXTENSION RISER WITH NOTES
---- COVER OVER INLET&OUTLET TO FINISH GRADE OVER D-BOX= 42. '± FINISH GRADE OVER CHAMBERS= 41 .9' - 42.31GENERAL
I FINISHED GRADE WITHIN 6"OF F.G. (TYP OF 3) F.G.OVER { SLOPE @ 2%MIN. OVER SYSTEM 3/4"TO 1-1/2" DOUBLE WASHED
------FINISHED
FOUNDATION= 42.7'+_ TANK EL.= 42.5± REMOVABLE WATER-TIGHT COVER OVER STONE TO CROWN OF PIPE € I. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
RISER TO WITHIN 6"OF FINISHED GRADE 4"SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
I g 9"MIN- 5"DIA. OUTLET(S) MIN SLOPE 1% BOX TO F.G. (SEE NOTE 19) 2"OF 11$"TO 112"DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES.
36"MAX. STONE OR GEOTEXTILE FILTER FABRIC
I PROP.4"SCH.40 f --� - � _ _. 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
PVC SEWER PIPE DESIGN ENGINEER.
4 SCH.40 PVC TO 9 MIN TOP OF SAS= 39.30' PLACE RISERS ON AL If
2"DROP MIN. CHAMBERS WITH "
DISTRIBUTION BOX .. 9'MfN. 3. 4 SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
36 MAX' 38.3® 36 MAX. SYSTEM UNLESS OTHERWISE NOTED.
f \ MIN.SLOPE01k 6" 3" 3"DROP MAX. 3" 9" 3" 9" --- ' �� ► INLET PIPES TO 6"OF
---- - --,-- __ MIN.SLOPE Q 1% BREAKOUT EL= 38.80 FINISHED GRADE
L ' 48'f "' 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
14" 14" 39.35' L = 52 t PROVIDE WATERTIGHT ELEVATION =38.80' FOR A DISTANCE OF IV AROUND THE PERIMETER OF THE SAS.UNLESS A
4"PVC IN FROM lj"'-'�,JOINTS YP. a 4 p o a 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
, 4-- ` (�') NOTE: SEPTIC TANK � 4"PVC OUT TO � � � Q � � � � � � a a 0 � � o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
41 �0' - (£ `") ALL INLET AND LEACHING FACILITY Qp 00 � p 5. SLOPE ALL SOLID PIPE AT 1.0°to MINIMUM.
i48 OUTLET TEES SHALL 12" 6„ pp o a U 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL
(A) 39.601 BE PLACED DIRECTLY 38.72' MIN. 38.55' 2' " op
(B) 39.60 GAS BAFFLE GAS BAFFLE UNDER A COVER. 0 00 vQp C-� C� C� 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
51.3'TO MAIN HOUSE 1000 GAL. 4 HRS DETENTION OVER MECHANICALLY po 0 0 001 0 CJ 500 GAL. 6"CRUSHED STONE 00 op NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
32.5'TO COTTAGEL�:j (48 HRS DETENTION) (2 ) COMPACTED BASE
6"CRUSHED STONE ( 3 13 5 8.5'(TYP) =I 3 5' 3.5' 3.5.
AND DESIGN ENGINEER.
OVER MECHANICALLY OUTLET DISTRIBUTION BOX 4.83' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L DATUM. BENCHMARK ELEVATION OF 42.00,
E COMPACTED BASE TO BE INSTALLED ON A LEVEL STABLE 32.5' m'P•) ESTABLISHED ON A NAIL SET IN UTILITY POLE#3,AS SHOWN ON PLAN.
BASE. FIRST TWO FEET PROPOSED 1000/500 GALLON TWO COMPARTMENT SEPTIC TANK (H-10) PIPES TO BE LAID LEVEL.F OUTLET 36.30' GROUND WATER ELEV.= < 30.80' 11.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
LENGTH 10'-6" WIDTH 5'-8" DEPTH 5'-811 CROSS SECTION VIEW 3 - .500 GALLON H-20 CHAMBERS 5'MIN. CHAMBER END VIE DWI THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
fl s. I y,,� {; <. f �€ ,;Ia lr- DIMENSION AS PER , A ' 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
€:€_F c;. . F,_ .t ' : . * - _ !,0.,`l tf C . susACME-SHOREY I �� DISTRIBUTION BOX T KCAL Cr � .R a O� I s- TO THE DESIGN ENGINEER.
