HomeMy WebLinkAbout0375 MARINER CIRCLE - Health 375 MARINER'S CIRCLE, COTUIT
A= 024 028.002
III
�.I
TOWN OF BARNSTABLE
LOCATION ),5 C-r(,r-U C,�e- SEWAGE# D 6 J U
VILAGE ASSESSOR'S MAP&PARCEL
.INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Q V C3 QX
-. LEACHING FACILITY.(type) t A:: Rmk6 i ize w 3
NO.OF BEDROOMS /0 10
OWNER
PERMIT DATE: 110 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching FacilityNA Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) NAFeet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
A-9 ,20
r 27
� a 31Oa�x
® f 3 Sig
eA
- ; f J
No. go
v+R o Fee
THE COMMONWEALTH OF MARSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[pplication for Migogar by.5tem Construction Permit
Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �7 S Gr C C c G� Owner's Name,Address and Tel.No.
co�;,t 1r1t,.r y O S 4.c��y e�3 e ar
Assessor's Map/Parcel S �-
0;)4 — 3 �2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
S c.o k' S-kc k"t \, �ti S
Type of Building:
Dwelling No.of Bedrooms�_ Lot Size sq.ft. Garbage Grinder((Vd
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow Z y 0 gallons.
Plan Date _ .j nR a--)J`of v Number of sheets Revision Date
Title
Size of Septic Tank 2>c`�S�:�. hZSC Type of S.A.S.
Description of Soil f�C��� C o c r���..��) �1 t't K ?.Y f L ft j X /a r�
Nature of Repairs or Alterations(Answer when applicable) �y !► ���,c.`7«�Ur�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of'Compliance has been issued by this Board of Health.
Signed Date
Application Approved by ` Date _a
Application Disapproved for the followQg reasons
Permit No. r9 0 10 . 110 Date Issued
No. Fee. 00
�t THE COMMONWEALTH F MASSACHUSETTS Entered in computer:
k. .,+�. _._,.,� Yes
PUBLIC HEALTH DIVISION - TOWN OF'BARNSTABLE, MASSACHUSETTS s
2pprication for Mizponl *p5tem Construction Permit
Application for a Permit to Construct( )Repair( ,yiJpgrade( )Abandon( ) [I Complete System ❑Individual Components
Location Address or Lot No. ✓ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Co��'c
S
Installer's Name,Ad ress,_and Te.No. Designer's Name,Address and Tel.No.
Type of Building: �4, S Mc,
Dwelling No.of Bedrooms Z3 Lot Size sq.ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Ca Wet ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow Zr-1 gallons.
Plan Date `` Number of sheets Revision Date
Title v
Size of Septic Tank �4 Type of S.A.S. - �c.�(x :J
Description of Soil i
Nature of Repairs or Alterations(Answer when applicable)
r
Date.last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date w
Application Approved by Date 4
Application Disapproved for the o low' reasons
Permit No. n o Io - 1°o Date Issued OkFr'
------------------------------- ——— '-----
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(V11)Upgraded( )
Abandoned( )by e �(
at � -v has been constructed in accordance
with the provisions of Tie and-Vie for Disposal System Construction Permit No..d alb Re dated 6-9k I J
Installer Designer
The issuance o t s permit s l�be construed as a guarantee that the sy a ill unct on as esigned.
Date 1 , Inspector
-
/—p.--
No. 6 —610
t1d Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mioogal 6potem Construction Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: 1 /) Approved by
f
Town, of Barnstable
SME 1p�
o Regulatory Services
�nxrisrAa� Thomas F.Geiler, Director
9 'K"9.
gg i6 . Public Health Division
�pl A1�� e
FD MA'S "
Thomas McKea
n,Director
200.Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 133 Ib Sewage Permit# ���^ Assessor's Ma \Parcel a
n ay -c�a� o o
Designer:g I&TEP FE4�1
A 1 ?PE Installer: SCcrTr- q. FQ_.A,►r)t—
E A4 C-E
Address: g2_3 p.�Z e,,A Address: W5 CL'b 1eA9_ e6-t7nt
YA-P 4crr.>7r+Fb9-, HA- vU;7j HYA-u1-.,(S, MA. 6260 t
On t..(, was issued a permit to install a
(date) (installer) z
septic system at based on a design drawn by
(address)
S K P Hb� A. 14AAsij, 6- dated.
(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.
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.
Gtqqp j���Lq�,qq �Af,
(Installer's Signature)
ARL
(Designer's Signature) (Affix Designer's Stamp 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.
Q:\Septic\Designer Certification Form Revised.doc
TRANS. NO.:
CITY/TOWN: �?7���
APPLICANT: &6 -AVM
ADDRESS: 371�' 1414--.44 .V6✓— LeXe 0_ 4
DESIGN FLOW: gpd
REVIEWED BY: DATE: Cv Z8 Zo l V
r
N/A OK NO
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)]
Locus Provided [310 CMR 15.2204(t)] ✓
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)] ✓
System located totally on lot served [310 CMR 15.405(l)(a) for
upgrades]- if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas etc.)
1310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)]
Location and dimensions of system components and reserve areas.
