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HomeMy WebLinkAbout0080 MARINER CIRCLE - Health �80 ro".Mar o Circle 'F 1Cotuit 23060 �I i 1 ` TOWN OF BARNSTABLE LOCATION XN(\,o C.rc-ke SEWAGE# DO ' (03 VILLAGE. �G l� V;, ASSESSOR'S MAP&PARCEL 0&3 Z C)6 O INSTALLER'S NAME&PHONE NO.V-.,i= oe.Qs4 �oa���, 1.na 000??V'-(5DS SEPTIC TANK CAPACITY k O O Q r,-►`t o,,S LEACHING FACILITY. (type) a- SgO Cat, Le,,,c,�,(size) a3'L X 10,V w K NO. OF BEDROOMS D C x 3 --)r OWNER G r` -73�Y a•-, PERMIT DATE: COMPLIANCE DATE: 7141 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > �', �/ Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED A Ll >. o?C's'" 3a= 5 27 No.p Fee ago V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 01pplitation for Dioozat 6wem Con5trUCtiott permit Application for a Permit to Construct( ) Repair( ) Upgrade(r/` Abandon( ) ❑Complete System U Individual Components Location Address or Lot No. 'C20 i V, G 3-6 C;d'GVf, Owner's Name,Address,and Tel.No. I �� f V1A t•'�w-e,A� G',,vt�C Assessor's Map/Parcel 6 03 8t<, � 0 C�U � O C-151 vo?® -"QY_( Installer's Name,Address,and Tel.No. Qf� 1'� wG' Designer's Name,Address and Tel.No. •'N� A T`w� p.c�..�o>F �/ So g• ` e a-4S oSS C S -t awy-r�-d. :v,,,e-, Ste- �t 3 -.-)X 6 Type of Building: Dwelling No.of Bedrooms �o Lot Size _ `�, U®® sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Q QCO gpd Design flow provided o7 7�( gpd Plan Date `� f � ) Number of sheets Revision Date Title Size of Septic Tank to o �"�t �e v rl Type of S.A.S. Sow a AA <'(,, wm -,5.r S qj tie Description of Soil S� Nature of Repairs or Alterations(Answer when applicable)�j.,ti..�6l� 'k-l-,Z© IpR3 ww 4 n - O Aso 110tN, <= c".S ud 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 Certificate of Compliance has been issued by this Board of Health. Si Date Z> Application Approved y Date Application Disapproved by: Date for the following reasons — Date Issued a Fee VS; THE COMMONWEALTH OF-MASSACHUSETTS Entered in computer:PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zlp'pCfcation for Digogar *pgtemc Congtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(V) Abandon( ) ❑Complete System &Individual Components Location Address or Lot No. VN-C 4-6 C:,'GSC, Owner's Name,Address,and Tel.No. 12,".l As`sessor's Map/Parcel 03 �6 / y-C O �S </o?p -Q4�( Installer's Name,Address,and Tel.No. �. sos� G' DesigneryName,Address and Tel.No. "•ham 4 TwC� Q.a s5o>c 37/ Sag ��g-6oss C-:5 t e. sew-a4q- 3-2so Type of Building: Dwelling No. of Bedrooms a� Lot Size 4DO, O©© sq. ft. Garbage Grinder ( ) Other Type of Building g .,<S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Q DO gpd Design flow provided gpd Plan Date `� f I Number of sheets ( Revision Date E' Title Size of Septic Tank ti Ogp G'.o Type of S.A.S. TOp 9,,Ar C'L.�o,.•�n�aYs Description of Soil . �M t Nature of Repairs or Alterations(Answer when applicable)—I-AA-34 F Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenante of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and no(to placd the system in operation until a Certificate of Compliance has been issued by this Board of Health. gne� Date e� Application Approved by-rj A .. --� Date Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (V,/) Abandoned( )by at ct5'�) �/Y\,Or-`ti� C_t t- e-` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � C) l dated 1 Installer /�„ _ Designer #bedrooms Approved design flow() gpd C7-- The issuance of this ferinj't shall not be construed as a guarantee that the system will ct�o as desi ned. Date �t ' Inspector - %A-, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogal *pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( � Abandon ( ) System located at �'� 4 f;.,.C C-'-, (.e 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 three years o must lie completed within thf the date o�his permit. ------- rj y Date �jr,`�� Approved ��� ff; k 25251 P!3302 41r-8036 02-1 1-2011 & 10=26a DEED RESTRICTION Whereas,Amy C. Griffin is the owner of property located at 80 Mariner Circle,Cotuit, Barnstable County,Massachusetts,by deed dated April 6,2000 and recorded in the Barnstable County Registry of Deeds on May 9,2000 in Book 12996,Page 66, said land M being shown on the Town of Barnstable Assessor's Map as Map 023,Parcel 060, and more N particularly described on Exhibit"A"attached hereto and incorporated herein. 