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HomeMy WebLinkAbout0028 POINT ISABELLA ROAD - Health 128 POirlt I80bellA Plvf4 Cotuit A = 074--015 C 7 IINSTALLER'S TOWN OF BARNSTABLE LOCATIONOrw7S5� � 4 A 1D SEWAGE #v�S--/II.LAGEASSESSOR'S MAP & LOT NAME&PHONE NO./3a�- / SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3VO Ce �lia wrO.r�l 3 (size) NO.OF BEDROOMS BUILDER O OWNER As- PERMrrDATE: 4Y- `I�f COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by /�a � ��f a� 1 y', �� d` �G' y�' oy�' o � f��wGal,,,]'` No. CAL Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppfication for Digool �&pgtem Con5truction Permit Application for a Permit to Construct( )Repair(+/)Upgrade( )Abandon( ) El Complete System TIndividual Components Location Address or Lot No. ° Owner'srNe,Addr ss an Tel.No. .ass or's Map/Parcel (� Installer's Nam Address, d Tel.N . 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.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 443 gallons. Plan Date Number of sheets / Re/t ion Date Title Size of Septic Tank X 5'7'%f7 Type of S.A.S. —v � oW 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 Certifi- cate of Compliance has been issued by t ' Bo d Healph. Signer-->S Date Ti Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued y, - -. .. .. z ........- ., -. AC. No. M1t , ery Fee .� TI-1 COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -;TOWN OF BARNSTABLEt MASSACHUSETTS f� �r Zipplication for Zi! ogaf *pgtem Construction Permit Application for a Permit to Construct(,. #Repair(1/ )Upgrade( )Abandon( ) El Complete System eIndividual Components Location Address�c Lot No. 5F&a Owner's e,A ess Tel.No. s 0'sors 1 /Parcel r ' i �s CO7400i Installer's N Address, dTel.I$o Desi n is Name,Address and Tel.No. yz 8' z Type of Building: Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder(� Other Type of Building �� �'`£'No.of Persons Showers( ) Cafeteria( ) 1 Other Fixtures ll --- Design Flow y//7412 gallons per day. Calculated daily flow y� gallons. .�_ Plan Date Nu}uber of sheets R��'sion Date Title yr ✓�� q'�! T Size of Septic Tank /©n_PP? �Xf�7`%/ Type of S.A.S. 3 "J`w Description of So> ; .. Ids ym*Z_ Nature of Repa rs or Alterations(Answer when applicable) f 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 `ssued by this Board •,Hea Sign d Date Application Approved by Date Application Disapproved for the following reasons "t � I Permit No. Date Issued ———————————————————— -- —————— -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (certificate of Compliance �, THIS IS TO CER FY, that th ,On- ' Swage Dis osal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )byL�o�s - at OIX E S �© LI/,T h been cons cte Irin cord nce with the provisions of T e 5 and the for Disposal System Construction Permit� 5 dated /U t Installer C��_10 N-t Designer The issuance of this permit shal nottte co�tstrued as a guarantee that t e systerp uncti n s designed. Date e Inspector a _... ———————————— _--=------_.. . . No./ �0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS -- Di!5poga1 *p5tem Construction Permit Permission is hereby granted to Con4 ruct(T),Re aid ) pgra ( )Abandon System located at Z $ lyl e �� ���� CO cf 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 mist be pleted within three years of the Oate of this p Date: ✓ co� Approve y I f FROM :down cape engineering. inc FAX NO. :15083629880 Nov. 07 2005 01:49PM P1 Towle of Barnstable Regulatory Services a Thomas F. Geiler,Director D"MKAS& Public Health Division 039. . 60 +" Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 -4 4 Fax: 508-790-6304 - 6 4 office: 508 8G2 Installer& Designer. Certification Form l Date: Sewage Permit# 0005"V?O Assessor's MaplParcel 7/ ��C/� Installer: 0/` Designer: 0 '�- Address: Address: P D• 40 X 70 �4- On 1,�/-0 01Y51111- was issued a permit to install a (date) A L (installer) O2a d r`1 �1�a�b ` �-O/l� I septic system at � � � based on a design drawn by / (address) dated (design ) /_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. � �N OF*Sn ARNE H �yc OJALA (Ins er's Signature)\ eNIL y No. 30792 C'fBT�,R ► ONA, (Designer's Signature (Affix Desi tamp Here) PLEASE P.ETURN 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:Health/Scptic/Designer Certification Form 3-26-04.doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' A DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: � � �(' _J�3,:R 4 f C--�— Owner's Name" c.