[310 CMR 15.220(4)(e)] ✓
System Calculations [310 CMR 15.220(4)(0]
daily flow ✓
septic tank capacity(required and provided)
soil absorption system (required and provided) ✓
whether system designed for garbage grinder ✓
North arrow [310 CMR 15.220(4)(g)] ,✓
Existing and proposed contours [310 CMR 15.220(4)(g)] ✓
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)]
Location and date of percolation tests (performed at proper f
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? [310 CMR 15.242] ✓
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] ✓
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)] `
Address GZ�{ ° !�2€ °��2 Sheet 1 of 7
f
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220(4)(k)]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case ✓
within 150 feet of the proposed system location in the case
of private water supply wells
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)]
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.21l(1)[1])
Profile of system showing invert elevations of all system
components and the bottom of the SAS [310 CMR 15.220(4)(o)]
Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor (required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
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)]
Test hole adequate to demonstrate four feet of f suitable material?
1310 CMR 15.103(4)].
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103(3)]
Benchmark within 50-75' of system [310 CMR 15.220(4)(q)]
Materials specifications noted? [various sections of 310 CMR
15.000]
System components not>36" deep (unless Local Upgrade
Approval or LUA requested) [310 CMR 15.405(1(b)]
l
Address 00• C>28.00 2 Sheet 2 of 7
r
N/A OK NO
Size OK? [310 CMR 15.223(1)]
Inlet tee located ten inches below flow line [310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter[310 CMR 15.227(4)] t/
Note regarding installation on stable compacted base [310 CMR
15.228(1)]
Separation between inlet and outlet tees (no less than liquid /
depth) [310 CMR 15.227(2)]
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)]
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)]
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" (by 7/07) [310 CMR 15.228(2)]
Access to within 6 " of grade - one port for systems<1000gpd,
two for systems>1000 gpd [310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)]
> 10 ft from building foundation [310 CMR 15.211(1)]
Buoyancy calculation Required/Done [310 CMR 15.221(8)]
H-20 Where appropriate? [310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
Required when other than single-family dwelling or flow>1000
gpd [310 CMR 15.223(1)(b)]
First compartment 200% daily flow; Second compartment 100%
daily flow [310 CMR 15.224(2) and(3)]
"U" pipe through or over baffle, outlet of each compartment with
gas baffle or approved filter [310 CMR 15.224(4)]
Address_ O 2q C2s?• no L_ Sheet 3 of 7
N/A OK NO
Located at least ten feet from any water line? [310 CMR
15.222(2)]
Disposal piping at least 18" below water line(when water and
sewer cross, see 310 CMR 15.211(1)[1])
Cleanouts required/provided ? [310 CMR 15.222(8)] ✓
Thrust blocks specified in force mains? 310 CNM 15.221(6)(c)] ✓
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)]
Siphon problerri/(leachfield below pump chamber)
Endcaps or vent manifold specified?
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)]
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed)
YDISTKIB'U'.TIO£� by OX ��,L^,*r����������� _�f4✓SY.sJ 7 rv<.,` A f y�;. $��f�',"��,�vf�� �� 7c ,,�-;M Y`rzS'pc�9�'.�E� 1 j
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)]
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310 t/
CMR 15.323(3)(a)]
Riser if deeper than 9" [310 CMR 15.232(3)(f)]
Inside minimum dimension 12" [310 CMR 15.232(2)(b)]
Minimum sump 6" [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd);waterproof manhole if>2000gpd ,, /
[310 CMR 15.232(3)(d)] V
R � ��d��,xNMI� _�
-�r..�s��'�..�aa.3�,.v1
Capacity(emergency storage above working--design flow)? [310 /
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as.septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible)
Alarm floats - alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6)and(8)]
Stable Compacted Base [310 CMR 15.221(2)]
Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)]
Address b Zq• 0 2 e - 60 2— Sheet 4 of 7
N
N/A OK NO
ONS �S EMS 5ag
� .GFjL w� �
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(1)]
Required separation to groundwater? [310 CMR 15.212)] ✓
Aggregate specified as double washed [310 CMR 15.247(2)] ✓
System Venting required/provided? (system under driveway or ✓
>36" deep) [310 CMR 15.241]
Inspection ports specified and within 3"final grade? [310 CMR ✓
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310_CMR 15.211(1)[4] and
Guidance Document]
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]Each structure with one inspection manhole(if>2000 gpd must
be to grade) [310 CMR 15.253(2)]
Aggregate 1'minimum-4'.maximum. [310 CMR 15.253(1)(b)]
2' sidewall credit maximum [310 CMR 15.253(1)(a)]
In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)]
j g
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)]
100 feet-maximum length [310 CMR 15.251(1)(a)]
Minimum separation 2x effective depth or width whichever /
greater(3x if reserve between trenches) [310 CMR 25l(1)(d)] �/
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
n
minimum 2 distribution lines [310 CMR 15.252(2)(a)]
Maximum separation between lines 6' [310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6"minimum, 12"
maximum. [310 CMR 15.252(2)(g)]
Separation between beds 10'minimum: [310 CMR 15.252(2)(0]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address 0 2 0ZG ° 2 Sheet 5 of 7
N/A OK NO
Pressure Dosed System ? Provided pump and piping /
calculations as required [310 CMR 15.220(4)(r)] ✓
Pressure dosing required on all systems >2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system -make sure jet is directed as not to
scour soil interface [Guidance Document]
Inspections once per year(systems<2000 gpd) or quarterly /
(>2000gpd) good to note on plan [310 CMR 15.254(2)(d)]
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Impervious barrier and/or retaining wall ? [Guidance Document]'
Impervious barrier installation must be supervised by
designer [310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)]
Side slope not exceed 3:1 ? [310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2) and j
Guidance Document]
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 (2)(e)] d
v �.t✓'t" �'''p ,fir =�'�s+t° x a/' �4�"'-'��+,� '�'�.-Y.t, .-::� .k° S ° 'ram`s��-�� '�.'s'�.�"�y � `
Check DEP Approval.letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge ✓
to scour soil interface
AlteZ is
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applicant submitted a copy of a maintenance
Are the variances listed on the plan? [310 CMR 15.220
(4)(q)]
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414]
Address 4!�G?�,'. 66 Z Sheet 6 of 7
N/A OK NO
s� e�'a �-
NZtYOgB/1 .S'ensztiveAreClS.:€ �
OR
21
..�., _5m°{;k
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 v
310 CMR 15.216 also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)]
Xr Fes''+v. s s ' ,il: Y`sa✓1? ". ..! ,c�k t4D 'Ya tc u� t. s , 'E4?' -,3,r ,£s v,.�� .s "€ "',fops' -.Ml+�Ce��Q�Z
Pumping to septic tank ? [ 310 CMR 15.229]
Shared System [310 CMR 15.290]
I
Address b2`� ' b�$ �2Z Sheet 7 of 7
DEEP.OBSERVATION HOLE LOG Hole.#4iter
Depth from Soil Horizon Soil Texture Soil Color Soil
Surface(in.) (USDA) (Munsell Mottling (Structure,Stones;Boulders.
