HomeMy WebLinkAbout0614 POPONESSETT ROAD - Health I
614 Poponessett Road
cotuit
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UPC 12834
No, 2-153LW opOST•CONSJ��
HASTINGS, MN
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COMMONWEALTH OF MASSACHUSETTS copy
F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 Q
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS /
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
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Property Address: 614 Poponesett Road
Cotuit,MA. 02635 "~
Owner's Name: Ray Pendergast < a;i
Owner's Address: Same u7 OD r
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Date of Inspection: 7/07/2005 �
Name of Inspector: (please print) Brad J White'
Company Name: Windriver Enviromental rr"
Mailing Address: 107 N.Main Street
Carver,MA 02330
Telephone Number: (508)-866-2576
CERTIFICATION STATEMENT
I certify that.I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my .
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: -7 Date: 7/07/2005
The system inspector shall submit a copy f this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
System Passes.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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Page,2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 614 Poponesett Road
Cotuit,MA.02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
System passes.Recommend regular service.
u
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass",section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined please
explain.
The septic tank is metal and over 20 years old*.or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health): .
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
''obstruction is removed
ND explain:
T;tla G'T--t;—P—All G/100(1 2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 614 Poponesett Road
Cotuit,MA. 02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
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
.Ik .
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less.than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
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Titles C T»C—t;— 17-411 Cnnnn 3
Page,4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 614 Poponesett Road
Cotuit,MA.02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
T;tio r, T" .,t;, R4/1';i100n 4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 614 Poponesett Road
Cotuit,MA.02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks'?
_X_ _ Has the system received normal flows in the previous two week period? "
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection'?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ,
_X_ _ Was the facility or dwelling inspected for signs of sewage back up'?
_X _ Was the site inspected for signs of break out'? k
_X_ _ Were all system components,excluding the SAS, located on site'?
_X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information. For example, a plan at the Board of Health.
X_ 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)]
F
Titles r, Tnc—t;nn.P—n 41.14;MMO 5
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 614 Poponesett Road
Cotuit,MA. 02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):440gpd
Number of current residents: 2
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): Yes
Seasonal use: (yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 237gpd
Sump pump(yes or no): NO
Last date of occupancy: Current
COMMERCIALANDUSTRIAL
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: Pumped may 26,2005
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool '
_Privy
No Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
System was installed in 1987 per as built plan of system.
Were sewage odors detected when arriving at the site(yes or no): NO
TirIP G Tncnartinn Rnr.,,�ii cnnnn 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 614 Poponesett Road
Cotuit,MA. 02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
BUILDING SEWER(locate on site plan)
Depth below grade: 22"
Materials of construction:_cast iron X 40 PVC other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer is in good conditon.
SEPTIC TANK: X (locate on site plan)
Depth below grade: 10"
Material of construction: X concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 6' x I F
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: Measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.): tees in good condition.Tank is structurally sound.No
evidence of leakage in or out.
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass__polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Titles G T--t;n Ti° 611 4;1700n 7
-Page 8.of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 614 Poponesett Road
Cotuit,MA. 02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass___polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)(24"below grade)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): Distribution box is level and distributing evenly.No evidence of solids
carryover.No evidence of leakage in or out of the box.
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.):
T41. G T--t;n Pn fil v')nnn 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 614 Poponesett Road
Cotuit,MA.02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_leaching pits,number:
leaching chambers,number:
leaching galleries,number:
_X_leaching trenches,number, length: 2 @ 31'
leaching fields,number, dimensions:
_overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): Soil is dry.No evidence of hydraulic failure.Vegetation is normal.No ponding on the surface.Taken
from previous inspection
CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Title C 9
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. Page 10 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 614 Poponesett Road
Cotuit,MA. 02635
Owner: Ray Pendergast
Date of Inspection: 7/07/2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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T;tl. a r., .,.f;- 17-All G/')00(1 10
.Page 11 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 614 Poponesett Road
Cotuit,MA. 02635
Owner: Ray Pendergast
Date of Inspection: 7(07/2005
SITE EXAM
Slope �.
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 11'+ 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:
_X_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: No indication of groundwater at 11'.
Taken from previous inspection.No evidence of groundwater @ 11 per previous inspection noted well above
usgs adjusted high groundwater.
T;rIA C 1--ti—Pn All r'1100 l 11
ASSESSOR'S MAP NO. PARCEL' -�._ � \
LOCATION N0.
t o. v E55r=-r
VILLAGE '{
I N S T A LLER'S NAME B ADDRESS
BUILDER OR 0WMER/--
Pu u <10WA140
DATE PERMIT ISSUED
D A T E C0MPLIA, NCE ISSUED
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No.. .....D�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i ..oce>i+......................OF...Qls�2nl5??.. !
