HomeMy WebLinkAbout0240 OXFORD DRIVE - Health 240 OXFORD DRIVE, COTUIT
A- 021 080 - - ---- --- - - - - --- --- - --
TOWN OF BARNS'TABLE
LOCATION Q X rO J3V r SE WAGE#
VILLAGE lop(U 1 ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. :JO C Y`S S'CP T/C
SEPTIC TANK CAPACITY d O O
LEACHING FACILITY:(type) A s 5 00 G L chaMAa%gsize) /3
NO.OF BEDROOMS
OWNER DAry/t-1
PERMIT DATE: 0 COMPLIANCE DATE: a a i
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 leach' g facility) Feet
FURNISHED BY ¢.
c.,.1 L
LY
LA) N W
G
"-
rb' �
z e
lry - t i
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zfpplifation for -Mispo8al i�pstrm Construction permit
Application for a Permit to Construct( ) Repair(! ,Upgrad Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Ow�nner s gg Ad-dress and Tel No
Assessor's Map/Parcel av —0,go OTv/T c
Installer's e,&(Ires g 1.No '2 80—77�2 D igner's Na e,Address,and Tel.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No.�� Date Issued O �-
4 {
j f
No. �� • Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS. Yes `
-s
application for Disposal 6pBtem ConBtrUttion permit
Application for a Permit to Construct( ) Repair(GL)pgradg�•(`) Abandon O ❑Complete System ❑Individual Components.
Location Address or Lot No. �� �'� � �'c .��l. Owner's Name,Address and Tel.No.
1 1)Pi9//!'4 ei1'ZINvS
Assessor's Map/Parcel a;� 67O7"r//
Installer's Name,Address,and Tel.Np.` 1$0`77_1` Designer's Name,Address,and Tel.No.
Type of Building: '
Dwelling No.of Bedrooms Lot Size ;. sq.ft. Garbage Grinder( )
Other Type of Building .No..o£Per-sons Showers( ) Cafeteria
Other Fixtures
Design Flow(min:required) T� gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
f - Title . `
t
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) - G�,X 'l
"-,.4 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.
Signed2 := %� :FJI =�, Date
Application Approved by Date
Application Disapproved by ` Date
for the following reasons
Permit No. DOa) 19�,5 Date Issued
_ .. , - - - -- -- - -- ---- -- -- - --------------------'----._.__r.------'--1---•--------- ------------- -'--•---
---- - -- ' -THE COMMONWEALTH OF MASSACHUSETTS
' BARNSTABLE,MASSACHUSETTS `
Certificate of Comoriante
THIS IS TO CERTIFY,that the On-site SewageDisposal system Constructed( ) Repaired(,'—)— Upgraded(C_').__
Abandoned( )by
at
"Cr has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit No/ dated J) /1 G �-=J,
Installer t/c?S C,/ /./t/��15�� ^( Designer (�/b / , icy^/67.�r4J
#bedrooms Approved design flow , gpd
l
The issuance of this,permit shall not be construed as a guarantee that the system will Mctions
gs des gned.
signed.
Date 11 t 2—j Z&,I Inspector � ;
- - - ---- --' -- ---- - -- -- -- - - -- ---- -----
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS y
PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
Mispe-al 6pstem ConstrUttion ermit
Permission is hereby granted to Construct( ) Repair(/,)_- Upgrade( ) Abandon( )
System located at
s
e'� r all
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with :
r �
Title 5 and the following local provisions or special conditions.
f
Provided:Construction must be completed within three years of the date of this peE emit.
1h
Date 1` t<a /t^�-�
/ f s Approved by
.. J
Town of Barnstable
�t"e, �� Regulatory Services
Richard V. Scali, Interim Director
ELARN rnet.E,
MAS& Public Health Division
i639' 1�
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: Sewage Permit# Assessor's Map\Parcel 0Z I OF,-)
Designer: �" } vv�f , �•S, Installer: ✓ �r c" �,��
Address: L vdc 149S'e- Lam, Address:
On ;//- 2 o(, /Qe_& AwJ was issued a permit to install a
(date) (installer)
septic system at Z LI O 0,Y /w-, 17v'' based on a design drawn by
(address)
6E-. G'r(:Q*'#,/4 "GBH 49,Se dated ff OUT
(design
V I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed i liance with the terms
of the I\A approval letters (if applicable)
GLEN �cyG
ERIC rn
(I staller's Signature) HARRINGTON
NO.1070 co
(Designer's igna e)." (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.
