HomeMy WebLinkAbout0602 PUTNAM AVENUE - Health 602 Putnam Avenue ;}
Cotuit
r
A 038 014
IA __,
TOWN OF BARNSTABLE �� DP WAD 03 1
LOCATION 9d Z SEWAGE #
VILLAGE Ll� %�� T� ASSESSOR'S MAP & LOT
Q�,�
INSTALLER'S NAME&PHONE NO. GD/�7`D�p 1 C�ee5.,7 -7 71-O=W
SEPTIC TANK CAPACITY �iJ DD
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:�p 30 �J
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
13Ll �3D �� 'l Z
C-3p--
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
k
SE r' y 2605
F BARN
TITLE 5 TOWN EALTH DEARNSTABLE .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTE YORM
PART A
CERTIFICATION
Property Address:.( 90�" (.' aZ—C—
Gu j
.Owner's Name:
Owner's Address:
Date of Inspection�. .p —�c�/J'yl,, �., 34 /o
P
Name of Inspect ° (please rint 1-� l �`7
Company Nam t� '
Mailing Address:
S �
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP.
approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
eeds Further Evaluation by the Local Approving Authority
•ils
Inspector's Signature:
The system inspector shall sub rt copy of this inspection report to the,approving Authority(Board of Health or
DEP)within 3.0 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
�;ef�:N•t.:r f :. ' ,pk.�L*..•,.. ;,,..:; i.t—...;,, -s ......:at'. :.»...�.. .. .' ,.., ..�.. . - ., .- 1z w ..,� r
This report only describes conditions at the time of inspection Ad',under the conditions of use'at that {
'.time:This inspection does not address how the system Will perform'in the future under the sa'me or different
conditions of use:
Title 5 Inspection Form 6/15/2000 page I
Page 2 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.-
SUBSURFACE j,..
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property.Address:
Owner:
Date of Inspection
Inspection Summary: Check A,B;C;D or E./ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below..
Comments:
B. System Conditionally Passes:
One.or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair;as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,NND)in the for the following statements: If"not determined"please.
explain.
The septic tank is metal and over20 years old*or the septic tank(whether metal or not);is structurally
unsound,exhibits substantial infiltration.or exfiltration or tank failure is imminent:System will,pass inspection if the
existing tank is.replaced with.a.complying septic tank as approved by the Board of Health,
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance.
indicating that the tank is less than 20 years old is available.
ND explain. -
Observation.of.sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with . .
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution.box is leveled or replaced
ND explain: . .
The system required pumping.more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection.if(with.approval of the Board of Health).:
broken pipe(s)are replaced
obstruction is.removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARfA
CERTIFICATION(continued)
Property Address: ,/ ti,,
Owner: • A,
Date of Inspection: � Jt,�¢�� =C���,rt
C. Further.Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board ofHealth 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 CMR15.303(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 l 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;facilityand
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
3. Other:
3
, f .
Page of 11
OFFICIAL.INSPECTION FORM—.NOT FOR VOLUNTARY`ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: - �a� e.•
Owner:
Date of Inspection: _ �� C��
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or."no"to each.of the following for all inspections:
Yes N
Backup of sewage into facility or system component due.to overloaded:or clogged SAS or cesspool
Discharge or ponding of,effluent to the surface of the ground or:surface waters due to an.overloaded or
clogged.SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an.overloaded
or SAS or
f cesspool
Liquid depth in cesspool is less.than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ Any portion of cesspool or privyis within 100 feet of a surface water supply or tributary to a surface
water supply.
j 1 Anyportion of a cesspool or.privy is within.a Zone l of a::public well.
_ IA Any portion of a cesspool cr privy is within.50 feet of atprivate 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 certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence.of ammonia
nitrogen.and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria:
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria,exist as
described in 310 CMR 15.30.3,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.within400 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.
Page 5 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM
PART B
CHECKLIST
f
Property Address:
Owner:
- tion. l
-06Date of Inspec
Check if the following have been done. You must indicate"yes"or"no" as to each'of the followins:
Yes No
Pumping.information was provided by the owner,occupant,or Board of Health
ere any of the system components pumped out in the previous two weeks
� _ Has the system received normal flows in the previous two week period?