SEPTIC PRECAST CORP. 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC.STRUCTURES SHALL BE MADE WATERTIGHT.
H-20 CHAMBER DETAILS
Ili I Ir k Ey, ; _ r i=i r pia.. NOT TO SCALE _ v _ NOT TO SCALE NOT TO SCALE __
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
:f a + }" REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
NOTES:
` APPROPRIATE AUTHORITY.
#, F"ISTING , - t � g * 1 4 :, PERC NO. 15442 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED
1.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF _ t- ',
• � I INSPECTOR: Donald Desmarais
1-BEDRCO" THE PROPOSED LEACHING SYSTEM TO ENSURE CONSISTENCY WITH ,, . �,7�ii„ � � ,. C1 ��,, , `";', UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR
COTTAGE TEST PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL �► °° ` r 1Y, 1 TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING.
� � �. sl EVALUATOR: Michael Pimentei, C.S.E.
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA.
ENCLObED ' ' *. - = ' j Il C.S.E.APPROVAL DATE: 10/27/1999 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
W .. ..a f)
o, PORCH C-3
h, 2). ENTIRE PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2, ;, +' :; - ` r x r ) t DATE: August 8,2017
C-1 THE ESTUARINE WATERSHED AREA,AND THE WELLHEAD PROTECTION * � _# -_ 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
_ TEST PIT#: 1 MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
OVERLAY DISTRICT. •, �, � REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
NE' ELEV TOP= 42.00'
- LOCUS ,
r .a - FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
�' ` : ELEV WATER= <31.00 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
1.3� SWING-TIES CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
p PERC RATE_ <2 min./inch SITE
# - 4 ,
2) DESCRIPTION BC-1 BC-2 BC-3 w 40_w
G, (1 , /rtx 16. PROPOSED PROJECT IS LOCATED WITHIN:
p q . ; { : ,� t# , DEPTH OF PERC= 36 -54
4 r TANK INLET COVER(1) 53.9' 36.2' -- ► * tx , w � ! ,� � ��#_ ASSESSOR'S MAP 36 LOT 12
3) 4) - . .;
TANK OUTLET COVER(2) 60.5' 29.5' - TEXTURAL CLASS: 1
" f OWNER OF RECORD: KEVIN P. CHASE&CAROL A. MCCARY
„�{i µ-as �" ; ,« ;;,,;,;•-'
CORNER OF STONE(3) - 41.5' 51.9'
AV-
` "'" ADDRESS: 699 MAIN STREET
o
CORNER OF STONE(4) 47.2' 48.9' ; .' �"; "' - ers
Fill COTUIT
b r, ' C 1 , MA 02635
N -- .• : <` * Loam Sand
p CORNER OF STONE(5) -- 76.1 81.2 , .--'. « y' u.+� A 1 y FEMA FLOOD ZONE X
rn ... r.. . c . ,. ► .r''"' - . . OYr 3/2
f d' '. �' ."�* 10" 41.1T COMMUNITY PANEL# 25001C0756J
CORNER OF STONE(6) -- 72.7' 83.0" .' '"• k `
*/,`YM1° t 17. DEED REFERENCE: BOOK 24315, PAGE 76
_ k •_ «� : . ' &k B Loamy Sand
(6 20.9 'M ,;.` ", , .,, _ '",_ '! 10Yr 5/6 18. PLAN REFERENCE: PLAN BOOK 511, PAGE 4
*« « «` 19. A 4"PERFORATED SCH.40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A
« t
5) � ,y ` �«n .� ----�' . * 36' 39.00' DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"'OF FINISH GRADE. A
t ti �1C
P' REMOVABLE THREADED INSPECTIONS.
;` ; ,���„� Perc <�� R VABLE 7 EADE CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR
20 OWNER/APPLICANT/CONTRACTOR SHALL BE kESPONSIBLE TO OBTAIN A1114H AND ALL
REQUIRED PERMITS AND APPROVALS FOR THIS PROJECT.