ito c % v I
DEEP OBSERVATION HOLE LOG Hole# 7-
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones,Boulders.
o si a % rav
� I � lv t✓� '�z
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistec
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture. Soil Color Soll Other
Surface(in.) (USDA) (Munsell Mottling (Structure,Stones,Boulders,
Consistency,
Flood Insurance Rate May:
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes.—
Within
100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas.observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?.
Certification / /
I certify that on T (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 train in ,ex rtise and experience described in 310 CMR 15.017.
Si nature Date
4 g
Q:\.SEPTICiPERCFORM.DOC
Town of Barnstable P# 3
Department of Regulatory Services
BAMSUBM _ Public Health Division Date S G 0
MAM
i639. 200 Main Street,Hyannis MA 02601
ArED MA'S�
Date Scheduled— (O v Time Fee Pd. b o
Soil Suitability Assessment for Sewa a AsP osal
Performed By: Witnessed By: ,/ J
LOCATION& GENERAL INFORMATION
Location Address 3� Owner's Name
Address
�,�� - az�- G� tc-
Assessor's Map/Parcel: a
r Engineer's Name
NEW CONSTRUCTION REPAIR C�
Telephone# 6 3
Land Use Dd,--X A L Slopes(%) Surface Stones Ny
Distances from: Open Water Body '— ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line �b¢ ft Other ft
i SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands fn proximity to holes)
77 r,�
C
I`J
C:j
r
-0 �
C
4V,��
�A AV-A u C-A Ct i.0 IL
Parent material(geologic) � 'f►S a°f Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face ��4
Estimated Seasonal High Groundwater Nf
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: r�l J�® ✓�� 1L �,
Depth Observed standing in obs.hole: __In. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in, Groundwater Ad)uatment ft.
Index Well# Reading Date: Index Well level— Adj,factor— Adj.Groundwater Uvel., a
PERCOLATION TEST Date Time�_�+t+.
Observation
Hole# Time at 9"
Depth of Pero q 6 Time at 6" .
Start Pre-soak Time @ �'dv Tima'(9"-6")
End Pre-soak
Rate Min✓Inch �Z
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 wi6in.100' of wetland,you must first notify the,
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:ISEPTICIPERCFORM.DOC
TOWN OF BARNSTABLE
LOCATION T,� C1 GZ c/e SEWAGE
VILLAGE C ./J%� � T ASSESSOR'S MAP & LOT 42�y-016-Do�
INSTALLER'S NAME & PHONE NO.Z-7]-G�C
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)/JECHST i// (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER4
BUILDER OR OWNER �� /Ji61 % Sli/✓/Jf/G�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 0
VARIANCE GRANTED: Yes No
�,�J �
� �' ( I
" ��
�t /��
/�\ � ".
��r��
1 '
No. ....1..... / Fln$.............................
THE COMMONWEALTH OF MASSACHUSETTS
- BOAR® OF HEALTH
3 ,fie p irFatijan for Uiipas al Works Towitrurtion F.amit -
V� Appl' on is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
Y
s . .a .! ............G.....o T
.?_
_______
Location-Address or Lot No.
yc C :S' !a 6 vCC y ----------- 11 i2 i�l E Y�-... ![ 4.L- ---------------------------------••---
� ' ]] �j ; Address
Installer Address
d Type of Building � Size Lot....LLZ..�......st icet
U Dwelling—No. of Bedrooms..........................4_.._..........Expansion Attic (✓) Garbage Grinder (q/c�
Other—Type of Building No. of persons............................ Showers
P� YP g -•-••-•-•-•------•--....•-•- P Cafeteria ( )
Q' Other fixtures ..................................
Q ---- •-------------------------------•---------- --- ----------._.....-•------------•-------•----------------
Design Flow...................................J�__ .....gallons per person per day. Total daily flow............................ .Z.®.....gallons.
W --
WSeptic Tank—Liquid*capacity.! o®_gallons Length 4Q t._.l..1f. Width-S_`--_?_----. Diameter---------------- Depth.,�._V'
x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-one- Diameter.....LO ......... Depth below inlet.._ ...... Total leaching area.. 7....sq. ft.