� Owner's Addres Date of Inspection: Me- MailingName of Inspectar.- (please printCompany Nam Z Address: ? Telephone Number: GC CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the.information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority •ils Inspector's Signature: Date: /"0 -f&I The system inspector shall submit a copy of this inspection report to the,approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of]0,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office.of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,land the approving authority. Notes and Comments 'k'j"i,. Y'Ra +. ,. t .i... ..M ., ,. . ", . e w.n a ......w . ♦... . .. a.. .♦ -n. .. ..1A..a.e,. •.. .. , ..h+b.M w..n.. .a ./. {.... tk-. ****This report only describes conditions at the'timeYof ins ectioft'a'nd under i i ' �' ' at- �' p the cond�tion�of use at that: '! t' time. This inspection does not address how the system will perform in the future under the ame or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of.11 {. OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESS d MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ®' & Owner: 4 4 9 Date of I spe ion. 0C)s Inspection Summary: Check A,B;C;D or E./ALWAYS complete all of Section D s �' A. System Passes: V I have not found any information which in that any of the failure criteria described in 310 CMR 15.303 or in 310•CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.- Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass,.section-need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by.the.Board of Health..Will pass. Answer yes,no or not determined(Y,NND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally: _ unsound,exhibits substantial infiltration.or exfiltratiori or tank failure is imminent:System will.pass inspection if the existing tank is.replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank.will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation.of.sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution.box is leveled or replaced ND explain: The system required pumping.more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection.if(with.approval of the Board of Health): broken pipe(s)are replaced obstruction is.removed ND explain: Page 3 of 11 OFFICIAL INSPECTION.FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DI.SPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: d C � ,Gl Owner: Date of In ec n: C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any):determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 7 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has aseptic tank and SAS and the SAS is less than 100 feet but_50 feet or more from'a private water supply well**:Method used to determine distance **This system passes if the well water analysis,performed at a DAP certified.laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered:A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—.NOT FOR.VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: J*11"V-Q_ Date of spe ion: D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes No. tJ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . Discharge or ponding ofefiluent 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 iquid depth in cesspool is less.than 6" below invert or available volume is"less than '/z day flow �/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped /V Any portion of the SAS, cesspool or.privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water.supply. V Any portion of a cesspool or:privy.is within.a Zone.1 of