SEPTIC DIMENSIONS & SETBACKS G Med Sand LEGEND
SCALE: 1"=20'
2.5Y 6/6
j LOCUS P LAN
5Ox0 EXISTING SPOT GRADE
No0
SCALE: 1"= 1000'
- 50 - - EXISTING CONTOUR
50 PROPOSED SPOT GRADE
132" 31.00'
a
� fO MAP 36 50 PROPOSED CONTOUR
LOT 15 �E, 34 v€GIs pPO : PUMPED, , ? '_ DESIGN - EXISTING OVERHEAD UTILITIES
$ s; „ , No Mottling, Standing or Weeping Observed rx__. _. NG
` tfV!.i.i-i Ci�'AP a Li s av , A:zuC ABANDONED
ati \A,'IT� CLEAN COARSE G ,'rI s �".D f`,590�'�1D,���1ED '°- f�ti
�G (�°����'ROX I_0'_-A7 - TOTAL NUMBER OF BEDROOMS (MAIN HOUSE+COTTAGE) 3 g� /� - GAS - EXISTING GAS LINE
a PPRCIX LOCATION) ,� � TEST 1�" I T DATA
PROP, CLEANOUT(TYP OF 3) NUMBER OF BEDROOMS (DESIGN) 3
: :. € . ) . " : PERC NO. 15442 _____._.W _W __-__ EXISTING WATER LINE
(APPRO , C OCCATI O N)i \ 61 DESIGN FLOW 110 GAUDAY/BEDROOM
N880 01'18"E "�`;� 1� N87° 59'S0"E Donald Desmarais
r•. INSPECTOR:
15.1 V ---�-� 227.07 E ISTING r TOTAL DESIGN FLOW 330 GAUDAY ! TEST PIT LOCATION
x 1-BEDROOM 43- _ EVALUATOR: Michael Pimentel C.S.E.
EXX ST€�;G I,0001 GALLON < FITIG T t,� O S`_ � ``,, 'e � _ - _ . - -- COTTAGE. � DESIGN FLOW x 200 % 660 GAUDAY
A, r, �i; ; `D f :.," *: C? rCl=iOPEt i:J'FzTiJ >� _ _`._ ^ay.. C.S.E.APPROVAL DATE: 10/27/1999 `
' EXISTWG CESSPOOL
� P _ ENCLOSED USE PROPOSED 1,000/500 GALLON TWO COMPARTMENT DATE: August 8,2017
AND FI' t t:C w/ CI._EAN SAND) PER 310 'AMR 15,354 �,� `t� --- '� � PORCH
\ COMPARTMENT 1: SEPTIC TANK TEST PIT#: 2 EXISTING 1,000 GALLON SEPTIC TANK
42x6 ,--PROPOSED 1,000/500 GAL.TWO
COMPARTMENT SEPTIC TANK EE
DESIGN FLOW x 200%=330 x 2= 660 GAUDAY (REQUIRED)
MAP 36
` s DESIGN CAPACITY = 1,000 GAUDAY (PROVIDED) ELEV TOP= 41.80' EXISTING 4 SOLID SCHEDULE 40 PVC PIPE
\
LOT 12 i 42x8' 3 PROP. SEPTIC PIPE TO BE ELEV WATER= <30.80'
COMPARTMENT 2: PROPOSED 1,000/500 GALLON
( i r i ' /""42x8l ,.,: �� SLEEVED 10-FT ON EACH SIDE
25,651 ±S.F. O ` FI NC. 4 a
O' I �' d I, s: --) OF WATERLINE CROSSING
DESIGN FLOW x 100%=330 x 1 = 330 GAUDAY (REQUIRED) PERC RATE= O TWO-COMPARTMENT H-10 SEPTIC TANK
DESIGN CAPACITY = 500 GAUDAY (PROVIDED)
CHI°JI. . r ` 3Xa , O 1 DEPTH OF PERC=
o PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE
Z � `, '!j �f% ��/ 4. -n MAP 36 TEXTURAL CLASS: 1 ® PROPOSED DISTRIBUTION BOX(H-20)
o c� 4 ,t r s (awl :'' �t-'y PROPATER . H-20 D--BOX 0_ - LOT 13
METER 42x2' `"- INSTALL 3 - 500 GAL. H-20 CHAMBERS wl STONE o PROPOSED 500 GALLON LEACHING CHAMBER(H-20)
42x3' m
0.. 41.80'
32" O �- SIDEWALL CAPACITY 6 Fill 41.30'
ENCLOSED PORCH CO )C 4 1 PROPOSED THREE (3)500 GALLON (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAUDAY A Loamy Sand
STONE: WALL. (TYP) � ^},,j �� °. DRIVE � � �42xo' H-20 LEACHING CAMBERS W/ (32.5' + 11.83'} (2) (2') (0.74 GPD!S.F.) = 131.2 GAUDAY 1, 1 OYr 3/2 ,
r 10 40.97 REV. DATE BY APP D. DESCRIPTION
t r 42x2 O f SURROUNDING AGGREGATE
`� GARDEN APPROX..