L/ 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)
_ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
V _- Were all system components,excluding the SAS, located on site 9.
_ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
o the baffles 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 do
�_. 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 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FO
R VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM;INFORMATION
Property Address: . V -,
Owner: � -
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL.✓
Number of bedrooms(design): Number of bedrooms(actual).:
DESIGN flow based on 310.CMR 1.5.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have.a garbage grinder{yes or no): /YU
Is laundry on a separate sewage system(yes or no):afif yes separate inspection required]
Laundry system inspected(,Cy�e .or no):A�®.
Seasonal use: (yes or no.):�J
Water meter readings, if av fable(last 2 years usage(gpd)):01/40 l�J " ��� -01
Sump pump(yes or no): D
Last.date of occupancy:g4444/
COMMERCIAL/INDUSTRIAI,N/6
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:Al)y- ., Tj 0/,�C � '' '
Was system pumped as pan of th inspection yes o ): ,
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE,,OF SYSTEM
_e, ptic tank, distribution box,soil absorption system
_Single.cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the'current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
—Other(describe):
Ap roximate age of all com o ents,date inst lied(i own) nd source of information:
'p "
Were sewage odors:detected.when arriving at the site(yes or no):,�V
Page 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cor_tinued)
Property Address:
Owner:. lv'�VZZII) i
Date of Inspection: �C
BUILDING SEWER(locate on site plan) i 0
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 ofleakage, etc.):
SEPTIC TANK: V locate on site plan)
Depth below grade:
Material of construction: k.-*'C-oncrete_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
cert
Dimensions:
i t
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:
How were dimensions determined:. �t
Comments(on pumping recomme ations, in4et and outlet tee or baffle condition, structural integrity, liquid levels
as,4elated to outlet invert,ev, enqe of leakage, etc.): _
GREASE TRAP:(0ocate 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.):
7
Page 8 of I 1
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 yjX_ttz7X �. .
Owner:
Date of Inspection:
TIGHT or HOLDING-TANK: Vo tank must be pumped at time of ins ection locate on.site plan)
P p P )( p )
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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet inve-t:�
Comments(note if box is level and.disiribution to outlets a ual,any evidence of solids carryover,any evidence of
akage into or out of box,etc :
y{
PUMP CHAMBER (locate on site plan).
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition o:'pump chamber,condition of pumps and appurtenances;etc.):
Pate 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: &aj
j �,1xe- tt_
Owner: I
A' filv lie
Date of Ins ection: ? . . 92VJ
SOIL ABSORPTION SYSTEM (SAS): ocate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number: c
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,
plc
IaPA
I(J &" �f� / /,�/q�n i✓ G_ ,
.. � �tJv{�►��j C✓W �"`d'`��3'`(s�✓cx.�'iy �'r C�C...C✓T✓d��, z�..�,Q.,{�e �."
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=):
PRIVYA/L) (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 i 0 of 1.1
OFFICIAL INSPECTI.W FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEVVAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
� L
,
Property Address: 1,
A
Owner: Gi2C:L
Date of Inspection: i
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 water supply enters the building.
PL
15D(
4�
0
>�.� C)Ml
f
Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: P,,�
.L1
.Owner:
15
Date of Ins ection:
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 waver 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:
/hecked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11 ,
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: 2 7 Lot No.
Owner: &PI) //?!/' - Address: �
Contractor: Address: J�
Notes:
STEP 1 Measure depth to water table
to nearest 1/i 0 ft. ................
Z��✓
;. 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 J
water level �� G/
for index well ........................... !�
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) f`
determine water-level adjustment .........:................................................................................
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ..........................................................................................................:..
1
9
Figure 13.=-Reproducible computation form.
15
,,,�,. ,
��
1 � SrIG/c.��.j'..
1 �-, a�
. .
.,
V _
. . � �
� .