a,.public.well. Any portion of a cesspool cr privy is within.50 feet of a.private water supply well. Any portion of.a cesspool or privy is;less than 100 feet but greater than 50.feet.from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certd'ied laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence,of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other failure criteria: are triggered. A copy ofthe analysis must be attached to.this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as described in 310 CMR 15303,therefore the system fails. The system owner should contact the Board of " Health.to determine what will be necessary to correct the failure. E: Large Systems: To be considered a.large system the system must serve a facility-with.a design flow of 10;000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to'each of the follo..wing: (The following criteria apply to large systems.in addition to the criteria above) yes . no _ - the system is within 400 feet of a.surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any ques,ion in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Paee 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: P Y Owner:11*9 1 Date of I pe lon: o Check if the following have b:en done. You must indicate"yes"or"no"as to each of the followins: YNo /Pumping.information was provided by the owner,occupant,or Board of Health . t/ Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? _ V Have large volumes of water been introduced to the system recently or as part of this inspection? . Were as built plans,of the system obtained and examined?(If they were not available note'as N/A) t/ Was the facility or dwelling inspected for signs of sewage back up V Was the site inspected for signs of break out? V _ Were all system components,excluding the SAS,located on site _ Were the septic tank manholes uncovered,opened,and the in_erior of the tank inspected for the condition of/the Kb ffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum _ Was the facility owner(and occupants if different from owne-)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location:of the Soil,Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property.Address: } Owner: Date of pecO n:, S. FLOW CONDITIONS RESIDENTIAL. V' Number of bedrooms(design):. Number of bedrooms(actual).: O DESIGN flow based on 310 CMR 1.5.203 (for example: 11.0 or x#of bedrooms): .. Number of current residents: _ Does residence have.a garbage grinder{yes or no): Is laundry on a separate sewage systeWs or no). [if yes separate inspection required] ] Laundry system inspected(ye r no) g . Seasonal use: (yes or no.): ©�D ��`73, ��� Water meter readings, if av ilable(last 2 years usage(gpd)):®�4 / Sump pump(yes or no)�: O Last.date of occupancy: ✓ COMMER.CIALANDUSTRIAL 1\161 Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the.Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped 8part of the-i sp�ction(yes or no If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE Of'SYSTEM I _w5eptic rank,distribution box, soil absorption system —Single.cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the:current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Ap roxi. ate 11Aage of all components,dace installed(if known)and source of information: Were.. ewage odors.detected when arriving at the site(yes or no)' S . Pa.ge.7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM-INFORMATION(cor_tinued) PropertAddress: � V Date of I pec 'on -- '7� BUILDING SEWER(locate on site plan) Depth below:grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): - SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:jzConcrete_metal_fiberglass_polyethylene other(explain) If tank is.metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) o Dimensions: k �{ Sludge depth: 10/1 — I rk 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 b0jVryj of outlet tee or baffle: How were dimensions determined:.' Comments(on pumping recomm., dations, inlet and outlet tee or baffle condition,structural integrity, liquid levels a elated to outlet invert, evidence of leakage, etc.) &e - e? GREASE TRAP7k) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8.of 11 OFFICIAL-INSPECTION FORM-NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / (, Owner: Date of I e t'`o / 70490 TIGHT or HOLDING TANK:/ (tank must be pumped at time of inspection)(locate on,.site plan) Depth below grader - _ - Material of construction: concrete metal. fiberglass.