MAP 36 ® ryp L®CA IION -� 24" -�41Px$' BOTTOM CAPACITY Loamy sand PROPOSED SEPTIC SYSTEM UPGRADE
LOT 2 APPROX. GAS LINE- _-- ,- PROPOSED INSPECTION PORT o C _ B 10Yr 516
(LENGTH x WIDTH) (0.74 GPD/S.F.) GAUDAY PREPARED FOR:'' (32.5'x 11.83') (Q.74 GPD/S.F.) = 284.5 GAL/DAY
Rt35FtED '_ �,� �� 32'" v°�" 36" 38.80'
\ 1 1s°' � GRAVEL CAPEWIDE ENTERPRISES
SMELL 1
�. 18 DRIVE � �.�
DIVE �a 24„ �` j ., 24 6BUSH (TYP)
° >: _:- ; `} R -- � TOTALS: LOCATED AT
S88 58'03'W ... � '
r y € ". 1 3
15.02' 221.78'_, -- - .�' CHAMBERS
- -a„�rY�rr r"�„ ��-ancweY�= s�wv ._ fi f.:. ,bi.
COBBLE APR �� .-, ��_. ..: � - � �- , . --
:;,......... .. . ._..�..... .- - E ` - -- TOTAL LEACHING AREA 561.8 SQ FT
-
,: . � , ., 69 AI
- S88° 56'27"W fir= ? 1,�� 3_i. i Ja '
TOTAL LEACHING CAPACITY 415.7 GAL.roAY C Med Sand COTUIT, MA 02635
3 � - ''' EDGE OF P/ltfFENT
i._.k, . Benchmark
RIGHT OF WAY 2.5Y 6i6 SCALE: 1 INCH = 20 FT. DATE: AUGUST 21,2017
0 10 20 40 80 FEET
Nail set in U.P.#3 (VARIABLE WIDTH)
t i�,of�As�
Elevation =42.0Y --- --
� cy PREPARED BY:
Approx.M.S.L. RESERVED FOR BOARD OF HEALTH USE ® JOHN L a
132" 3o.8a' CHUB ILL JR. JC ENGINEERING, INC.
o/4180 2854 CRANBERRY HIGHWAY
SITE PLAN IT EAST WAREHAM, MA 02538
I VIC rx
No Mottling, Standing or Weeping Observed
SCALE: 1"=20' _508.273.0377
Drawn By: BJW Designed By: BJW Checked By: MCP JOB No. 3897
l
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� I I I I ELEV.= 46+5 ' " % LEV.= 46+2 � I �l I . I I - � I I I I I . . � I I'll � I I I . I � � I I . . I I I I I
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11 i, " .1 � I I I I I 1. " a SUBSOIL I � I �_ a. SUBSOIL ". I I I I I . � r1l � I � AdSUMED DATUM
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I i I I " I I I I 11 OF THE STATE SANITARY CODE AND ANY I .
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� � E. FEBRUARY 7, 1990 1 � � I I I I I � I 1 8. CONTRACT I � ;
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11 I I I � I . 11 I I " . � I I � INSTALLATION OF SEPTIC SYSTEM, OF ANY DISCREP- , I , : , " i
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11 I I ' ll I I I - 11 I I .1 I I 11 11, � I' ll I. , I I - 1 I . I � i I I � I I I 11 � 1 � I
. I I � I i ' ELEV= 46+7± ELEV= 46+5± - I � � I I I I � I� ,�
I 1, I I � I �I I I I � I I I I . , I I I I I . - � I 1, I I
- t ., I I I I 11 11 , � - I . 1 1 * I I I : / ELEV_ 47+0± 1 : I I . 1. I I � I
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