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131
WII.LIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,RLS.-,Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
April 9 , 1985
Mr . William Moore
P . 0. Box 68
Centervi MA 02632 p 3F,O/y
AV
RE: 0 3 ��
Pu nam Ave
n
Lan Cert 36608E
Dear Mr . Moore:
This is to inform you that on April 9 , 1985 two -
deep test holes were dug and a percolation test was
performed on the subject lot.
The test was witnessed by Mr . James Conlon, ,Agent
for the Barnstable Board of Health.
The test showed that the soil is acceptable, where
tested, for the installation of a subsurface sewage
disposal system.
Very truly yours, ,
Peter Sullivan, P .E .
Baxter & Nye, Lnc.
PS/fmj
Enclosure
�A0" OF M9s�
PETER
su«rM r . -
No. 29733
i
. Fss/ONAI E�L��
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPBVG
MASSACHUSEM ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGLNEERS
,PCrAT I O N O N O•.. a
1LAGE y • DATE
'PLICANT ��I�SUC� FEE yd�
DRESS NO. (Non-refundable]
:GINEER �! ,e. /7�_. ^ �) -�- T-ELEPHONE NO.�.. ).r-C .
T!E .'SCHEDULED Q
(Applicants signature
• SOIL .LOG
-3-DI,VISION NAME DATE g-BS TIME_ZO.'ad
-
TANSION AREA: YES P__1N__O 9 ��i✓� ���� �E.NGINEER N*
,WN YATER APRIVATE WELL i� C"�. �,�(' BOARD OF HEALTH
EXCAVATOR
ETCH:, ,(Street na-me, etc® ,dimensions of lot exact Iodation of test holes and
'•`percolation tests, locate .we'tIands 'in proximity to test holes )
• NOTES :
NJ
,RCOLATION RATE :,„��%ice
,ST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
3 Z . �G.�c%E� 3
5 5
6 6 '
/V!ZZ -
9 9
10 10 ,
12 /-1 A_ Ar _ 12
13 13
is la
15` 15
16, 16
JITABLE FOR SUB-SURFACE SEWAGE : LEACHING FIELD t_ `EACHI.NG PITS
• LEACHING TRENCHES
'ZSUABLE FOR SUB:-SURFACE SEWAGE. REASONS : •
)TE ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
�IGINAL: COMPLETED xN ENTTRE`�Y BY P� , . A. AN�R TURNED TO BOARD OF HEALTH
No. g THE COMMONWEALTH OF MAS ACHUSETTS FEE
/ BOARED OF HEALTH �� ✓✓✓
OF
ffir4n,4�hi-e
APPLICATION FOj/)�DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - ®Complete System ❑Individual Components
I DQ7i V A?1Y 1
Y l l CA onc' L_oFation Owner's Name
Map arcel# Address
Lot 7L� elephone#
t- CL/ Install s Namek Designer's Name
Address LInn/����lddress
Telephone# / Telephone#
Type of Building: Re / Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons LO Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required). gpd Calculated design flow �� gpd Design flow provided3� gpd
Pla . Date o Number of sheets k Revision Date
Titl
Descriptio of Soil( )
Soil Evaluator Form No. Name of Soil Evaluator' (C5ry-(0,r\- Date of'Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 4-7)7 6
The un ned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 an r agrees t to pla a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ate
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
€!:c �"l7�P�'.� r"i ,.•n .�,>�ti� ,x..-, r', i rr'ti .�_. wr,�.• :. F�:.".c , - •. s�, - r ,... . . cv i'�`t, �'.
No.. ,..' THE COMMONWEALTH OF MASSACHUSETTS FEE Or
x. —�
.'.
xr _, • BO R .• F HIE ALTH•
• * F
APPLICATION FO DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (Repair ( ) Upgrade ( ) Abandon ( J Complete System []Individual Components
GL (caeai�_CtL�r
1 10 3q OC 'L"gcation Owner's Name
VO Map arcel# Address
�n 3 ,
Telephone# 4
Instal s Name /" Designer's Name
� 5` •� ru r
Address ddress
Telephone# Telephone#
Type of Building: 510 - Lot Size Sq.feet n -
Dwelling—No.of Bedrooms !! __e Garbage Grinder
l ( )
Other,=Type of Building No.of persons r Showers ( ), Cafeteria ( )
Other fixtures �.