0 Whereas,Amy C. Griffin,as the owner of said Lot,has agreed to a restriction as to the ,s number of bedrooms which can be included in any dwelling existing or constructed in the future on said Lot as a pre-condition to obtaining a permit for the installation of a new septic t j system; ai 2 Whereas,the Town of Barnstable Board of Health,as a pre-condition to granting the permit U for the installation of a new septic system in accordance with 310 CMR 15.000: The State a Environmental Code,Title 5,is requiring that the agreement for the restriction of the number of bedrooms in any dwelling existing or to be constructed on the Lot be put on o record with the Barnstable County Registry of Deeds by recording this document. 00 Now Therefore,Amy C. Griffin does hereby place the following restriction on the above 2 referenced land in accordance with this agreement with the Town of Barnstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: The property located at 80 Mariner Circle, otuit, Q, p l�rh' C Massachusetts, and described on a the attached Exhibit"A",may have a dwelling containing no more than two(2)bedrooms. Amy C. Griffin hereby agrees that this shall be a permanent deed restriction affecting the above described premises. FOR TITLE,see deed recorded with the Barnstable County Registry of Deeds in Book 12996,Page 66. I L/ I Bk 25251 Pg 303 #8036 WITNESS my hand and seal this �� day of February,2011. Amy C. Grif COMMONWEALTH OF MASSACHUSETTS Barnstable,ss: On this /I dayof Feb 2011 before me the undersigned �'Y> gn notary public,personally appeared Amy C. Griffin,proved to me through satisfactory evidence of identification, which were M R b c_.. ,to be the person whose name is signed on the preceding document, and acknowledged to me that she signed it voluntarily for its stated purpose. Notary Public My Commission Expires: "EJOILUCKNI commonweatth of Massachusetts M .° '�i�ci v°y�('r•:. Commtssian Expires Mar.9,2®l1 %,� ��.... .VGO�J� : Bk 25251 Pg 304 #8036 Exhibit"A" Property description The land,together with any buildings thereon,situated in Barnstable(Cotuit),Barnstable County Massachusetts,bounded and described as follows: NORTHWESTERLY by lot 115,as shown on hereinafter mentioned plan,one hundred twenty-five and no/100(125.00)feet; NORTHEASTERLY by lot 119,as shown on said plan, one hundred sixty and no/100(160.00)feet; SOUTHEASTERLY by Mariner Circle,as shown on said plan,one hundred twenty-five and no/100(125.00) feet; and SOUTHWESTERLY by lot 117,as shown on said plan,one hundred sixty and no/100 (160.00)feet. Containing an area of 20,000 square feet,and being lot 118 on a plan of land entitled "Subdivision Plan of Land in Barnstable(Cotuit),Mass. For Cedar Acres Realty Trust, February 4, 1970, Scale 1"=50', S.R. Sweeter,Engineer,Dennisport,Mass. BA38-C2591, Sheets 1 and 2",which plan is duly recorded at the Barnstable County Registry of Deeds as TUBE 167 Fmo` '.Y 0�DEEDS I , a sp OHN F.MWE2.qEQ1!!TEL _. J BARNSTAB LE REGISTRY OF DEEDS Town of Barnstable �t Regulatory Services Thomas F. Geiler,Director WAMABM Public Health Division `� Thomas McKean,Director FD MA'S A 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Date: �c�(4 N,Q Sewage Permit# Assessor's Map/Parcel W-3 (0 0 Installer& Designer Certification Form Designer: h Halo. -, P,nAv C Si,,l G­ni • Installer: Address: Pb LK 2-o3 o Address: p® ZC)x 3 7/ On OQ I t f;;?o I l �� � s��rc , was issued a permit to install a date) (installer) septic system at to Ntarirey' �r�l�f h�v,�- based on a design drawn by (address) 'a. o n o dated 0)J'I 1 (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. Stripout (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. Stripout (if required).. ected and the soils were found satisfactory. �N of 4( LINDAJ. „ PINT ( staller's Signature) V L 4 • 9�'rSFG/sTEA (Designers ignature) (Affix Des p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.s gAoffice formsWesignercertification form.doc '14 ' kfl I.;0 % t" 4 -J-j I 4j, v Aj e 1; ci c I i: VI:joorl; oj 1"Ali'l 1; LAY;,,; Nf) 1,11"'IA i1i; Vll-A�4,, jell ljl; f ?n a i . ti f,j, I`:" :�l It 1C, iwnoil 10-j o ler rl %I J4 AG V!j PR e-3) 'J I 2i fl 14 i Town of Barnstable P# j $ Department of Regulatory Services e Public Health Division a� Date 200 Main Street,Hyannis MA 02601 Date Scheduled ( rr Time l Fee Pd. f pv Soil Suitability Assessment or S Disposal f ewage Di Performed By: Witnessed By: v\ W. - T kl LOCATION& GENERAL INFO Ct' ItTION Location Address r p _ NIA ` Owner's Name �M (.t7 Cc 2 Address Assessor's Map/Parcel: Z 7 ^ / O eJ - (D Engineer's Name �� NEW CONSTRU � rmmf!!