��olyetfiylene ottier(explain): Dimensions- Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan ) Depth of liquid level above outlet inve_t: Comments(note if box is level and-distribution to outlets al,any evidence of solids carryover,.any evidence of 1 kage into or out f box, e .): A PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no) Alarms in working order(yes or no): Comments(note condition of pump chamber;Condition of pumps and appurtenances; etc.): Paae 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:1211.1 --. Date of In pee`i n. e 4a Z 4� 06 SOIL ABSORPTION SYSTEM (SAS): {locate on site plan,excavation not required) If SAS not located explain why:. Type aching pits,number:_ leaching chambers,number: leaching galleries, number: leaching trenches, number, length: . leaching fields, number, dimensions: overflow cesspool,number: innovative/alternative system.Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, r el iA s A", / CESSPOOLS:k(cesspool must be pumped as part of inspect ion)(loate on site plan) Number and configuration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspools Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition-of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: ;� :(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 1.1 OFFICIAL INSPECTLON FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pr J operty Address: Owner: ..'' Date of In pe o 0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system.including ties to at least two`permanent reference-landmarks-or benchmarks. Locate all wells within =00 feet.Locate where public w4ter supply enters the building. XPP (PC k. . , r l u �r7 �eacl Pag e l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: P Y Owner: / ' �r� Date of I pec on: r��`' SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground Water- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers=(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 4 k 1 l . Permit Number: Date: _ Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: (� �d �1� Lot No. Owner: C C Address: Contractor: Address: `1 � c�c>��.Y 001�r ' Notes: z STEP 1 Measure depth to water table LT os� z1 '- to nearest 1/10 ft. ................. ..... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well..........................`' �.......• OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... r month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) / determine water level adjustment ...:..:..:.:.............................................................................. STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4)' from measured depth to water levelat site (STEP 1) ............................................................................ ............................... / 3 t Figure 13.--Reproducible computation form. .15 qq I i } ZIT ki { -s"NO e 4 No..- -•-- ._....... V{ . ., FEB.,.. ..................... THE COMMONWEALTH OF MASSACHUSETTS Fa. BOARD OF HEALTH .cv�_/,,).................OF.........E./.Y12.Pa.SP.W. 1 L:C�......:.....-._.._._..._. Appliratilau for Ta nstrurtion Prrutit Application is hereby made for a Permit to Construct ( &,"'Or Repair ( ) an Individual Sewage Disposal System at: A-bi�v. ....s �P:s?:r6I�A .A.±�L..-...2s27k:i'?....... ........••. Q l..../.0............................................................ .. ......••-- Y L3attion-Address or Lot No. A s�© �.•--- "s vc ... .....•..------•----... �`. 3 7 3 C4 i %t. ... . ....... -...-•------.... . . .. . . ...... Owner Addre s aM-T....., .