Z Other Distribution box (X) Dosing tank ( )
'-' Percolation Test Results Performed by.a��.l��c'l.5 ce2._�.__ X.T> 12_ __! _!! ........ Date___/4uus ..2�`�
aTest Pit No. 1....._&......minutes per inch Depth of Test Pit...1.45:4....... Depth to ground water-
Test Pit No. 2................minutes per inch Depth of Test Pit---- !......_. Depth to ground wat
---•--••-•--••.......•-•--.•... ..................•--------......-•----••---......•-----•-••----••-•----•-._..._...----
O Description of Soil----T-----U -aa...--.'�� 'i e S: hso.;l 1- 6��-_1�..S h�.�---------------
x $TEPHEN•___$
U = ---------JOgceQiucn...< e[A toc---73?�' _°._ _'Z�" (_o zPI_f. 'Sep �6/._w ALLYN
j /� WALSON
z`�u-1�4 q") ►YYlc cdtu►n.... a n :. Nu.30216-- en.
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------I
-------------------------------------------------------------------------•-------•-----------.....--•--••---•----------------------------------------•--•-••••---•••••---•
Agreement: Soo
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i ccordance with g/=sj/'p9
the provisions of l y I LE 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.
Signe!�t
...-------•--------4 --
-
Application Approved By_ .. . "--- --------Application Disapproved for the following re -----------•---------•------------•--...••-•--••----•-•-•-•••--••••-•••--•-••-••-----••----•--•-••--••--•---•.
•--••-..........•---...--•-•-•••---••...............•-•-•----.....••---•--••••------•---...._..-----•._...•-----•--•---••------•-••••----••-••--•-•--•- -•---••--• ....................................
Date
Permit No...... ..®.._...._ ..�............... Issued.--.8 .......................
ate
/!L,No ..� ..�
Fss 75.` ... ..........`.:1 �.THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
wco� ................OF..... /t2/VSTH�3t_C
Appliration for Eliopooai Works Tonitrnrtion Pumit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:.,,. e� d '
L--- ---_.....
Location-Address or Lot No.
/�/«� Surrbur;( ----------• � '�c.44i
W Q //r er Address
Installer 1 Address
Type of Building // Size Lot...Z_LZ..4.1.•..•.�--Meet
Dwelling—No. of Bedrooms..................'.__....Z.......___.._..Expansion Attic (V ) Garbage Grinder ,(/o)
PL4Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures .....................................................
W Design Flow.................................� gallons per person per day. Total daily flow_-______------_-----___Z.z.o......gallons.
WSeptic Tank—Liquid capacity/�`.'9P..gallons Length�Q.`= ...._ Widths-_?._t... Diameter-------------.__ Depth-5----6.'...
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---0_nG---------- Diameter....U&---------- Depth below inlet--s 2..._..... Total leaching area_d Z.....sq. ft.
z Other Distribution box (K ) Dosing tank ( )
aPercolation Test Results Performed by��,_�s1!'l _�t..�.._LaX ._£..N y __........ Date_-t-4�11¢_-.2"q
Test Pit No. I------ -------minutes per inch Depth of Test Pit__!.!_!l........... Depth to ground water ........
<s, Test Pit No. 2................minutes per inch Depth of Test Pit...!A.4i _____. Depth to ground w
Ri .....-----••----------------•••------•-•----••••--..........••------•••-......------......------..........---•----•••-••-
Description of Soil..:T.e!...... .....Tv moll-�-_. t:�i-,_ficc ® STEPHEN $
V .. ......... ......e_._.%.fJ K -t-p-�.y'�%0�2: f� .....ka�.`......------. ......1io 34?fr Q y
1�m r1� r XALEY
---------- ------ ` " N„ rtsarr
W 4-- �'Y:�1caAlvl'' � --••• ............................................................... ....
U Nature of Repairs or Alterations—Answer when applicable..............................................................
----------------------------------------------------------------------------------------------------------------------------------•----------------------------------•--
Agreement: et v CA-
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ccordance with
the provisions of TTLi; ��
p S 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.
Signed_v....... .--------8------------------- ............................... ------
J f 6 Date
Application Approved By`, J t/� i7� -�` ce .
Application Disapproved for the following r -•-•••-•--••---......•----•-••-------••-••------•••---•----------•-•••---••-•-•-•-•----•-•--••.................
....................................... ••••••--•-•-------••--•--•-••--•--------•--•-••-•-------•-•..........-•-•--••--••-•----•---
}�l7 �• ]] Date
Permit No....�_.�_...."._..._--._ ....I---------------- Issued..V C....
•-- ----------------------
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF E LTH
........0F..... .... . . ...........
Trrtifirttte of Toutplianrr
THISS CE IFY �T�hat the ndivi�al S wage Disposal System constructed ) or Repaired ( )
by.. .... r. .!.Il..,_' t C://sd AI-----•-------------------------------a--•-•----------
at- 01� �''• 1(. ....4:,/ � ns ller ��-�•:!-J i-------.........................................................
has been installed in accordance with the provisions of TI 5 of he S t to Sanitary Cod aeEE
e• in the
application for Disposal Works Construction Permit No.._ � l` -. da.ted_. --- -------•-----------
I
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARA THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
, ,
DATE._.. f/
.....� }/- _-�--__----... -••.................... Inspector, /.!��? lnat`' ........
THE COMMONWEALTH OF MASSACHUSETTS
QARD H
/ ,/l
F .0 �r ..........OF.. f! 6/_4�....
- FEE. .....................
Bigni�1 fork ion t 4�ilan �eruti
Permission is herebyranted-..."-r-'� _
ins» 3 r r1 ..............................................
to Construct or air ( an-Individu Sewage-Dispo st
at No�,Q i � 5_ C �1..--E.•/ ---- J �.r -•-------- .......