QASeptic\Designer Certification Form Rev 8-14-13.doc
1
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld(io+srna Trudy Cox*
s.e,+wy
LL�m(Paul Celluccl m David B.Struhs
e corra"830,w
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION
Property Address: 240 Oxford Drive Cotuit Mass .
2/2 6/9 6 Address of Owner.
Date of Inspeatiom (If different)
Name of Inspector. Joseph P. Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville ,Mas.s . 02632 508-775-3338
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:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's 9ignatud�� f Date: v7?
v
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
--Zi have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
�11 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,strucfurally 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 11/03/95) 1
One Winter Street 9 Boston,Massachusetts 02108 a FAX(617)556-1049 0 Telephone(617)292-MM
V'
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddrese: 240 Oxford Drive Cotuit,Mass . 02635
Owner. William Ellison
Date of Inspection: 2/2 6/9 6
Bl SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or h0h static water level observed in the distribution boat is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cl 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,aafety 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:
LIA Cesspool or privy is within 50 feet of a surface water
AS Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS'TRE 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 water supply or tributary to a
Ab surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
1 The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 Oxford Drive Cotuit ,Mass . 02635
Owner. William Ellison
Date of Inspection: 2/2 6/9 6
e
D] SYSTEM FAILS: s
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to Correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
A�D 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.
JIA-,k Ak
�1 Liquid depth in cesepeel is less than 6"below invert or available volume is less than W day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Q�Q Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
AY Any portion of a cesspool or privy is within 50 feet of a private water supply well.
10 Any portion of a cesspool or privy is less than 100 feet but greater than 60 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 above:
A)d 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:
G{r_:t the system is within 400 feet of a uu.rface drinking water supply
1�14 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 consl.ilt the local regional office of the Department for Anther information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Pro Address: 2 0 Oxford Drive Cotuit Mass . 026
>��r 02635
4
Owner. William Ellison '
Date of Inspection: 2/2 6 9 6 •
Check if the following have been done:
,pumping information was requested of the owner,occupant, and Board of Health.
/None of the system components have been pumped for.at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
,.V/As built plans have been obtained and examined. Note if they are not available with N/A
, The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
„L/All system components,tuding the Soil Absorption System,have been located on the site.
_The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum.
/The size and location of the Soil Absorption System on the site has been determined based on existing information or
app ted by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddresa: 240 Oxford Drive Cotuit,Mass . 02635
Owner. William Ellison
Date of Inspection: 2/2 6/9 6
FLOW CONDITIONS
RESIDENTIAL-
Design u•
Design flow: j J ns���y •
Number of bedrooms: _
Number of current residents
Garbage grinder(yes or no):g,Q
Laundry connected to system(yes or no):k3
Seasonal use(yes or no): J
Water meter readings,if available: 1 M = _
44, 000 gallons= 120 55 gallons per ay.
Last date of occupancy:L�l-/
C O M M ER C LAL/I ND U S TRIAL•
Type of establishment AM
Design flow:_A2jj_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)-L)—)q
Non-sanitary waste discharged to the Title 5 system: (yes or no)_,
Water meter readings, if available: AM
Last date of occupancy: 4119
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECO 3 an source of information:
dear AUA AO
System pumped as part of ins rl ion: (yes or no) K
If yes,volume pumped: ons
Reason for pumping: - kk NS
TYPEM SYSTEM
Septic tank/distribution box/soil absorption system
J _ Single cetsPool
---AJ16_ Overflow cesspool ;
Privy
41 _Shared system(yea or no) (if yes,attach previous inspection record, if,''
, 2 Other(explain)
APPRO)aMATE AGEA)of,all com2oaents, date inst,�,i ed(if known)ILad source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03195) 6
SUBSURFACE SEWAGE SYSTEM INSPECTION FORM
C
SYSTEM INFO. i ION (continued)
Property Address: 240 Oxford Drive Cotuit,Mass . 02635
Owner. William Ellison
Date of Inspection:2/2 6/9 6
e
SEPTIC TANY:Z-114
•
(locate on site plan)
1�
Depth below grader
Material of construction: Z000ncrets_metal FRP_other(ey'. ::)
Dimensions ' 1 -wk G
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 bTtTes, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) r e v A r_yy 2 -l r p a r2 T�ry 1 Q t & Q 41 t 1®t to®S a y o
in place : SeDtic' tank is structurally sound And shows nn signs of lenkagP ,
GREASE TRAP;A,j 1F►,.