% v L....................... .._ s..... .// Installer Address Type of Building .� Size Lot...76.00-----Sq. feet Dwelling—No. of Bedrooms..........7:?............................Expansion Attic (ND) Garbage Grinder�_r aOther—Type of Building ......leaf 4.......... No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .......................................................... ....---•--------------- --------•-••••----------------------........-------- ........ W Design Flow...........lf A -.....................gallons per Ft9da�y. Total daily flow__._.._..3.3.o...................gallons. WSeptic Tank—Liquid capacity1 ,0 .gallons Length!®........ Width.6•.W."... Diameter................ Depth...57. ..... x Disposal Trench—No..................... Width............ Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No .............. Diameter.... 11.... Depth below inlet.....C........... Total leaching area...3-'. _.__....sq. ft. Z Other Distribution box ( ) Dosin&tank ( ) aPercolation Test Results Performed R-_ - Date... v4? ,.a Test Pit No. 1. _t.....minutes per inch Depth of Test Pit.....1.2..`..... Depth to ground water.... ...... Test Pit No. 1s::_2 .....minutes per inch Depth of Test Pit....rt ....... Depth to ground water.,'U,/V97...... --•-•-----------------------•--•---•----••------.................................-•-•••......--•••••......................................................... O Description of Soil...0..- xS.,.Ze'.4j.z ------..T,&"s..-----•��,esr�.<.r�a�z�........-1A.....3-v 1 ...----��r . �.�..�------------- V b 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 TITLE 5 of the State Sanitary Code— The undersigned her agrees not to place the system in operation until a Certificate of Compliance has ,been ' sue rlth. Sign ..... ._.gDate Application Approved By....._._._- .�•_•.. ..G1 .. Date Application Disapproved for the following reasons:-------••---------•-••-•...........................•-••-'•----•-------------•------......_...-•-•-------•..... •.............•-•-••-•-•---------------•----•-•-••---••-•••--•....--••---•---•---••--•-........--•••--•-...-•------•--•-•-•- ----•---••--•.._...-••-•--•----•••--•--•••-......---•--•-•••-........._. Date Permit No......................................................... Issued.•••. g Date No.- •- ............ Fic .......,e......"............. THeCOMMONWEALTH OF MASSACHUSETTS w, BOA D OF HEALTH �.C1.rv.v.I► ................OF..:.... 'j': 1 t; :� '.a�._ `...................... Aypfiraffvn for Uiuppsul Works.Tonstrurtiou 'llamit Application is hereby YFinade,for'a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at:,., _. ... ............................................................ cation-Address . or Lot No. 4` j ,........,�� r�s,y Qr ,� pp�� g / W !/ !Q t 4 Owner Adr`7 /eflS M f a -------------------------------------- Typea .. ............... J� qInstaller Address of Building Size Lot...260-0.0....Sq. feet Dwelling 4 No. of Bedrooms._._ ...._Expansion Attic ,(^ao) Garbage Grinder XzF..r a Other—T e of Building Ai No. of persons f a �p g ---- p --------- ._. Showers ( ) — Cafeteria ( �)•,�:: Oher fixtures ..._••• --•-•--••--------•-••---••---•-- ...-•------------------•-• { w g ;gallons per °gyp r y gal Design Flow__.ff{ ...r!f_tJ_.__.. da Total daily flow.__.....__t ._ ..... ........... lons. 9 Se tic„Tank_,r I squid capacity/�"0�gallons Length/® r,.�Widths >� .... Diameter................ Depth .�' P w Disposal Trench No......_.... `�`'"_. Width.................... Total�Length..._..__ Total leaching area-----_.._____._._.sq. ft. Seepage Pit N.&___�•`�._ "DiametItr....f' ."� . Depth below inlet..... ...... Total leaching areas _�_>6...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by._. *?VA >...A,... Date__ V;;�<?'............ a ._ minutes per inch Depth of Test Pit.._.e.;._ .._.. Depth to ground water_.&0�4v_e.___. Test Pit'%�To 1' .___. Lt, Test Pit,�ro. 2.&C' .; __..minutes per inch `Depth of Test Pit.... :`....... Depth to ground water r_trA0;*t_e"...