Street
as shown on the application for Disposal Works Construction P it No.Z_77.&/Dated.--- .....-�-.�...-----....
FaIth-DATE. ,R/ ---------------------_----_---- e
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS I
LSIGN DATA
1 E5r P1 T D - -
ATA: -
s,ndla FamI ly Z 13uGrooms No Ga,6a9c Grinder Date / u9us4�:: z , t 98q
besk,s I10 = 2Z0GPD Test- 13� S.W;:1.-scN
S�Pr�c. Ta,hl< t ZZ0X 150 o Gc,Ilo,hs
US E S 1506 G A t_t_o►,L N K
I-coc►� P;t Cep dt�a x 5,7 d-4p41 w, TP�2
rt-,Z�..stehe.
SteQewe,ll : 178 5P x 2 SGpel/SF = 445Gpp -rofr0iIE! 7Lps0li Q
Qof-4o.m 7°!SF'x IOGpd � SF= _ � Gip SubCo�1 Svloteil
Z97 Spy SZ4 GPD
ISM C GE��/►NN'1 i
Ie 0FP4gsr j%4 &1 `+4. IYVI�o��vrh 5arlc�
STEPHEN $G n�
ALLYN , VJIU.IAfbl tic. I
U WILSON
N'> 44 Y E
.o ,p No.3021F
No. 19 4
o IS7E
ON
v \ su n Cn/v Wofn-J q �{lo Ctfcic./
144 — -88.2 144
,rev To. o
A-Jjus+ inicf cover Fatindaton
io one +oo+
Z hcasfanc Trlish 9radG . _6
Dist IV 1500 luv
r' 98.1 ljox INV 98.5 Ga//o.+ 1�44.0
v� 48.3
7.an/r
.� d
92.Z P o•r+om o f
/o' — J`>'STEIyI P1?OF'lLE CNoT +o SGALe)
L CC-szTIFY T-tiIHT THC PROP. ttousE SEPTIC SYSTEM DESIGN
SHOWN F- GRIFOIQ COMPLY5 WITH T-HE LOC,9770AN1 Z_:o_T,Z �7YI.4R/NE/Z C/RG�(�
S►bEL.IIJE ^ND SEThACV( REQUIr2er11EtJT5 ��-TlJ/._'' __:
OF THE I-X)WN (O r= AtwD ----- -
SG�4C.6'
IS NoT L..oc:..a"T'Sb WITHI►.1 A lrL0oZbPLr4lrJ
� I r• �' f "" ( --C' �✓Li4/V REFERENCE, -- -- - -
,,.,_-., _..�._• 1 Lc � APPL/C/'}yt/T : --cnrr ----- _-_--
H -
\
TlII5 Pt-RK1 15 NOT Ory AN L3Axr k WYE , ]INC,
'QST'Rur))E►Ji' SURVE`? AND T--V-lE Ot=FSCTs R�,��hr� anal Suiveyora
SHOWN HiFRff01.1 S►40UL-D NOT fat USt D ;n rzrs
?b ESTABLISH LOT L.I NC:S . !ems rcaV,A-I-far Votss ,
.QouTE Z B
OF A(d ?r
STEPHEN
ALLYN �;�
WILSON y s
,!No.30216�
�J
S k
mot&°/06-
wl
Q N aV 0� v b
N
O b w
IV
�o
1bX* BUT 2
RA Add,
2 �
-Tv M-t �3
oV
a .O v
�r -
SC FILE
P
C
�c
SN6d77' 2 o Imo' � � y
DESIGN DF,T/a TEST I—{ T DATA:.._P" 4A .
S„Ngle Family', Z f3ccQrooms , No Gar6a9e Grinder Date.',: .lwgvsF_.z , �98y
Des t5o Flow e 2 "A I10 = ZZ.pGPp
SeptLeb Tani< ; Z2ox 1507a = 330 Gc,1lo-is LJI+v1t9s; 7;
USES (SOOGALLaKI -t"ANK 'A
L-cash Pit Cep cQ�a x S,?'c�{,eci-�vc dap�1 vv 1-I�Z stone. TP TP�Z.
SieQewall 178 SF x Z S(SpA/SF = 445GFD -ropso;Ie I i
C3o1-4'om 70/Srx I O GPd / SF= = 77 GRp Su'b cc;1' Svlot0 l
257 SPA SZ4 GPD
M1 c e!"l�uwl
0r(}�a��
q STEPHEN 9L-,
x ALLYN mtq YdIkLIAfdI 9`
WILSON �e is C.
i
RI Y E .
.o No.3021&�4D No. 19 4
Sllg s
)4A"— (/✓v wonro-) -88�2 IA4a W" !dale/
eeui e. Top o¢
A,Jjus+ inlet Cover- F'ou►,dattor� t
to one +oo+ below £1 /Q2
Z h�casfanc '�tnish grade .