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.� 'radian for Uhipogal Workii Totuitrurtion jhrmit
App1* on is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
... 1�.�. ee- -.t I-N9--a0.. o I�. ? .......... ........
Location-Address / or'Lot No.
?czs�1.._C►^ez . r--....................................................... ..........------"94pa:!.-C.asC: f...ee e-_!Z............................
��/{J �.�j /�Owner ,,(, Address
............1-l-I�l::CIr' �..O—CP.. / _ �/i� { S.Q.L. ............................................................
Installer Address
UType of Building Size Lot-__�.�Tt �o._....Sq. feet
Dwelling—No. of Bedrooms.................... 4'
.................. Attic WO) Garbage Grinder (X)
��...0 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ................................. .
d
W Design Flow..................................5;:5.__gallons per person per day. Total daily flow_._.._.......__......_..4.4-'......gallon.
1' Septic Tank—Liquid capacityZ Ogallons Length_4 -�.`�__ Width__ft':���. Diameter................ Depth..7. 4�r..
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
___-. Diameter.....1.'`�...._..... Depth below inlet_;,Z_67...... Total leaching area. C)(o_....s ft.
Seepage Pit No..__. p g q.
Z Other Distribution box (7() Dosing tank ( )
aPercolation Test Results Performed by._Cva..Zo-d.p `ter �` i� �� ✓� Date...lX:T-:-A�.J.99 .....
Test Pit No. 1.......RA.....minutes per inch Depth of Test Pit.---I_ 9__....... Depth to ground wate ......
Test Pit No. 2....----....minutes per inch Depth of Test Pit..... ..... Depth to ground w
Tea i- P.1- kb i ..A the..o 1�' a� gTEPF1E(Y' 'L
x Description of Soil..Zit' 1.J_B--LL--j..ToP--.e a.I .1L..:31 --- a-- Q_4... t ci
L N =i
l4 hilt ... c :.�site...rx�rar ..7. ? r S�- ��s .....W1tSIIN y
�_----- .... „s 'a__�No.30216
UNature of Repairs or Alterations—Answer when applicable_.!!-1.!1^ k__-�e�nj.h,__A................
.............................................................. ............................................nryo....Srl�d<------------------------------------ M.W
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in accordance with
the provisions of iii 11 5 of the State Sanitary Code—The undersigned further agrees to place the system in
operation until a Certificate of Compl• ce has b n issued by e board of health
gned...................... ------•-•-----•--•••--
Application Approved By..................... . ___ - to
Date
Application Disapproved for the f o110 i g reasons: -. -- -----•--------------------•-------------
�—
Date
PermitNo..-:.................................................... Issued.......................................................
Date
Y � �
No................-....... ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
?'a� ....---..OF...Q19f!✓.`aT?lL
A lirati Big�� tt for poii l Works Tottstrurttort ramit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at:
.................._....._...-••--..... ._.. . ------....-----•----•-........••--_... ......---•------------•-••• ,1 � .. ----•-------......_......•............----
Location.Address or Lot No.
r..-------•-•-...........................................
;. ....... ?oltX.:2s 9_?y-..a�A. .!✓.............................
Owner Address
,� --- •--••-•-------• •-••--...---- ...........................•-•---........--
Installer Address
d Type of Building Size Lot.. �4&.Sq. feet
U Dwelling—No. of Bedrooms.....................4..................Expansion Attic (0) Garbage Grinder (x)
aOther—Type of Building ............................ No. of•persons............_..__.__.___-___ Showers ( ) — Cafeteria ( )
Otherfixtures .......................................................................................................................................................
W Design Flow.................................,.t`',S_...gallons per person per day. Total daily flow............. .100''Q.....gallons.
WSeptic Tank—Liquid ca.pacityZQQQgallons Length_//NO.... Width..,dr!& Diameter_'!-^ Depth..?�'4...-.