(locate on site plan)
Depth below grade:,
Material of construction: concrete_metal_FRP_other(e:plain)
Dimensions:
Scum thiclmess: AA
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baf le:_DA
Comments:
(recommendation for pumping,co tion of inlet and outlet tees or b>"'es, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.), A)A
(revised 11/03/95) s
f
SUBSURFACE SEWAGE DL! "rlo I-'"Y9TEM INSPECTION FORM .
SYSTEM I: ; (continued)
pwpertyAddre" 240 Oxford Drive Cotuit ,Mass . 02635
Owner. William Ellison
Date of Inspection: 2/2 6/9 6
TIGHT OR HOLDING TAN&" • ,
(locate on sit*ply •
Depth"w grads-AA
Material of construction:4&ncrete--Pow_FRP
Dimensions: MR
Capacity: ns
Design flow: ons/day
Alarm level
Comments:
(condition ol inlet tee;condition of alarm and float switches, et,!.)
DISTRIBUTION BOX: '
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal,evidence of solids Carr:.• '- ^"'^sa8e into or out of box,etc.)
is Distribution box has equal flew-N.o signs..-sf �QUaga --
j box. No sighs gf sol ids aarry nvar�CO�'37 i a hrnkpn M,iat' bw
PUMP CHAMBER:ALge,
(locate on site plan)
! Pumps in working order.(yes or no)_LL .
Comments:
(note oo n of pump chamber,condition of pumps and e;^„ 0^)
- .7 ..._., . ...c..
i
i
(revised.11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IN. rl:�:.uiTION (oontinued)
Property Address: 240 Oxford Drive Cotuit,Mass . 02635
Owner.. William Ellison
Date of IInspecuont 2/2 6/9 6
SOIL ABSORPTION SYSTEM
coca"on site plan,if possible;excavation not but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type ..
leaching pits,number:' .
Isai chambers,num�beer.
kaChin g galleries, (J
cachinnumber,
trenches, length
leaching fields,number,dimensions:
overflow cesspool,aumbar.'n_
Comments:(note condition of soil,signs of hydraulic failure,level of xnding, condition of vegetation,etc.)
.gn-il nonditions see page 9A, No signs of hydraulic failure or ponlTrIT71—
U.ogP+.n+.jnn iG normal _ No repairs are needed at this time .
v CESSPOOLS:
(locate on site plan)
Number and configuration: M IR �
Depth-top of liquid to inlet invert: M
Depth of solids lstiyer. �1
Depth of scum layer. i
Dimensions of cesspool:_ �l
Materials of construction:
Indication of groundwater. N
. inflow(cesspool must be pumped as part of inspection)__
Common+:(note oondition of soil,signs of ,level_tin 1'bwt•w�E.►1�'6' S hydraulic failure / l of pon ding, condition of vegetation,etc.)
i
PRIVY:J,�/V Qi
Qocate on site plan) -
Materials of conduction: A2d Dimensions:
Depth of solids
Comments.(note conditionofsail.signs of hydraulic failure,level of :.iing, oondition of vegetation,etc.)
(revised 11/03/.95)• 8 i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 Oxford Drive Cotuit ,Mass . 02635
Owner. William Ellison
Date of Inspection: 2/2 6/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate an wells within 100' �. G�y¢J'w^
' E
r
DEPTH TO GROUNDWATER
Depth to groundwater.