z Th Di:t V 1500 INV
98� BoxINV �s.S Ga//o. I�y9,o
v� x 48,3 Syots� �+8,8
./ T1
- -/D -- - S�STEYr) PROF iLE- CN(nr +0 SC.ALe)
L CEK i IFY THAT THE PROP. HoUsE SEPTIC SYSTEM DESIGN
SHOWN �IE1ZEUrJ CorA LYE W17H THE LOCF�T/OA/=Z -T_-Z �yylRl4/NEK C/RCL& -
51bEL1IJE ihND SETC�ACI'( REQUI2e►11E1JT5
g.TUl-T .. _
CF rrit 'tz�VuN O r- BA�NST/4flLE f�I�1D
15 N o7- WITHIN A t'LC)GZbpL► Ikj
f77 .9PPL/C
b ) — -----
laAT Iff
THI-n Pl-AQ IS NOT ASeD O&j A.&j 13AXT-ek nJyE , rNC,
I� I►JSTRUrr)ErvT SURVEY AND nIE OF=FSCTS 19- rooreec/ �an� Svrve era
SHOWI1 HIFRffON 51410UL.D NOT' [BE USC D Givi/ FrT�inre/'s y
Tt� ESTH3LISH L-07 1.IN eS
. ds rcit✓i�Lt r �lJ�tSS ,
Z. 8 ct I
z -
OF
STEPHEN �G
ALLYN
WILSON y
No.30216�p (q a
�p FG/S'fEQ� �a
S N
3
fv 0 2g3. o n
�o'V 30 ov d
N
1' o �b -TpR 2
o f"
v
�d o k P.
10
D.B.
,o\y Lvr 2
/o o i
Hojv
e n
Oo y ti
Fv4, Add. 3
zo
OV
�0 2V'Y
th
o ,O v
` 160 7 3 05, Z
Q
C
�c
t
F00
ps........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratuan for Di-lipmiMl Works Towitrnrtiun Permit
Application is hereby made for a P,e mit Yto C nstruct ( ) or Repair an Individual Sewage Disposal
System at: ,
................................ ..........................A..................................................................
1r
..................
c tionress �/7 t\� or Lot No.
' . .q
wncr •' ---
_
� t
W ur -r-.. . l9S NY...i..,
S i�k S �!tie, VLcc4,_ b 26
....................
� Installer Address •
Type of BuildingSize Lot--__------__---.•___------Sq. feet
U
t-, Dwelling— No. of Bedrooms.-_-------------•____-...-------------.----Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons._- _---_-.__--___-.--_.-_-_ Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow.------------------------------------_......gallons.
WSeptic Tank—Liquid capacity____-.--__-gallons Length---------------- Width---------------- Diameter---------------- Depth----------------
x Disposal Trench—No. .................... Width___---.._-.-.-__-_.- Total Length.................... Total leaching area.
................... ft.
Seepage Pit No--------------------- Diameter.--_-.------.-.-.._- Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by---------------- --------------------------------•----------- -'---''-••-- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(�. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
w' -------------•----------•-----------.----•-•------•--------'•-----•------••-----•--------•------•------•------------------
----------
•--------
.•--------.-----
0 Description of Soil...................................
U ` .---------------------•--------------....-------------------'------•---.
---•-•-•--••----------•----••-------------••-•------------•---••--------------- -•--------.-----•-•-------------------------------•---•-- ---------- s
U Nature of Repairs or Alterations[—Answer when applicable.................... -!.............._---..-- .,. .--: }-`:
Ir
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com ce ha been issueq by the board of health.
Signed .... I L__), `f
---------------------------- ---- ---------------------------------
Date llcaaon,Approved B i _� `...` y`._.. �l z �'�
PP PP y _ ..... ... Date..................
Application Disapproved for the following rearonr- ....................
--- --------- ----------------- ----------------- --------------------------------------------------------
................ ......... -------- ---....------... ......-- ------......-----------------...-------------......---------------*....... .....------ ..... ..`1.Z-1.—r
�i Date
Permit No. .. 4-' .... .... Issued .... - 1:� _ cis —
Date
E
4 p �
,i -- 0......
THE,'COMMONWEALTH OF MASSACHUSETTS
BOAND OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Di-n.Vuuu1 Works Tomitrurtiun 1rrmit
Application is hereby made for a P mit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
............................ .................... ............•......... —--............................................
�crac�lion- d ress or Lot No.
-7
a ` Add,
s................................
W Y_"• ':t[,J e•^ .1^"--'•�!'•��`4.+ . .t. .��_ YVN4 (ItS� Cer �1 L16
Installer Address
UType of Building Size Lot.................... Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ___________________________ No. of persons------------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ----------------------------------------------- ==
--------------------- ---- .
W Design Flow____________________________________________gallons per person per day. Total daily flow----__-_.____-__-_-•-----•-•---__.---,._.__.gallon,
WSeptic Tank—Liquid capacitv............gallons Length-------------'--- Width--------.------- Diameter-----.---------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area-...................sq. ft.
Seepage Pit No-------- ------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY........_................................-............................... Date----------- ------••.....
Test Pit No. 1----------------minutes per inch Depth of Test Pit--.--.__.______-_.._ Depth to ground water........................
0-4
fs. Test Pit No. 2................minutes per inch Depth of Test Pit-_.-_-_----______- Depth to ground water........................
------------------------------------------------------------------•------......--••••......------•--.........................................................O Description of Soil------......- -- ----------------
U - - - - -•
.............••-••--•---... `� �` - --------------------- ---- ---------• ---------------------------------------------•-------....------------------.
W -1--------------- ------------ -
U Nature of Repairs or Alterations Answer when applicable____________________L �L� ��..v�
.....•••••• ....•----
--•-----••..........•••--••••-------..�.....� �� �._ �'�-
)t Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Com ki�)Ice ha been issued by the board of health.
-n Signed �
-------------
Date
Application,Approved BY ------ -- ------ - ..... .. -
........... ----------------
Application.Disapproved for the following reasonr: .................. ............. - ...