__._ a, ,< .... Description of Soil 0+ , _�'` t�i' '_. ` '>.d r ,rza..'.....f � �f r t ------ w w U ,-Nature of Repairs or Alterations-Answer when applicable............................................................................................... Agreement ' The underaigiied agrees to install th"foredescribed Individual Sewage Disposal System in accordance with the provisions of TIT`.,• -of the State Sanitary Code—T e undersign! her agrees not to,place the system in operation until a Certificate.'af Compliance has-been sue bo alth. igne -__----•-- --•-----•-- • ••-- •- Date Application,Approved By - ------- Application'Disapproved for the following reasons ---------------------• // .............................................................................. ( .......... -... Date e } Permit No........................................................... Issued-........................... �b . Date THE COMMONWEALTH OF MASSACHUSETTS a ° BOARD lir HEALTH ...........OF..."......... 4- ,. ................................•..... C9rr#ifiratr of f omplianrr THIS IS CER IFY, T t the, ndividual Sewage Disposal System constructed ( r Repaired ( ) Ph ..._ •--•---•-•-----•--•------•----•-------•...................•-•---------•-------..._._...---.............----••••••-•-••--•-•....._. Installer at._...--- . x ...�.. a has bestalled-i.. ac'c�o'rd®ance with ie pfovis ons of i-L jg ta� nitai o`d a scribed in the application. for Disposal Works Construction Permit No _ .__ dated-- ------- _.. THkISSUANCE OF TINS CERTIFICATE SHAL`�NO BE CONSTRUED AS A A�TEE �WAT THE SYSTEM WILL FUNCTION SATISFACTORY C/ S DATE ` - ........................................................ Inspector--------- ........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD 1OF HEALTH t OF..... .. ' No 7 x:____• .L...... ¢ FEE .. Disposal Work.6 f.unstr #ion ramit Permission is hereby granted .................. .............. . ------- to Construct, ,,,,,), or Repair ( )� av, i Se �5i s s at Now:.... .... .:..__fit.... .. ':..••-- - -•-•- as shown on t e application for Disposal:.Works Construction Permit N, ......... :..... Dated _. . -�... ....... DATE 7 �;> " FORM 1255N'HOBBS. & WARREN; INC., PUBLISHERS - - - .,,. LO CAT IO , SEWAGE PERMIT NO. VILLAGE ; � � INSTALLER'S N E & ADDRESS B UILDE'R OR OWNER DATE PERMIT ISSU ED <:2_ 3-' _-7 a D A-T E "*M-P L I A N-E E-- I S S U E..D f �� � U' �� 1 r, `� ,,e r � � Y , � �. I , L� �� r � � � �s o� ..o iJETLAN' 7 L c T H O L_E � f JULY �07 19 7/5 .i 0`\�° LOT l I �� a PANT_ Mc_RRA T N pEr 7 Ka DOD LdT /D t ELEVt O-/8 LOAM AND ` e a 5JOSJIL /B /q4 " MEDIUM 5AND ' 3 5 t e LOT 14 Fr!r� iGS }. Ll�E / ELEV &a 4 �'� i �� •.s. / 43f8 li ,,, NO WA ENCJ! �"r'TEv Y EST / 110 hOLES O,o SOWN VvlATEF i5 !�Y/ 1L/4 / I t''1iNFR7fC Y�f1�® T AA'K ��TF r r LEACH o' �o' 'I o., LOT 15 C.B. ASSL)M't � Sow" ELEV 50,0 9 y TL:-:447c:E �. -. t � �20•PO SED SE P T/.C, 5 y5 TAM. CANS T2 UCT/ON SHA [_[. CpNF02M TO .MASS • U5/Gti1 FLO!!V E Nvi,2 czn•/MEn/rc�L Goof. Ti rL:� Y _ j ,L C-q CA/ 2A TE a M/A/. 4,�54CIV A E,54 - '.aC?.3 AT/DN5 SEa . L�<iC/ / TOP OF P2�,00 Fo un/oAT/On/ 2 .,OF .aE.4 S�'p/VE 9.6 4 N N 0 1AlPC,?✓/O S Co VE,�L # - , C TO_,a2E Ve c/T /A/G� yl!/ T"/N/A/ / OF . /�T2 4 7/.v6 I ./ coves Z o CleA.DE. I BOX _ I; �.Z/"6V>DE oVeR t M/nJ/nl Un/ _6 M tit 3"n i/ . ' 4 '�/A Alb a . mot-- f G� /TCH - Ft-Ow L,�E M/,v p _'�-_ 4 Di`1. •.`_E4.�"� /OL' .�/7- 0 '�'/ TCe/"' T Min/ /4�" �4 /fool . 2.. Mini pirefi 3�4 ��L D/A. :. MiN j /4"/moor y n a �0 of WAS HEO /ntvFZ r C 5 TD fvE . /iV VE2? CA pA G r T-y ' .4 rZ ounlQ . . / �WA TG-�T/G hN T�. $dTToM OF _ ` ( P/r/NVEZT \ 35.0 _C� tI Jam/ .•/ _ � "A ,P- F_-/-fCE ON TAN,L D/ST.42/BUT/O'N 80X GONCTZE7 p lC,yO�n1G',eETE S'T/�E,c/G77� 3000 Psi tiI/n1 .F V EN f" \ f 1 \I ti 3. f S EEL 20000 y yrf f LOAD//�/G A4�;' 7� Dom/VEVIAY NOT.TO �3E LOCATE, I Lt-RTIFY THE -BUILU!/V� .SNp%i1V oN Tfi'/-S /� 4''Y, DES/G�1 LO�L�ivG /S lJS�D: . PLAN !S PROPOSED 4� 1�OSED SMOGION AND l T .DOES CON�"c7PM TO C',t,1lL D/1Yu S 7c3/?CI; t?..' T11E 70PiN 0' RAPA/S'fA B L� \ j4 •;�$� � ,Q.I -_ l Z. { Dq TE .