&Lt—feet
method of determination or approximation:
(revised 11/03/95) 9
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TOWN OF Barnstable BOAIID OF HEALTH
SUBSU11FACE SFWA(;F DISPOSAL SYSTEM INSPECTION FO11M - PART D .- CERTIFICATION
...........
-TYPE OR PRINT CI,EARLY-
PROPERTY INSPECTED
STREET ADDRESS 2/,.0 Oxford Drive Gotuit'Mass 024 5
41
ASSESSORS MAP , BLOCK AN4 PARCEL # M, 2U_ 4"6% -
OWNER' s NAME William Ellison
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph. P. Macomber Jr. .
COMPANY NAME J.P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Tovn or City State LIP
COMPANY TELEPHONE 508 ) 775 - 3338 FAX 508 790 1578
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 maintenance of on-
site sewage disposal systems .
Check one :
XXXj =XSystem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe. environment as defined in 310 CHR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA .section of
this form .
System FAILED
The inspection which I have conducted has found that the system fails to
Protect the ptiblic healt1i and the ,environment in accordance with Title
5 , 3.10 CHR 15 , 303 , and as specifically noted on PART C FAILURE
CRITERIA of this inspection form .
Inspector Si nature Date 2/2796
One copy of this t ification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF HEAL111.
If the inspection FAILED, the owner or"" 'pe'rator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in ,310 CHR 15 , 305 .
4-A A--
THE COMMONWEALTH OF MASSA.CHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
o
Joseph P. Macomber, Jr.
Has satisfied the. Department's qualifications . as required and--is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided M" 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 9. 1995
Acting Director of the ' ion of Water Pollution Control
i -
- o
ASSESSOR'S0 ,
MAP K k^ PARCEL
L.0 c.A, ION SEWAGE PERMIT NO.
h
Vi LAGE
� INSTALLER'S NAME i ADDRESS
cA `
U I L D E R R OWNER
rw
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w!U...........oF......... ;5 ...... ............................
Appliration for Disposal Works Tonotrnrtion Vrrmit
Application is hereby made for a Permit to Construct �\) or Repair ( ) an Individual Sewage Disposal
System at:
........... ---.... •................................... ....................... ....................................................
(o,, ' 1• Loca on-Address or Lot No.
7�— _ V tJ V O►1 ......•... ••................................................................................................
�� Owner Address
a ....... —...... lC:--••••••.....••. `...... ......................................................
M Installer Address
Type of Building Size Lot...ZA-61p......Sq. feet
U Dwelling—No. of Bedrooms.......... .....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons......................:----- Showers ( ) — Cafeteria ( )
G4 Other fixtures ----•----•--------••--•-•----••.........................
W Design Flow..............5 ....................gallons per person per,.day. Total daily flow.........5 50.......................g-allons.
WSeptic Tank—Liquid capacitv./ ..gallons Length......&...... Width......4....... Diameter------------:... Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------i----------- Diameter......IQ......... Depth below inlet.......& ........ Total leaching area;Y!A...sq. ft.
Z Other Distribution box (V) Dosing tank ( )
Percolation Test Results Performed by..._�G��,t?, j....O ................................... Date..11?' �4.Z `S
as Test Pit No. 1: ".....minutes per inch Depth of Test Pit..... Depth to ground waterA4�4_.�tnC...
Li. Test Pit No. 2...4'�-L.....minutes per inch Depth of Test Pit.......N.......... Depth to ground water....I............... 4
Q+' ........................... ---- •------•..........................................•---.........------.........-•----•-•-••..................••.---•-
1' x Description of Soil......................... .�Q1tY-1.......:.............................................................................................................
V ......................•-••••--------•--......---.........-----------•-----_---------•-••••.....•-•--------------------•-----••------•--•••---•-_.......-----------------...............•---------------••
W •-••--------------------------•---•••--•-----••-•-•--•--•--•-------••-----_•----••••----------••••---•-•-----••-----...-••••---_••------•-••-•••--•-•--------------...-••-•-----•-------------.......---
UNature of Repairs or Alterations—Answer when applicable.................................................................................................