��lZ-``�f
Dare
Permit No. ..- -----------._ . Issued
t Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of (gompliance
THCS TO CE TIFY, That the IndividuakSewage��s osal System constructed ( ) or Repaired (L/�
�.
by ..................-Gt. Z..... �-• `
i tau-
at ----------� -_ rn t�r , h+ r- s - C ti �� - ... -.h....%_
----------------------------------
has been installed in accordance with the provisions of TITL 5 of The State Environmental Code as described�n
the application for Disposal Works Construction Permit No. _. --40-;7 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �- �`'.. 1--�'.. -----...._-- - Inspect ........ `..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
7 °, `'
No.:...... .............•- FEE..----.........-•.......
Rapil -trr1 No ii Tun tr uan, rrmit
Permission is herebygranted...... . -...__.. w
to Construct ( .),,o Repair ( an Individual Sewage Distgsal Syst
atNo..._._.•••••••-•••---•-•-•�••-•---•-•-w-'•G_.`....`...__.�.,^ t �.`.v-�1_............................................................... ' ...
s t �r-
as shown on the application for Disposal Works Construction Per '"._ 0_FDated--_-.1_
.----.•.---
.r' i Board of Health
DATE .... ----••-•--•--••--••••-
FORM 36508 HOBBS A WARREN.INC..PUBLISHERS
M
f
CERTIFIED SEPTIC SYSTEM. REPORT
LOCATION
375 MARINER 'S CIRCLE MAY , 2 1995
COTUIT , MA .
HEALTH DES-►.
MAP 24 PARCEL 023 002 'PMoFBARN8TAm
PREPARED FOR
SELLER
MR. & MRS . HE14RY J . SU14BURY
2912 HILTON DR .
LEXINGTON PARK... MD 20653
BUYER
MR_ HENRY O ' SHAUNESEY
11 HIGHLAND AVE
S . YARMOUTH , MA 02664
PREPARED BY
HILLIARD HILLER, JR.
41 MAPLE AVE
CENTERVILLE, MA 02632
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 375 -'esi9R11,40C-4e'5 c�.4ccE
Owner' s name y , h`ZARy T a /�W/19'4_Gi9 "�
Date of Inspection yllyJr
PART A
CHECKLIST
Check if the following have been done:
c/ Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks,
and the system has des-feGeivi" Rer-mal €letir _ates dui-ing-that
-ge rer-. Lie--vim,} r 61 ;Mate have net been i twed into the
-systera-,reeently er as part ef this inspeetion.
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 site was inspected for signs of breakout.
All system components, excluding the SAS, 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.
_L,,,' The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
f
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
a number of bedrooms
0 number of current residents
_,42. garbage grinder, yes or no
y laundry connected to system, yes or no
_Al seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: lq92 yG ooa G.rL
i
,19573 78 G�c.
y5 Last date of occupancy JSy y yC
GENERAL INFORMATION
Pumping records and source of information:
^/hS System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:A-14 6k6o.
Type of system
_/ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pri-v�
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
AA9 Sewage odors detected when arriving at the site, yes or no
r -
9
SUBSURFACE SEWAGE DIS
POSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: Y
(locate on site plan)
depth below grade: /o
material of construction: 1/ concrete metal FRP other(explain)
dimensions: ''/%a'' x S'Y,X y i�v� Ci7L T�iX/fc
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
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, recommendations for repairs, etc. )
A-1,28/.0 3/2ly� f�vy�o
G-rl� L
7-A-.6
DISTRIBUTION BOX-: //
(locate on site plan)
O depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
/ l31---x IS Zlf4-WL a -:::�22&47 7-
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments :
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : z/
(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 and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
R i,'.�i� .dy�s��i!G Tft;�= S �Ti� ���/f �viz y 3
yl itT 6oL10S Ay ,-617- AvG v/J r, .E :5�S_
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, recommendations for maintenance or repairs,etc. )
PRIVY:
( loc.ate 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, recommendations for maintenance or repairs,etc. )
i
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanen references landmarks or benchmarks
locate all wells within 100 '
37S
/ a
DEPTH TO GROUNDWATER.
depth to groundwater 3 - ---1
method of determination or approximation:
6,',Z-z-0 �'G�l/frT/O� P� 13�9�P.�5T/IRG.E G/S z GS'
6 Rov-o
U6 Gy' �+oSvSTiiE,�/T �50GJ a 5 3 2 B = 7 ,
r
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
- IV Discharge or ponding of effluent to the surface of the ground or
surface waters?
* Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Al Required pumping 4 times or more in the last year?
number of times pumped
_,f/ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
c�/ITiFicf�i��: o% C�s.�s/mil✓sT,vG/_-' .� �u�-- /so7 i
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within. 100 feet of a surface water supply or tributary to a surface
water supply?
V_ within a zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
Al within 50 .feet of a private water supply well?
IV 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 analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
3 7-5-
Name of Inspector fj`lG�iiS'�o jflGG�� J/2
Company Name
Company Address �✓C> �x ,25zv
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature
Da t e y/ 4// 5;;�
Original to system owner
Copies to:
Buyer ( if applicable)
Approving authority
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CTEr#ifira e of Compliance
TN IS TO CERTIFY, That the Individua Sewage Disposal System constructed ( ) or Repaired
s �. ....
... ... �.... .:........ .... . . .
has been installed in accordance with the provisions of TITI.�- ,
5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No.