� Telephone# S© -7 3-7-1 Land Use Slopes o Surface Stones Distances from: � Open Water Body�_ft Possible Wet Area 1 _NJL ft Drinking Water Well _jN I A ft Drainage Way ` ft Property Line -- O __ T, ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test hole s&perc tests,locate wetlands in proximity to holes) �•tST t^j ri— 13�rM Parent material(geologic) C 1 aciA,( wkjzc S� I Depth to Bedrock 7 a �O Depth to Groundwater. Standing Water in Hole: I V 1, Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: ln, Depth to loll mottles:Depth to weeping from side of obs.hole: in, Groundwatertosoil mottleAdjuss: ft Index Well# Reading Date: Index Well levCI—�— Ad,t 1 AdJ,Groundwater Level Observation PERCOLATION TEST Dol,p _ Thne,.r� Hole# Time at 4" — —— Depth of Perc tI ' Time at 6" Start Pre-soak Time @ ;�0 Time(V-0) End Pre-soak 0, Rate MinAnch L�mlv(tnC�t Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division 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 Conservation Division at least one (1)week prior to beginning. Q:\.SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole#-- -- Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottling (Structure.,Stones,Boulder;. ' o i teny;y.96 Gravell 2�-S - M.LS 1-0 IV S- g K LS ,o • R- Sk tI 3)— C, C Spec lD ale Depth from DEEP OBSERVATION HOLE LOG Hole# Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. b —3 �3�z fnsi en 11 ravel � , iQ ` N� lDj 4/I tt �/L lit - 13 z C, C S aid 0 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Mu Mottling (Structure,Stones,Boulders. Consistency.%G, e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Co si ten 1 ,t Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No _ Yes Within 100 year flood boundary No. Yes_ Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervio s material exist in all areas observed throughout the area proposed for the soil absorption system? eS If not,what is the depth of naturally occurring pervious material? Certification I certify that on ov (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trai ing,expertise and experience described in 310 CMR 15.017. . Signature Date-=�� Q:WEPTICIPERCFORM.DOC 1 �Z 2313 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM • PART A CERTIFICATION MAP �2:3 Property Address: PC) "Pu crep— &&r Owner's Name:_�/►�� Cam— IF F- u/ Owner's Address: Date of Inspection: - R.ECEI\JE® �r— Name of Inspector:(please print) AUG 0 4 2004 Company Name: Mailing Address:�a 04k 51"?-EE7' TOWN OF BARNSTABLE jy„ �c�iJ3ri4�LE rr/� p � HEALTH iDEPT. Telephone Number: S�� yzvT ZvSo CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �,h Date: �o O The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 d/k, F Owner: it Date of Inspection: c Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: k I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 AIAP-11�tp— ei'e: Owner: FTIA! Date of Inspection:— C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: T Cesspool or privy is within 50 feet of a surface water - T Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) t. Property Address: 20 M19eweko, elk. Owner: (- Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No C Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped T Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. -X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply T the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 000 G Date of Ins ecti n: Check if the following have been done.You must indicates s"or"no"as to each of the following: Yes No /j Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? lC _ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? k _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) �L T Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? )C _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. _ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ go Awi/vIu- &AEi Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3y Number of current residents: 9- Does residence have a garbage grinder(yes or no): A)O Is laundry on a separate sewage system(yes or no): KZ[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): /UO Water meter readings,if available(last 2 years usage(gpd)): 1000 Sump pump(yes or no): 1UU Last date of occupancy: E i COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part o the inspection(yes or no): 0 If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,4ate installed(if known)and source of information: 6/UP4R /?. Tb kP'T, Were sewage odors detected when arriving at the site(yes or no): A)O Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 A) 4 <�Ioe; Owner: ,A1 Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: I2 Material of construction:-> concrete_metal_fiberglass polyethylene `other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): __(attach a copy of certificate) Dimensions: 8,4"L Sludge depth: tl" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: �5'" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 1"4q'5;'Wd.E- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,,evidence of leakage,etc.): 5-No el kooE L14C P4601,0 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:�. �� 1�1 Q IAXR_ �a2 �t C Owner: rs21F�iA. Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:4(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakag in o or out of box,etc.): A T u%D/ Ci•(1 Cs Lei)P-C, 14 'l _j//KE Di= IA)qeer o� PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): O00 0,1.d UAC,,q to, a_ TDrt1C .2Q k &"U-%, 494eH P/r sir C_ > FJ /.vS C?r/ZA3 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Cie-,t � Owner: r—,91PF111fi Date of Inspection: ZZ4Z& SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. "A(Z I 86 -35 - pts e ' 9 � A '� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9D (fi2 Owner: G'—,/ IFFIAJ _ Date of Inspection: D SITE EXAM Slope �' j SANS Surface water Check cellar /`►,I AJ. %q Q_ Shallow wells Estimated depth to ground water 10.E feet �A Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I CommonweM of Massachusetts Executive Office of ErMonmentai Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 ' Envfronmental Protection 02536 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PO PART A CERTIFICATION Property Address: 80 Mariner Circle Cotuit Address of Owner: �O�plge� Date of Inspection:M7197 (If different) C► Name of Inspector:John Graci Mr&Mrs.Thomas Daley Company Name,Address and Telephone Number: d CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection Is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Need/bmit her aluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does not Imply any warranty or quarantee of the longevity of the Fails septic system and any or its components useful life. Inspector's Signature: Date: 5112197 The System Inspector shall sa copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as 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 completion of the replacement or repair,passes inspection. 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,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 11115/95) One Winter Street 9 Boston,Massachusetts 02108 9 FAX(617)556-1049 9 Telephone(617)292-5500 1 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Mariner Circle Cotult Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 FUNCTIONING 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 of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 lank 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 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 in 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 cesspool. — SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Mariner Circle Cotult Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 D] SYSTEM FAILS(continued) 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). Numbers of times pumped 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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 large systems in addition to the criteria: The system serves a facility with a design flow of 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. (revised 11115/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 80 Mariner Circle Cotult Owner: Mr&Mrs.Thomas Daley Date of Inspection:5/7197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. NaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X 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. X 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. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 80 Manner Circle Cotult Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 gallons Number of bedrooms: 2 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yes Water meter readings,if available: nla Last date of occupancy: ►1a COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nla Last date of occupancy:_!La OTHER:(Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection:(yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: nla TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1080 Sewage odors detected when arriving at the site:(yes or no) No (revised 1 U15195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Mariner Circle Cotult Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'6'H 5'7"W 4'10' Sludge depth:4' Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 0 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.) The septic tank and all components are structurally sound Recommend pumping the system every two years for