�/EALT�/ �t0E.c/T , /. . l 11 ' i n 1,4 SYSTEM PROFILE � TEST . HOLE LOGS MW,§-!FNDN, AT EL. 34.7' �+w P " GRADE (NOT To SCAIE) PROVIDE INSPECTION PORT WITHIN � ACCESS COVER TO WITHIN 6 OF i�N* ACCESS COVER (WATERTIGHT) TO 6 OF FINISH GRADE ENGINEER: RICK JUDD, RS 1 ass t I33- ' MINIMUM .75' OF COVER;OVER:PRECAST WITHIN $" OF FIN. GRADE REQUIRED OVER SYSTEM , .* 2S SLOPE E TEM 33.0 - 34.0 WITNESS: DAVID STANTON, RS ; " DOUBLE WASHED PEASJQNE 9/21/Q5 z A' �+ RUN PIPE LEVEL ,��' DATE: s FOR FIRST 2' 3' MAX. PERC. RATE _ < 2 MIN/INCH y o GAU,ON;;SEPTIC 32.2'*k s ,s 7 31.0, CLASS I SOILS P# 11052 Focus TANK (H- 1.0 ) GAS BAFFLE 3Q.4T 30.30' p ME] C� C7 C] C' 030.17' 6" CRUSHED STONE OR MECHANICAL' [ f Q Cl ( Cl Cl Cl COMPACTION, (15.221 [2]� 2 CJ L: © Cl © L=1 C 1 C".1 O o 28.17' 1 ELEV. 2 pgNT VSABELLA DEPTH OF F40W •� q�- 6 E) 1 3/4" TO 1 1/2" DOUBLE WASHED STONE �» 29.0' - � (. �„% SLOP (_„�,._R SLOPE) , TEE SIZES: III {;1 WEFT DEPTH .� FILL „ FILL ,a Ft.#x w �. 24 r 1 4►e 10 OUTLET DEPTH - ,...., A/E A/E LOCATION MAP NTS r LEACHING LS LS NW, 4�II�, 6 f 41 FOUNDATION- EXIST. SEPTIC TANK 29' --- D' BOX 15' FACILITY .. ASSESSORS MAP 74 PARCEL 15 i�11*f� 9.67 34" 10YR 6/2 14 10YR 6/3 I #ryk q2 ., *THE INSTALLER SHALL VERIFY THE THE INSTALLER SHALL CONFIRM MINIMUM SEPTIC LOCATIONS OF ALL UTILITIES AND ALLTANK SIZE OF 1000 GALLONS, AND DETERMINE BW SUITABILITY FOR RE,VSE, REPLACE WITH 1500 GAL. B q� s41lkIl m �§, BUILDING SEWER OUTLET$ AND ELEVATIONS TANK IF NOT SUITABLE FOR RE-USE & ADD ye PRIOR TO INSTALLING ANY PORTION OF REQUIRED TEES AND GAS BAFFLE LMS SEPTIC SYSTEM LMS ' ;r, t5.2$ N 10YR 4/6 10YR 5/6 " 'UNSUITABLE SOIL % 1$.5 56» 24.33 40" 27.2 Aglff ND PERIMETER OF FAQIWTY, DOWN TO %, C E iI,I1TA E'LAVER. REPLACE *w +i CiQ . .90 C VNTH MED. SAND. , a a� 7 Q + PERC FMS bra I FMS �tw,001 4 ro 8,1. \ a,b7 2.5Y 6/4 > 2.5Y 6/4 126" 18.5' 132" 19.5' NOTES: * w,� NO GROUNDWATER ENCOUNTERED 411,44 SEPTIC DESIGN: GARBAGE DISPOSER IS NOT ALLOWED APPROX. NGVD ( ) 1. DATUM IS DESIGN FLOW: 4 440 EXISTING __ BEDROOMS ( S GPD) - ._49._GPD 2 ���_�n� r�onL WATER IS 1f USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 7 *' SEPTIC TANK: 440 GPD ( 2 ) = 880 4. DESIGN LOApING FOR ALL PRECAST UNITS TO BE AASHO H-- 10 # + ` � s ° `�s 6 .�� *,,•� 5. PIPE JOINTS TO BE MADE WATERTIGHT. LOT 11 RE-USE 100Q GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. LEA ENVIRONMENTAL CODE TITLE V. ' WSW, !# 2 40.5 + 9.83) 2 74 = 149 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 3I ` SIDES: �' ) 40.5 x 9.83 (.74) = 294 TO BE USED FOR ANY OTHER PURPOSE. „ 4. 4 TOP FNDN w'34.T ,� BOTTOM: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. I ,..., + ,7 43Sa , ST '1; 4.81 59$ Ft .r, TOTAL: B.F. 443 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT '\ INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED BdsICCFIMIA�RK �� , " 1 .h�26.5 24.31 USE (3) 500 GAL. H-10 CHAMBERS [;,ACME OR F COR'GRANITE S 4 71 +�4.53 3 ,;;' `Ar * 6,89 FROM BOARD OF HEALTH. z' ,�+.,� 26.00 EQUAL) WITH 2.5 STONE AT SIDES, 3.5' AT ENDS 10. PUMP & REMOVE FAILED LEACH PIT a.65 \��F'I 4 4 R. .8 % AND 4' BETWEEN UNITS 5 RAVED ,E 4i[ xs + Os '•, DRIVE Q' f 27.47 404t, . 1 L END 08 TI TL E 5 SITE PLAN44 k '• 3. � PROPOSED SPOT ELEVATION OF 28 POINT ISABELLA ROAD 10OX0 EXISTING SPOT ELEVATION,41 IN THE TOWN OF: 0 9 ' 1 ,oo PROPOSED CONTOUR aa,� ( COTU.IT) B A R N S TA B LE ,► 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI rsrtifiG 'r ; '�, 4. CON STR U CTI ON/D eM ELLO ` , ELEC METER CATV TEL RISERS 30 0 30 60 90 .' aN rss f- BOARD OF HEALTH 33, 3 SEPTEMBER 24, 2'005 �p MA SCALE: 1„ = 30' DATE: APPROVEJ DATE 34.04 i off 508-362-4541 fax 508 362-9880 �c9 SO. 9�F I ���ZHOF!/gss9 �(HOF/,fySJq` C> � � o ARNE ,h �.� down cape engineering, Inc. ��� ARNE H yc� H � �minu� a� Q. OJALA - I O CIVIL OJALA ,s ; ff'.T 90 CIVIL ENGINEERS No. 30792 No,26348 LAND SURVEYORS �.��Fc TERM ss\Oo� s vE fl cy 939 main st. yarmouth, ma 02675 , AR N H. OJALA, P.E., P.L.S. DATE .. a