------------------------------•----•------------------...................--_---••-------•---•-.._...--••----•-•----•-•-_•--••-••-----•--•-•-•-•--••----...----_•-••••-•_--•••-•--••---•-•••••••.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ilTl 5 of the State Sanitary Cod —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een i u-d b tlae-bo ca�i o hf e 1 .
.......... -••_ . ................... + 7__ .. ....... .... ............
Application Approved By--- -�----•- .. •-------------.............................................................. -��-_ -�-
Date
Application Disapproved for the following reasons-----------------------••--------------------•------•-------------------------------......--•--•---..............
•----•----•..................................................................•--------•---....------------•....-•-------------------_-•----••-_------•---•-•-_•-•--_--••---_......-------•-•---•--......
Date
PermitNo........ n��'j..... Issued.......................................................
Date
10
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT1=1r a
..............)5.W ......OF......... ?`:�Lu 1. .�)L ....................................
Appliration for Disposal Works Tonstrnr#inn rrmifp't,
Application is hereby made for a Permit to Construct �K) or Repair ( ) an Individual Sewage Disposal
System at
l) BUY( i� !Z
........... __..._........................... - ...............--................... ................•-•-----..- '7_`:.... ... ...._........_
{{ Location-Address or Lot W l
1 v°v'� "L90►'l
•- ........ _ _ -•• •-- - ................
Owner - Address
+
Q ----•-•-•-•••••--•••---••-----•--•••..._..... ...............•_.......+--._............-•-••-
Installer Address
Type of Building Size Lot...Z641-3__M......Sq. feet
�. Dwelling—No. of Bedrooms..........t._:�
............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___ No. of ersons_______________________ Showers
W YP =g ------------------------- P ----- ( ) — Cafeteria ( )
Other fixtures . ;.. -------------
-..........
-.................
-----
W Design Flow.. r� ..................gallons per person per lday. Total daily flow......... ......................gallons.
r
WSeptic Tank Liquid capacity;1yrI37?__gallons Length____.._..._._ Width.._.'`.._._._.. Diameter............:... Depth_.__..__.+_._._..
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area...............-----sq. ft.
Seepage Pit No........- Diameter...._!Pt_______- Depth below inlet.......(m........ Total leaching area:V_hS ...sq. ft.
Z Other Distribution box..O Dosing tank,.( )
Percolation Test Results Performed by..__IFa%_ !....................................................... Date__{ ' < ..i �.____.__:___.. ` ��
as Test Pit No. 1_��.....minutes per inch Depth of Test Pit....1 ............ Depth to ground water.6►q 4.T nic 91JA1K%r
(% Test Pit No. 2__&7:_._._minutes per inch Depth of Test Pit._.._._.'_`_____.__. Depth to ground water....l�.__..__.__..".
P4 i
0 Description of.Soil......................... ;,_ !QL,0_.....---.....---.._.....-------------------•-------------....--------------------------..._.._...-------•--....._..
U tiv._
VW ....••--••------••--•----------------•--••-••--••`•-•------•---•-----•--------•------••-----•••••--•-----•••---•---•------••--•-•-•----••--.._•--------•--••-•------------•---•...•••---•-••----••---_•--
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
...............
Agreement:. r
The undersigned agrees',to install the aforedescribed Individual Sewage Disposal System in accordance with l:
the provisions of TIT'1 '5 of the State Sanitary C - The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een i u b o i_ .
Si ---- -- --
Application Approved By..- ."------- `---- ..........: ............. /�la/-- _ _ _......_
Date
Application Disapproved for the following reasons-............................................................ ....................................................
Date
Permit No......... c 1 - ---- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
dw �ry
.....................O......... ...........................................................
-�, Trrtifiratr of Tnmvliattrr
THIS IS TO CERTIFY, That.the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-•--••'--••..._- ?!1 .........I .S. ` 1'�......................................
.......•_-
Installer.'`
at................ ••-••-_�.(�_....... ------------- ..............................................................
has been installed in accordance with the provisions of T1TL: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.�"�?__._� ..... dated-.- �.q��_��� ...............