maintenance. GREASE TRAP: (locate on,site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: nfa Scum thickness:n►a Distance from top of scum to top of outlet tee or baffle:nfa Distance from bottom of scum to bottom of outlet tee or baffle:nla 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.) nla (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8o Mariner circle Cotuit Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete_metal_FRP_other(explain) Dimensions: rya Capacity: n►a gallons Design flow: n►a gallons/day Alarm level: n/a Comments: (condition of inlet tee,condition of alarm and float switches, etc.) rVa DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) D-box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) Na (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Mariner Circle Cotuit Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: nla Type: leaching pits,number: 1,000 gallon leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflow was empty at the time of the inspection It is structurally sound It has not had more than 1'of water in It CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to Inlet invert: nla Depth of solids layer: n1a Depth of scum layer: n/a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: nfa nla 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.) n1a PRIVY: (locate on site plan) Materials of construction: n1a Depth of solids: rda Dimensions: n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a (revised 11115195) 8 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Mariner Circle Cotuk Owner: Mr&Mrs.Thomas Daley Date of Inspection:517197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �,c g r � All 9y DEPTH TO GROUNDWATER Depth to groundwater: 12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 No........... .......... Fss..s. . ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Applira#ion for Uhip sal Works Tonstrnr#iun Vamit 4 Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: ... `-s ....... ...���� -.. .................. ... --.......------......--................. o . L Addr o.........• ........ g . ----•----•-----^......................... ..._. O ner Address a = ... / ..... � _.......... a --....--•-•-•............................................. ....._.. � Installer Address Type of Building Size Lot.. Q.aQA2.....Sq. feet Dwelling—No. of Bedrooms__.....•. ,...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ��f _.. No. of persons..........'9.............. Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------••----•-----------•----------•------••-•-•----------•----............................................................ W Design Flow-.-_-:).- ...........................gallons per person per dray. Total daily �y flow ...........................gallons. W Septic Tank . capacity) gallons Length..�`.�.._. Width....9/_Z..... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....._..............sq. ft. Seepage Pit No........../..-...... Diameter........._._.._. Depth below inlet..7." ........ Total leaching area..'.5p6--4 t. Z Other Distribution box ( r) Dosing yt�j k ( ) ~" Percolation Test Results Performed by....1.4 !�' �� '.: r __________________ Date.../ _�/_e __._.___.______.... ` i' Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....- ...!. ....__. rT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........... ........ P4 ................. •• ............................•-•-•-•--••----•--•--....-......................................................... Description of Soil..... . '__ �!.. t� �' •--------•-------------C�....3.0-•-------= . V ------------- -------3 :r 407 .........h"L .• . .......c --------------------------...------------------------------------------....-----.............-----------.........--- 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 iIm E 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 board of health. f d.. ' ��. !..e '---=��---•.......................... .1110V2 ....... Application Approved B .....•/�WLSX -- .-...... ----------------------- --•---- IePP PP Y � �� Date Application Disapproved for the following reasons:-------•-----------------------------------------------•-----------•........................................... ..............•-----...........------........--------------•--......................----------------.._..._..•••-•---•-------- -------•-•••-•-••- •-----•••••-••--••----••-------•-•-------------- ^ Date Issued Permit No........•....................•--••---•---•••............. -�--...--- ..•---•-.....------•----....•.. Dattee No........................ Fx$.. !r�............ THE COMMONWEALTH OF.MASSACHUSETTS r BOARD OF HEALTH Applira#ion fox Dispao al Works Toni#rurtion Prrutit Application is hereby made for a Permit to Construct (.1) or Repair ( ) an Individual Sewage Disposal System at: .L. Addres�- orr ho.......--'.....-. ' ..........- Address a ✓�j2.f.'t./1 ./_.�) _.-•.......................•........ ......••.••----•----•----.........------...........--•--....................................... Installer Address Type of Building Size Lot..�G/LQn�2.....Sq. feet Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( ) Pk —Type g . ................. ----- No. of persons.........--.--.............. Showers ( ) — Cafeteria ( ) Other—T e of Building �s-t� �- � A4Other fixtures ....................••--•--------------........•--•--..-•--------•----••----•--........._.........----.....--••-•------........••-•--.....----•--•---- W Design Flow.... .. ................................gallons per person per day: Total daily flow...=�__ _n............._.._... ._._..gallons. W Septic Tank—Liquid'capacityl.�jY�.gallons Length..,X.`!?A_ Width..: �1..... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........,/......... Diameter...../....-_..... Depth below inlet_.2'.1........ Total leaching area---.,,STt_:.'` Ss 01(. Z Other Distribution box (/) Dosing tank ( ) Percolation Test`Results Performed by.....G9..`..�w-_-. . 1LdG�°1 ............. Date..Z)Ve .._........_.::._-. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water._--- -_ .-----. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...° ``_....... Q+' ......•-----•-•--•••--••--•••.....•-•...................•----..........-•-••••••-•••--...........••-----•--........--••-•--•--•-•----.........•---- O Description of Soil....C? .. .. � !4"4' `�- x - v �� -• ------------------------------------------------------------------------------------•-•----•---.....------...... ......... ........................:: 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 IT E, 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 a bo r health. S' n6e . ---------•-•--......•--.....•................... 60../ at Application Approved B Date Application Disapproved for the following reasons:-------•-- ----------•--------•----•----•-•-----•------•----••---------------•-•---••-----•-•----.....----•-. -•...........................................•-------••-......_..-•-•-----'--.........__............-----...............................---'�.• ----- - ............. ...---•------- Date PermitNo......................................................... Issued--- . -z------ ---------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............O F....... .............. '-�''. t...�............ ...........:........................... TntifirFate of Tompliantr TIfIS IS TO E TIF,Y, That the Individual Sewage Disposal System constructed ( <) or Repaired ( ) by..... ? ... ) -cuv� ,.r -----------------------------------------------------------------------------•---------........-----••--•-----...... Installef d �" `<` �' C..mt. r�.....C% r. has been installed in accordance with the provisions of T C 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 WILJL FUNCTION "SATISFACTORY. DATE......... ...--••--•...........................•--...._......--•---•--------._.. Inspector--•-� - ........ ......... . ..��t... .- ----.r••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF....... ....................... ........... .... No......................... FEE.- ---' DiopooPork oat - fit ' n rutit Permission is hereby granted =c. a_..- a.•-••--•--...--•••-•.................................................... to Construct ()e) or Repair ( ) an Individual Sewage Disposal ystem at No. «.r_ n ,c . •. . •..••.. ..-- -------------------------•--....•--••-........ X 0 /Ids �� v - _1_.......G�i` l street as shown on the application for Disposal Works Construction Per it ....Z Dated...... ................................ G Board of Health DATE.......I-------------------•••--'............................