x Disposal Trench—No. .................... Width.................... Total Length................. _.Total leaching area....................sq. ft. ,
6� �a Depth below inlet.�`'.0..6 7_..... Total leaching area. -04....sq. ft. '�N
Seepage Pit No..... ............ Diameter.__.. _. �-.___..__ �
Z Other Distribution box (2() Dosing tank ( )
'-' Percolation Test Results Performed by_ 4W.'Aipt'r _.1�P-�r/l�9i fl* Date...l.�T._.-A
Test Pit No. 1...... -----minutes per inch Depth of Test Pit..74Q........ Depth to ground wa
44 Test Pit No. 2..._-^-._._minutes per inch Depth of Test Pit-----1441,..... Depth to ground -----------
9 9 T4sf- Pl+.FbZ ipf....4a.G�.-IA1o►e.. STEPHEN
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O Description of Soil.. LLYN
.T.f �'�Zp Tv�zp*�; IZ�-z.'!(at�-LSO--$elr -suw t j-36n=- W1L'Si7N------
!.$rdr�r..r�eld_,dr re f ?b / l I .. - xric..Sri�a� Ti? + t2-t1,��' H
Tc{�s>���.12ti3L 1 Santda�-�u{as*11j- 9tuft
V Nature of Repairs or Alterations—Answer when applicable_. 4!! ti-4qr_.Wbj)v-_-/l9e4_-_________________
...........................--•---••-•••-•---•---------••--•-•--••••------------•-----•----•--...........--%'-04L-- ,------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,n accordance with
the provisions of T'TIE
p y 5 of the State Sanitary Code— The undersigned further agreesjpotlo place the system in
operation until a Certificate of Compl' ce has been issued by the board of healthi
;07
Signed..........:..... --.•-•---••. ••----....
�. Date
Application Approved By....................... ._._
Date
Application Disapproved for the f ollo i g reasons--------------------------------•------------------------...---•-------------------------------------......_..._
f Date
i
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-4--7 _
............ ! SJ \J...........O F........
Trrfifiratr of Toutirliaurr
_.. > - ..............................................................em constructed or Repaired ( )
by THIS ISM T Th t the Individual Sewage Disposal System
_ I staller
has been installed in accordance with the provisions of '1'1T1; j of The State Sanitary Code as described in the
application for Disposai Works Construction Permit No......................................... dated......--__......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT ON SATISFACTORY. �_ r
DATE...........`� --------------------------•-------- Inspector.......... ......IWvvv�-cn�-
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4.119
i���a��tl �r�� ��tt��rti�rt rrtZti
Permission is hereby granted------------
....................................... ................
to Construct (X,) or Repair ( ) an Individual Sewage Disposal System
at No............
Street
as shown on the application for Disposal Works Construction Permit Nod. `!p6�Dated---------ttn4.5-_d�S............
..........................-•--- t}
`- Board o ealth 1
DATE... } .......................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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N �- REVISIONS.
NO. DATE
LOCUS
N h
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REFERENCES-
LOCATION MAP
SCALE : I 2,083'
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FROM A PLAN RECORDED AT THE BARNSTABLE N 670 3 f30 W 24 .69 — N g4 0—
REGISTRY OF DEEDS IN PLAN BOOK 19 PAGE 143 - 1 , If''�Qp�SO C.0 ITQ�' =�, v.ce�`�► -� ,
AND DOES NOT REPRESENT AN ACTUAL SURVEY ON
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TOP OF CONC. BND .�•� r�
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I. B.M. USED '. F� I_ _. V. 2 7.5 2 { N G V D. i A0
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TOWN OF BARNSTABLE B . M. , R. M. 22 ELEV = 4. 25
N. G .V. D. ) 0 20 30 FEET
2. BENCH MARK SET, SEE PLAN DATE OCT. 3, 1985
COMP/DESIGN: 5-Ay/
—
_CHE_CK
DRAWN: T.C.
FIELD: REG / TJY/ JVB / RL2H
FILE N0
DWG. NO 1617 `;HEFT
JOB NO 03-1649-00; / OF
IL TEST PIT DATA. INDICATES INDICATES SEPTIC TANK DETAIL. ,c� v0 r: >�._ �- DISTRIBUTION BOX DETAIL: LEACHING PIT DETAIL: REVISIONS.
SO-�
PERC. V OBSERVED NOT TO SCALE NOT TO SCALE NO DATE
_ NOT TO SCALE
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NOTES: I. SEPTIC TANK SHALL BE STEEL 4. INLET AND OUTLET TEES TO BE CAST IRON OR <• NO. OF OUTLETS: MANHOLE COVER LOAM 8 SEED
4� BROUGHT TO FINISH GRADE OR PAVEMENT
" TP2 TP +1 -� - TP REINFORCED CONCRETE. SCHED. 40 PVC. TEES TO BE CENTERED UNDER
NOTES! /
TP / GRD. EL. 3, o -� GIRD. EL. MANHOLE COVER. �-1--- I. DIST. BOX TO WITHSTAND H-10 LOADING 2 MIN.OF
GIRD. EL. Z�• ► GIRD. EL. Z ,• 2 SEPTIC TANK TO WITHSTAND H-IO LOADING r-- � \ �\
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TRAVELED WAYS,WHEREIN H-20 LOADING I WASHED
SHALL APPLY.