ISSUANCE OF THIS\.CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S�TISFACTORY.
.�
DATE..:....................�......�t..��......_....:-••----=•-----...---:_._. Inspector.-_----�"'f.................-.................................................
THE COMMONWEALTH OF MASSACHUSETTS
!;
BOARD OF HEALTH
-L ...........:...OF.............. z ............................................... { �. •
No ._-: `� FEE........... ........
i Disposal Works Tonotrudwit frrufit
Permission is hereby granted........ ............. ......____---------•--_-•.................
to Construct qr Repair ( ) an Invidual Sev�ge Disposal S�y_.s_�t�em,' I
of No... - .... AAA -I.
Street
la /5� .
as shown on the application for Disposal Works Construction Permit--No�f�---3�__ D'ated....____..�............ ..............
r
Boardx--
of health
DATE........................ -------------------------------------------...........
GENERAL NOTES _
- —
. ADUFtESS: '�40 OXFORD ROAD, COTUIT VILLAGE. SRRNSTABLF
cp Approxima4 locati n 2. ASSESSOR'S NUMBER: MAP 021 PARCEL 080 0
N q7 —W— voter ne ¢ 33. DEVELOPER'S LOT: LOT #56 o ul
b
Ly x TOPOGRAPHIC INFORMATI N WAS COMPILED FROM
98 Existing contour ; AN ON THE GROUND INSTRUMENT SURVEY. fe e
x �I Lan
5. TOWN WATER IS PROVIDED TO THE SITE & SURROUNDING PROPERTIES. o
.; Existing 1 000 gal: H-10 loading SITE,
O O septic dank 5. NO.WETLANDS ARE LOCATED WITHIN 150 FEET OF THE PROPOSED SAS.
� A 7. REFERENCE PLAN: DEED BOOK 21397 PAGE 163, PLAN BOOK 271 PG 56
5 78' 8. UTILITIES LOCATED BY DIGSAFE.
"` 9. THIS DESIGN PLAN IS TO BE UTILIZED FOR THIS SEPTIC REPAIR ONLY.
Existing Leach Pit
Existing
be pumped and backfilied) 10. EXISTING SEPTIC COMPONENTS SHOWN PER 07-26-2021 SEPTIC INSPECTION, Ouford Drive
o 11, THE PROPERTY IS LOCATED IN THE SALTWATER ESTUARY PROTECTION ZONE.
11. THE PROPERTY IS NOT LOCATED IN A ZONE II Off GP OR WP 20NE. c Trudy Lane
a, #2 ¢
O Da: 2 - o
�,, t7kF0 101.70' X Denotes existing spot grade'
Q
� }
o ,0� ' tow�/'oR9 RpgO Test Hole �.! „COTUIT" "�
Water 'LP LOCUS
D�: +•M Ls� w t NO SCALE
a ^^ °
:o PROPOSED SAS _. 25'
Cy 57.29'
} .:► .T H-10 500— al . chambers
O
�. r' 2 9 ,;,;
4 of st one al I
around
,
• X 56:41 a . Wlth ,
o
...... .. •�'� In x 3 x leach ench.
� a 25 1 2 tr �' 0 0 .,�4
a - 56.41' $� 13'
:.Gp a 4'
O
k. :�i"'' oval .....•.58 ..•.• .•
SAS....LAYOUT
0 �., ewQy x 50.88 . B. M . PLAN
:67 ; ;.;;•`' C.B. FND. ,�.� H=20 se 71 NOT TO SCALE
D-BOX
55.24 'r: aetbec
0ISTRSJTIpIPES FROM BE ON BOX SHALL 12" CONCRETE COVER
Q •a. •v - // iiiiiii' AA SET LEVEL FOR AT LEAST 2 FT.
WE TING l//�llll :..rriii:i:' .•�J '•t r•.•,, i 3_g.OUTLET
'-LING // v�/ KNOCKOUTS/Q// ...... N L' 18 CUTLET I 12' INLET
TEST 48.8i3 PLAN-SECTION CROSS SECTION
UTION BOX
,
HOLESTR B
�. b e ��p tic S 0t..... . . 32
# ....• •"'' •• 3 HOLE
eb ..... ........•..... ..............