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t LOCATION SEWAGE PERMIT NO. VILLAGE _ 6�63� INls A LLER' NAME i ADDRESS S, ` UIrLDE R OR OWNS DATE PERMIT ISSUED l_ Z _ DATE COMPLIANCE ISSUED � _ f 3g no 33 �3 TOP OF FOUNDATION 24'd1ameter concrete covers TWO 0 5HOREYPRECA5T 500 COTU IT, fL=50.G raised to mthm 6"of fimsh grade GALLON LEACH CHAMBERS W/TH 3' MA (or as noted) OF 5TONE ALL AROUND Existing EL=49.7+ EL=49.B+ EL-49.9(max) 23.0' r.A cj cn o��i3 2 �at�et �c 48.2+ t o o Existing 47.Bt 46.9±- m e�(. I; o v ar 6EOTEXTILE FABRIC 7 h� (/N PLACE OF//4"-//2"PEA5TONE) o 0 0 cn pad Existm 47.0+ S g 46.7�- 46.50 _ 46.33 Ewstm9 O Existm N 46.20 ni ni 3/4"- /-//2°STONE 9 D-BOX Proposed LOCU5 Gas Baffle • _�.... ., . a. _ _ PLAN VI EW //'+� }-- /B' L /3' 44.20 TWO 0 5HOREYPRECA$T 500 5.4"t Existing Longest Run GALLON LEACH CHAMBER$ W/TH " DB-6 SCALE: I = 10' D(15T/1V6 /000 GALLON (H-20 Rated) 3'OF 5TOIVE ALL AROU/VD (END VIEW) EL=3B.Bt Bottom of Test Ho% SITE LOC U S 5EPTIC TANK o-BOX LEACh Parcel G7 NOT TO SCALE FLOW ROf I LE CHAMOfR,5 Town Water Parcel 56 Town Water I I ,) Assessors Map023 Parcel OGO NOT TO SCALE 1 25.00' 2.) Deed Book 1 299G Page GG p 3.) This property Is in a Zone II of a Public Water CON 5T RUCTION N OTE� 5upply and a Town Designated Wellhead LOT 118 �O Protection District 1.)ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 5Y5TE M D E51 G N CALCULATIONS Area=20,000 5.F.-t 51.3 4.) Flood Zone: .C CMR 1 5.000): STANDARD REQUIREMENTS FOR THE SITING,CONSTRUCTION, INSPECTION, UPGRADE, AND EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT AND DISPOSAL OF SEPTAGE,AND THE SEWAGE DE51GN FLOW REQU/RED:2 BEDROOM DWELL/NC(WITH DEED RESTR/CT/ON) LOCAL BOARD OF HEALTH REGULATIONS. (J //0 GPD/BEDROOM=220 GPD REQUIRED LEGEND Wooded / 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS SEWAGE DES/GN FLOW PROVIDED: TWO(2)500 GALLON LEACH CHAMBERS WITH Area POTENTIAL FOR VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE 3'OF57OVEALL AROUND 2.3 EXISTING SPOT GRADE DESIGNED TO WITHSTAND AN H-20 LOADING. IF UNDER AN IMPERVIOUS SURFACE, I me 24x5 PROPOSED SPOT GRADE SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. Vt=/(23.0x /0.63) +2(23.0 t /0.83)x 21x.74 30.2 1 2"Pine =264.5 CPO PROVIDED / h -- 4 EX15TING CONTOUR 3.)TO MINIMIZE UNEVEN SETTLING, ALL SYSTEM COMPONENTS SHALL BE INSTALLED / 24- PROP05ED CONTOUR ON A STABLE MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. 264 GPD PROVIDED>220 GPD REQUIRED 7P-1 w WATER SERVICE LINE 4.)COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK,THE SEPTIC TANK CAPACITY REQUIRED: 220 GPDX20096 =440 GPD REQU/RED v , 0 S OVERHEAD UTILITY LINE DISTRIBUTION BOX, AND THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 0 18"Oak , , G GA5 SERVICE LINE G"OF FINAL GRADE. LEACHING FIELDS,TRENCHES, AND OTHER SOIL ABSORPTION SEPTIC TANK CAPACITYPKOV/DED: EXISTING /000 GALLON PROVIDED O"Pme Proposed SAS EDGE OF CLEARING SYSTEMS WITHOUT ACCESS MANHOLES SHALL HAVE AT LEAST ONE(I)INSPECTION (See Plan View) FENCE � �,. -0--o---o- PORT CON51STING OF PERFORATED 4"PVC PIPE PLACED VERTICALLY TO THE BOTTOM A GARBAGED/5PO5AL 15 NOT PERMITTED WITH TH15 DESIGN FLOW 7P OF THE SOIL ABSORPTION SYSTEM WITH A CAP,TIED WITH MAGNETIC MARKING TAPE, aU 8" Maple TEST HOLE LOCATION ACCESSIBLE TO WITHIN 3"OF FINAL GRADE. 8"Pine Pine G"Oa � ST SEPTIC TANK 5.)PIPING SHALL CONSIST OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE 1 G"Oak 2O m�a 32.0' DB D15TRIBUTION BOX O 2 Parcel G I SAS 501L ABSORPTION SYSTEM LAID ON A MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2%FROM THE BUILDING � Existing Septic Components to 2 TO THE SEPTIC TANK, AND NOT LESS THAN I%OTHERWISE. be Abandoned(see Note#20) �„ I DB Towne Water. ® WATER GATE ' 4 , G.)DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4"DIAMETER I `p SCHEDULE 40 PVC(OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. Block I N Existing Septic Tank to LINES SHALL BE CAPPED AT END OR AS NOTED. be oundatio 1 N Utdrzed(See Note#1 9) I =%9 11 7.)LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO(2)FEET b I O 4` F, O Family BEFORE PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE O WATER TESTED TO ASSURE EVEN DISTRIBUTION. C0 8.)GROUT TO B AT E USED ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE I CERTIFY THAT I AM CURRENTLY APPROVED BY THE STRUCTURES IN ORDER AT PROVIDE A WATERTIGHT SEAL DEPARTMENT OF ENVIRONMENTAL PROTECTION PURSUANT TO Existing 2 Bedroom Dwelling '--O--O- Kitchen Bth 310 CMR 15.017 TO CONDUCT SOIL EVALUATIONS AND THAT Parcel 59 Top of Foundation EL=50.G± Bdrm 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE THE ABOVE ANALYSIS HAS BEEN PERFORMED BY ME / BENCHMARK SEWAGE DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND Town Water 0 Top Back Corner Concrete Garage EXPERIENCE DESCRIBED IN 310 CMR 15.017. 1 FURTHER EL=50.00(Assumed Datum) Livm 10.) IN ACCORDANCE WITH 3 10 CMR 15.22 1, ALL SYSTEM COMPONENTS SHALL BE CERTIFY THAT THE RESULTS OF MY SOIL EVALUATION AS a g Bdrm MARKED WITH MAGNETIC MARKING TAPE. INDICATED ON THE ATTACHED SOIL EVALUATION FORM, ARE ACCURATE AND IN ACCORDANCE WITH 310 CMR I5.100 AQ Bth 1 1.)THERE ARE NO KNOWN WELLS WITHIN 100-OF THE PROPOSED SOIL ABSORPTION THROUGH 15.107 0 4 SYSTEM. I I ZN OF tiGgs, '' % FLOOR PLAN 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL 6' LINDA J. RECEIPT OF THE CERTIFICATE OF COMPLIANCE,THE PERIMETER SHALL BE STAKED AND v 1 i Q4`" a p)V� NOT TO SCALE LA FGGED TO PREVENT USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. O iu c� tt Linda Into, Certif d 5oil Evaluator ,46 U J. 