/..!..:... `z. /_I`. dared. - .. ..._�J
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
`
DATE ....._..... ..%��..... !�.... ....................... Inspect 4-7z—,e— ......:. `�
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g PHONE: 508-775-6631
ACCESS COVERS MUST BE WITHIN INSPECTION 9' MINIMUM. / N VC R T E L. E VA T I ONS : DES / GN CR / TER / A : GENERAL_ NOTES
6" OF FINISH GRADE PORT 3' MAXIMUM COVER
FIRST 2 ' TO INVERT OUT SEPTIC TANK: 96.8_ DESIGN FLOW:
BE LEVEL M/N 2" OF PEASTONE INVERT IN DIST. BOX: 96.57 3 BEDROOMS AT I10 G. P.D. PER I . THIS PLAN iS FOR THE DESIGN AND CONSTRUCTION
OR F I L TER FABRIC INVERT OUT D I S T. BOX: _--96.4_ BEDROOM EQUALS 330 G. P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
i' DIAM PIP 314
INVERT IN LEACH CHAMBER: 96. 13
96. 4
DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER 95. 7 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
;p GAS 96. 8 I0'
BAFFLE 96.57 p 6. 13 - g5 3-- ADJUSTED GROUND WATER: N/A SE SE SITE PLAN.
SEPTIC TANK REQUIRED:
3 OUTLET 5 HIGH CAPACITY INFILTRATOR OBSERVED GROUND WATER: N/A 330 G.P.D. X 20OX - 660 GAL . J. ALL CONSTRUCTION METHODS AND MATERIALS AND
EXISTING D-BOX CHAMBERS W/3.5'' STONE AROUND BOTTOM OF TEST HOLE •1 : 89. 1
SEPTIC TANK PROVIDED: 1.500 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL
1500 GAL !0 'r x 38 ' 1 x ID'd
CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC TANK 6' CRUSHED STONE OR
COMPACTED BASE SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
DES/GN PERC RATE l .5 M/N/I NCH
PROF I L E : NOT TO SCALE SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3 ' IN DEPTH SHALL BE' CAPABLE OF W/ TH-
S TAND I NG H-20 WHEEL LOADS.
PROVIDED: 5 HIGH CAPACITY INFILTRATOR
CHAMBERS W/3. 5 't STONE AROUND. A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
460 S.F. x 0. 74 - 340 GPD APPROVED EQUAL .
CB/DH FND
7 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SOIL Tr_ S T P I l DA TA & PRE-CAST CONCRETE OR APPROVED POLYETHYLENE.
/ I ND I CA TES �_ 1 ND/CA TES BOTH SHALL BE WA TER T I GHT. D-BOX SHALL BE WATER
PERCOLATION OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE
TEST GROUNDWATER OUTLET.
t►�'6
E
Pad F TP *I PE 12963 TP *2 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE'.
HORIZON TEXTURE COLOR HORIZON TEXTURE_ COLOR 1-888-D/G-SAFE AND THE LOCAL WATER DEPT.
0' 99. 1 0' - - - 99. 1 FOR LOCATION OF UNDERGROUND UTILITIES.
FILL FILL
8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
/ 6' . ...- 98.6 8' - 9B.4 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
LOAMY IOYR LOAMY IOYR
A ,SAND 3/2 Q SAND 3/2 of THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
l0' _ ... ... 98. 3 rl ' _ ....... 98.2
CONSTRUCTION INSPECTIONS.
p LOAMY IOYR p LOAMY IOYR
' D SAND 4/6 C7 SAND 4/6
% 24- .............. .. ... 97. 1 24' ...... ... ............ 97.
G MED-COARSE IOYR C / MED-COARSE IOYR
u _ _ SAND 6/8 SAND 6/8
cc, A 46 " GRAVEL. GRAVEL
•°y / ' c�F o s
.()0
S T D9�%
120' NO WATER 89. 1 120-' NO WATER _ 89. 1
j PLAY AREA -------
DATE : MAY 26. 2010
TEST BY: STEPHEN hAAS
EXISTING WITNESSED BY: DAVID STANTON
PIT SHED PERC RATE: l 2 MIN/INCH
EXISTING
\ BM. CORNER Bid 1500 GALLON ,
EL-99.54-, SEPTIC TANK �pROEN
`\ D-BOX TP•I
SHED
TP
p F�c h 5 YII GH CAPACI TY
<</4G, INFILTRATOR CHAMBERS
M/J.5' STONE AROUND CB/DISC FND
\ SC4Q I,A• �
L 0 T 2
48. 701+ S.F.
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\ 375 MAR i /VE/z' C / RCL E . MAP .2-4 . PARCEL 028 -- OOP?
j SA R ivS TA S / E' . ( CO TCJ / T > "A .
Q � � PREr=',4 RED FOR
LEGEND H E /`V R Y O S f-�',� C� G H/�/E Is 5' Y
__-- ---- ■ CB CONCRETE BOUND 5 C,4 L E / - 2 O ✓ (JIVE- 2 8 2 O / O
A�P �.�: - -W-- WATER L INE
O HYDRANT
-G-- GAS LINE II CC_ \ / (�
T1 ,1r,111*c \�. J !Q T --OHW-- 0 VER HEAD W/RES E A G L- F S U R V E 'Y/ I I V G I NC
LIGHT POST-E- UNDERGROUND ELECTRIC LINE _ = 9 , 3 F2 o u t 6 A
rio75
L Ya rr u t h P <�08 M362O8 163
"' -- T---- UNDERGROUND TELEPHONE L !NE / 2
CTV- UNDERGROUND CABLEVISION LINE II\l�' - 5O8 432-5333
--- + 40.4 SPOT ELEVATION
r40 EXISTING CONTOUR
REVISED: JUL Y 7. 2010
40 PROPOSED CONTOUR
LOCUS MAP 0 l 0 20 40 LJOB NO I 0-0F/EL 0:CFW/F'd W CAL C: SAH/CFW CHECK: CFW Dn',N: SAH