NOT TO SCALE
1
sB`e" & - 50.34' acTEST PROPOSED . SEPTIC SYSTEM ' REPAIR
3sy ti ��a E`e 50 / HOLE PREPARED FOR
s.,
¢ LOT 56
DAN IBILLINGS '
} _ ,� ,� E L GT
AREA=20,810± S.F. CO
•rr: N
;? r; X-48.02' 0 3° 4 O X OAD
49.................................. ...X 49.91••....... o BLE MA
{} 2 0 FORD
MEd;. 1p� o OTUIT) BARNSTA ,
{i,t septic•••setback r N
PREPARED BY:
4260 OXFORD ROAD 19.1.00, k8''• Glen E. Harrin ton, R.S.
g
021-081 v 50.41 IN -' 9 Leda Rose Lane
town02648
w Mills,s
a �o-"'�• s M ill
e t0 r a rs M
SI
TE
PL AN
O Tel: 774-238-1813
SCALE: —' 2 0' Email: gharr880hotmail.com
B.M.=50.00' (ASSUMED) ' P
SCALE: 1"=20' DRAWN BY: GEH DATE: 4 OCT 2021
ON C.B. FND
DATUM: ASSUMED FILE: 240 OXFORD SHEET 1 OF 2
SYSTEM PROFILE w f
Existing Dwelling *NOTE: ALL PIPES ARE TO BE -4' SCHEDULE 40 P.V.C. 3 HOLE H-20 ^" T Not to Scale
DIST. BOX
D—Box cover shall be
within 6" of finished grade ,
Finished grade over syst0ni=2% slope away Existing Grade = 53't m
Existing Grade =54't m. 1/8"-1�2 Double—Washed Stone
Septic tank covers-must be Provide 4"110100103 tee on One chamber cover shall be 70or geo—textile filter cloth
CELLAR within 6" of finished °grade
d—box inlet —
within 6" of finished grade of SAS=50.5'±
S = 0.02' ft 5=0.011/ft Invert Ele =49.70'
WALL S=0.01'/FT.
12' EXISTING
1,000 GAL. 20' 13' ,- I= ® ® C3 ®. ® 24"
SEPTIC TANK 0' P=49.83'
® � ® ® ® ® ® ottom o Leach Facility Elev.=47.70'
'Existin Invert H-10 _
Install Gas Baffle
or a ual P=50.00' S' Mtn. 10' PROVIDED)
" Ex. Invert Elev.=52.45 3/4"-11i" Double—Washed Stone
6., OF 3/4"-11/2" STONE H _ 0
Bottom-of t Hole Elev 37.70'
- 6" OF 3/4"-11/2" STONE - . '� Y- m
LEACHING CHAMBERS. SAS LAYOUT
• � Scale: 1 =2
CORNER DWELLING/DECK .TO CORNER SAS
-A 1 -- 2 B 1 • 50 9
A-2 = 23'-6' B-2 _- 27'-4" 1
Min. 2"-t/a"-1�2"Double—woahed stone D 8 S I CI h Calculations
r
Ia. one chamber cover shall be or goo-textile filter cloth f ddrooms: 3 Equivalent to 330 Gal./Day; ;
within 8" of finlahed,grade To. of SAS Number a 6, .
Garbage 0(ap9q?L"f,Not allowed with this design
Septic Tank Cppa�Ity Required: 330 gpd x 200% = 660 gpd. '4 '. •fi;.
G Septic Tank Cpppelty Provided: Existing 1,000-gal H-10 septic Tank �'
C O O C7 C7 P 24" o Facility Elev. _ Leaching Copacity Required: 330 gpd x LTAR 446.5E Req'd.Area
LTAR for Class I soil at <5 min./inch, = 0.74 gal/sq. ft.