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/R[CA3T I,- ♦'-O" YIN. OUTLET f-1 SEE 1 I 1 �c
�r�NOTE 2 ' �/ �' oo a o 0 0 o q OR TRAVELED WAY SHALL BE
SEPTIC I• LIOUID DEPTH TEE 4 INLET j �� ,
TANK — i `- ; ►,
I I il.l1 i � � 4 OUTLET , II � _ / \O o - � �, \\ SCHEDULE 40 OR EQUAL.
DIA 6"MIN.
L------�J ---------�= — -- --
�r rN.L'S L - 4 lr
BOTTOM ON LEVEL STABLE BASE C1.9 v + ` _
• - OTT
�� = u�o� LEVEL STABLE DIA.-- -- ------
�'�� CROSS-SECTION -' BASE
PLAN VIEW CROSS-SECTION VIEW CROSS-SECTION
.. <�va wit rc a 1 ,vv �.-,v r l;.•.
DATE: DATE: DATE: DATE: INVERT ELEVATIONS. CONSTRUCTION NOTES:
0 C, 7 . /� /T-"a c: T i�;
O c r - ", /;4 . , u
TEST BY: C-
TEST BY: TEST BY: TEST BY:
INVERT AT BUILDING
L r.-..•,v✓.vim.
INVERT AT SEPTIC TANK(in) 2 S.j{='.
WITNESSED BY: WITNESSED BY: WITNESSED BY: WITNESSED BY:
INVERT AT SEPTIC TANK(out) 2 -,. 2 7 Ai�.r
= "
'�
PERC. RATE: PERC. RATE: PERC. RATE: PERC. RATE: INVERT AT DIST. BOX(in) -"
2- MIN./INCH MIN./INCH MIN./INCH MIN./INCH Yam` `oN
INVERT AT DIST. BOX(out) Zq 3ti'
INVERT AT LEACHING PIT A� 4.38
DATUM: BOTTOM OF LEACHING PIT 1 7 1
U.S.G. S. MAXIMUM GROUND
VERTICAL DATUM:
WATER ELEVATION
�;' G t/ J
OBSERVED GROUNDWATER
BENCHMARK USED: T•, i�ti , �.,.. ;�c �` ..:�» �, z z �� � �, E L E VAT 10 N
STEP 1 ' Measure depth to water table
_.._............. ......._......_.._ .._............_......_..... Date
to nearest 1110 h_ /a 3J lS 1.3
R10rtth daV/Ylir i
STEP 2 Using Water-Level Range Zone
and Index Weil Map locate
site and determine: T*5W 8'4
OA :,ppropriate index
O Water-level range zone _------_--------------_--_--_-----._...____. A
DESIGi CRITERIA:
STEP 3 Using monthly report "Current DESIGN FLv:
Water Resources Conditions" --
-� BEDRgMS AT-a-0-G.P.B./D 4-4c G.P.D.
determine current depth to Jo /2J4
water level for index well ---_---------------_- aS --!
month/Year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth REQUIRED SEPTIC TANK: The BSC Group
to water level for index well (STEP 3)•
and water-level zone (STEP 26) /.` / _
determine water-level adjustment .............................................____......_....
C 0 GAL.
SEPTIC TANK PROVIDED: = 29bC) GAL.
STEP S Estimate depth to high water SIZE OF LEACHING FACILITY REQUIRED: Cape Cod Survey Consukanu
by subtracting the water
DESIGN PERC. RATE: MNdJNCH
3261 Main Street
level adjustment (STEP 4)
from measured depth to water AF 44CV 3.3 � O 3
level at site (STEP 1) .......................... .. . . ......• DUte6A
. . . ............................ - Barnstable Village MA
02630 —
617 362 8133
SIZE OF LEACHING FACILITY PROVIDED: PROJECT TITLE:
SEWAGE DISPOSAL
SYSTEM DESIGN
— x ---- - -- — X /tea Pun/E- TT" /`:'4>
STFPNEN y
AL.LYN
WILSON )«;
�No.30,16�q PREPARED FOR:
��-• •`='��i� Goo v�r
DATE: 4 .uc�E•J` 1 f;
COMP/DESIGNA v✓
CHECK.
DRAWN: S.iW
FIELD:
FILE NO _ _
----�-- -- - -
DW_G NO: /01 -SHEET
JOB N0 GLs Iha'�,�'�I OF :_`