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN 4_ I f �o�0/cC p d �4 a rsre ��► Survey Mork by.*WRITING BY THE DESIGNER. TE HST I 1 O LE LOGS 0 A I � �Sst�"A� 14.)THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN A & H Land SerWceS AGENT OF THE BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE Test Hole#I (EL=49.9±) P#13!89 -0 125.00' 818 Route 2B, .S'u1t6 9 I WITH THE TERMS OF THE PERMIT AND THE APPROVED PLANS. 48 HOURS ADVANCE l 37-ffiest 77JbYazwo11tl, anJIA 026I'S NOTICE IS REQUESTED. Depth Layer Sod Class Sod Color Comments , Ph. (5A9) y37 17'7'?' Siaeil.• aamlaad�comcest.aet 15.)LOCATION OF UTILITIES 15 APPROXIMATE AND CONTRACTOR SHALL BE 0" 2" A Medium Loamy Sand I OYR 3/2 Prepared for: RESPONSIBLE FOR DETERMINING THE LOCATION OF ALL UNDERGROUND AND 2"-5" E Medium Loamy Sand I OYR 4/I Mariner C 1 rc I e OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT 5" 18" B Medium Loamy Sand I OYR 5/G IS NOT LIMITED TO, REQUESTS TO DIGSAFE, ANY PRIVATE UTILITY COMPANIES,AND 18"-1 32" C I Coarse Sand I OYR GIG Perc @ 58" , Amy Griffin THE LOCAL WATER DEPARTMENT. (40' Wide) 80 Mariners Circle, Cotuit, MA 02G35 I G.)CONTRACTOR SHALL VERIFY THAT ALL WA5TEUNE5 ARE CONNECTED BY WATER Test Hole#1 (EL=49.8±) PI"Op05ed Jewacje D15p05al 5y5tem TESTING WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENT5. 80 Mariner5 Circle, COtUIt, MA 17.)CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO Depth Layer Sod Class Sod Color Comments INSTALLATION OF ANY SEPTIC SYSTEM COMPONENTS. 0"-3" A Medium Loamy Sand I OYR 3/2 Prepared by: 18.) INSTRUMENT SURVEY CONDUCTED FOR PROPOSED WORK ONLY. SITE PLAN 3"-5" E Medium Loamy Sand I OYR 4/1 51 TE PLAN SHALL NOT BE USED FOR STAKING, OR ANY OTHER PURPOSES. 5"-19" B Medium Loamy Sand I OYR 5/G 19"-132" Cl Coarse Sand I OYR GIG /�wr�r 19.)EXISTING 1000 GALLON SEPTIC TANK TO BE UTILIZED. PVC TEES TO BE SCALE: (" = 2O' 4.►�i1Y �1A, INSTALLED ON INLET AND OUTLET PIPES IF NECESSARY, AND A GAS BAFFLE INSTALLED /��•V IN THE OUTLET TEE. DATE OF TESTING: 02/03/1 1 Wip Engineering 20.)EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLJ D WITH SOIL EVALUATOR: LINDA J. PINTO, P.E., CSN ENGINEERINGBOARD OF HEALTH AGENT: DAVID STANTON, BARNSTABLE HEALTH DEPARTMENT INSPECTION NOTE: O 20 40 GO CLEAN SAND AND ABANDONED IN PLACE. AREA TO BE COMPACTED TO MINIMIZE PERCOLATION RATE: LESS THAN 2 MIN/INCH IN"C I"LAYER P.O.Box2030 Phone:(508)299-3250 SETTLING. PRIOR TO FINAL INSPECTION BY THE ENGINEER,SYSTEM Teaticket,MA 02536 Fax:(508)548-5478 NO GROUNDWATER ENCOUNTERED NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. SCALE 1"=20' C:\CSMRR-Marmers\RR-Mariners-SOS Plan.dwg Date:02/01/1 1 1 5cale:As 5hown I By: LJP I Check:MA I Project No.C5NO145 l•.n : / f J h - c plT.A o yn s tjV.= f0 ' , Y2 FINISH GRADE .w..,+.... f 1N1.$H gRAO£ �_ f It1LSti GRAD£ ' 31 1 OCf>l OVER TASK- OVER. PIT A CHIMNEY �9VOCK . wHrR NEo�o SACKFII-L 3" PEAS TONE 4 C.I 4 V.C. 4 V.CJ/ i (op7C Q o 0 O O O O +� OOG3 �Ixo • • ' 40 re' o• O O Q O O • # . 3✓4" TO 1-1/2,� 1 GAt,LC+�I j�` ! ' a O O O v e CRUSHED STONE RE114FORCED GONG. a ° o 0 Q O o 4 d p • -• � '." p' 0 4 ♦• • ► • .. 15T• Box Y 9 �� O O V O a �` '0 • v ° 40 O O O © o �' o cc �+ ..� - .., (TO BE LEVEL p o ' o n O O o P ° BOTTOM OF PIT �7 P��V TA c a O O o . ° J Q ELEV. = _ 5 w..w.A AND STABLE) %' r SYSTEM PROFILE ( NOT'TO SCALE) LEACHING PIT - Q E�I GN CRITERIA L n t�.Um9E'R OF BEDROOMS , PER OA ° 1aFceasrc GRINDER = �o•u � t� Af. RALLY FLOW - .�_ ..:Y S� G. ' ,(//j/ zzb 11/ �• LEACHINS-AREA PR0Vf X0l■ _-__ !5Q5 32c> S-11t;,?1 Ws.l..L. v4.1,t .• •Q Ii�f�t4 x1,''�& Z.•'S �d-'".5��►DD I -"9'`rG nit �•.>�.1�1.�.. 1T C4� � � $� 4 � �� r� •� -moo. • '� LrfA� Nfui_c.N r�4 1 I ► I -* P II T H l tJCi .-+ PLAO PROPOSED SEWAGE F DISPOSAL. SYSTEM R N Of IWAO% r,r', '.� � V PROPOSED D�A/EL�..I Al G !1$SF�E+TED 916 NORMAti _ ,�� �..{oss►�A^+ u P�I ��R,I_ C�a? ) NSASS Dl!►'T .�l.�k4..i.�1w,-.. �� �..'�'7*; ZUs._.+t .� t 121 U'� ' - -- ---'---------. L? SCALE AS NOTED DATE Ta Ec 11 1 1:' PE 00%.AT I ON RATE MIMj/MMGN____ ;ti-TES �• + t t r` ire, OW1U D BY '5"owvA O►D ��) -TuR>G 166'7 �HF_F_-T`� Xlo , G�- Gi~F�.T PO"rD r..J�:.t+J� j �, � �J�C I�"r ��,�, .•x,. Sr•�XCs NORMAd GROSSMAN PE, R L S. poop, ����� � ��x_a 226 HOi_LY POINT ROAD ? CENTERVILLE, MASS. f -