4 5 4 Proposed Leaching Structure: 1-25'x13'x2' Leaching Trench
5' Min. I Area Provided = 325 sq.Ft. /// // ''::..:.; :•`•:
3/4"-111" Double—Washed Stone_ 6ptQm Leach ng r
H-10
S(deWail Leaching;Area Provlded = 152 sq, ft. -
CHAMBERS Total Ledohtrig.Agee Provldd 477 sq. ft. > 446 sq. ft req'd ////�//
/ 2
LEACHING CHA Leaching Cdpacity Provided �p77 4q" ft.X 0.74 gdl/sq.ft.=353 gpd.
'CROSS SECTION
PERK:' TEST & SOIL EVALUATION
CONSTRUCTION ' NOTES DATE OF TE5� HOLE: AUGUST 25, 2021
Performed By` GLEN E. HARRINGT, R.S. B
1. Contractor is responsible .for Digsafe notification f Witness:
and protection of all underground utilities and pipes. Excavator: ZACK; CAVOSSA EXCAVATION
2. The septic tank and distribution box shall be set Percolation Rate < 2 MP_I IN C1
level on should be4c'lean/sa,ndtoregravel with riot Test Hole t
3. Backfill
stones over 3" in size. No. 1
4. This system is subject to inspection during installation ; ELEV. PROPOSED SEPTIC SYSTEM REPAIR
DEPTH SOILS
by Glen E. Harrington, R.S. EPREPAR D FOR
5. The contractor shall install this system in accordance 0/A/5 DAN.IEL G, BILLINGS
with Title V 'of the Massachusetts Environmental. CodeIsoa�rrdty:and local Board of Health Rules and Regulations. AT
6. If, during installation the contractor encounters any 10YR4 2 47.49, aw 240 OXFORDROAD
soil conditions or site conditions that are different d
loam d
from those shown on the soil log or in the design, �� ' sandy" son - TUIT) BARNSTABLE, MA
II halt installation and immediately notify OYR5 6 44.67 " 10YR5 6 45.70
the installer she 4
PREPARED BY:.
i
Glen E. Har
rington,ton R.S.
9
7. No vehicle or heavy machinery shall drive over the wr Glen E. Harrington, R.S.
septic system unless noted as H-20 septic components. Ct C1 n q 9 Leda Rose Lane
8. All piping shall be 4" diameter SCH 40 PVC unless otherwise specified. meal m' medlVm 7 Marstons Miils, MA 02648
9. No wells are located within 150' of proposed SAS. son� / san �� O Tel: 774-238-1813
10: Provide 1 DB-3 H-20 d-box and 2 H-10 500-901 concrete 2.5Y6 4 2.5Y6/4 �►q(a'Ig•jEQ`�� Email: ghorr88®hotmail.com
chambers by Wiggin Precast or.equal. _ 'VITA
11. Existing leach pit shall be pumped and backfilled. x "_20' DRAWN BY: GEH DATE: 4 OCT 2021
12: The designer is not responsible .for undocumented septic components. SCALE 1
120'� 38.32 126" 37.70
DATUM: ASSUMED FiLE: 240 OXFORD SHEET, 2 OF:2
NO GROUNDWATER ENCOUNTERED
on-
-
50
e
_. _ ..
i
4C K --
t_J L`�7 c
cr?7E'-S+.' r) 9'!-''.JL' C1 LEI-e'? .�C'�i le. -
" ' .__._. C�. T I` U /f��...! �f= �2 T. S C F�c_� 1 - i c� t`''If�N 1-40 L� C 0 iJ�. 5 ��� ,:�.a/,� � ,t.,t
c -- ,., �.-_a.._.. Pt•c�/vt7�;�C�'• �''cOtJr;� ��.�� /`'
IP_otj Crr)/,-1/,T7c;m .. �e� t-0O7`� 3!'8"PeLL5`fvne
1 _ -
tLOMA �A
wa 5 ed Stone s N�
SEPTIC TFanIK r�c
,- Fj
LEACH PIT
.lz{ n �•�•`,�~ may/ E LQ tiI Nc�c/ E L'.At�_":__ T
O O'/ � �' }I }
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y
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cG7v:-, SNCJWAJ Oti/ TH15 PL c Al DC7E5
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j BFaC iC ,�E G?Ul�.'E t`'7EnJTS 0�= Tf�'�.
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