Design Flow(min.required) C gpd Calculated design flow gpd Design flow providedP�� gpd
Planr Date — (o e,\ Number of sheets 1 Revision Date
Titl 1K, cI ,_ ,e
Des cr"p o of Soil s)0',21 0�,�{`-3�� _ tL��v t 0l� '" (RQA SC"L C-
rS;oal Evaluator Form No. Name of Soil Evaluator C[lYl�101/Yx Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �b
The un a ned agrees to install the'above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 a er agreesJnot to pplace a system in operation until a Certificate of Compliance has been issued by the Board of Health. -;.: t
Signed r ate
✓ t'' _
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
yS
No "'� THE COM� O �W AL OF MASSACHUSETTS ���i�� �FEE��� `��.�_�._.
BOARD OF HEALTH
- CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) R"Coomplete System
The under gned hereby certify that the Sewage Disposal
System;Constructed(✓}�,Repaired( ),Upgraded( ),Abandoned( )
� at
has been installed in accordance with th visions of 310 CMR 15.00(Title 5) and the approved design.plans/as-built
plans relating to application No. � `� dated Approved Design Flow (gpd)
Installer A
^_ - Ad... .
Designer: Inspector ' v. DateThe issuance of this certificate shall not be construed as a guarantee that the system will function a
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
NO. � THE OMMO T W
F MASSACHUSETTS FEE D �_
9C . ARD OF HEALTH
0 3ZZ 01 DISPOSAL SYSTEM ONSTRUCTION PERMIT
Permission is hereby granted to Construct ( Repair ( ) Upgrade ( ) Abandon ( . ) an individual sewage
disposal system at _ as described
in the application for Disposal System Construction Permit No. _ (19 dated
Provided:-Co structAn shall be completed within three years of the date of this p mi A. 161�
nditions st-be met.
Date Board of Health f/
FORM 2 - SCP DEP APPROVED FORM 5/96
-w• •FORM.1255 (REV 5/96) H&W HOBBSB WARREN'" PUBLISHERS- BOSTON
r
TOWN OF BARNSTABLE t
i LOCATION G� Z Gl SEWAGE # ®/45�
VILLAGE/ '7'(�,� ASSESSOR'S MAP & LOT 4
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1��4�1
LEACHING FACILITY: (type) — Z-SMAVVI (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: /
Separation Distance Between the:
� 30 0/
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
R2ar 8
$ 30
C-3 p-
�i
-t
g O _T
PROJECT TILE_
1
[ a:. ,... . .. :� ......: .,art
,y
•
.: .. .. ,., ...:. �.�•}'.a-.'rrew.. 1.1 ... d'.,.f.. .'. a .1f>. -,> ,., :- .,-., .J. _a,. t. - -
.f r
1 A
l_
,F
„�:••-
_
%. Sit. .F. .,Y ,, - •.ny..__.
e. ... : ,..;..: ..S ., 1. ., ...r - ."n.':-:.•• ......'
V- 1 _.t
f -
, s
Pei
s
r f
Mgt
t
_
,
. .. ,. . .:•�r ,,ter. .. ,_..,-<-:,. ..ri,.-_ ,...�..,•..,. _. ..,,.,,y.,.5ws.,. ...,� ,,... ... :3.....>;...,_ ,a...:.vs_._-,.r-r-r.-,$. ,..5.'4 gam: .t.. ... .:5-
r.
a
+ u
r
-
,
F�
3- GW _
- t
-
t r�•:
—
µ
1.
1
I
t PREPARED FOR i
}
a,
.��
--'z _ Central Constru c ion Company, Im
Steve Devlin Psrsiknt
. ,. 261 Blackthorn Drive•Marston Mt7h,MA 02648.508420-1340
_
-
TI-1
l
O
,
S
DATE DWG NO.
DESIGN y -w
CHECK
-----
oN
----- DRAWN ;
JOB NO. SHEET OF
PROJECT TITLE
r
�� ! � Q,�
sao a-eacc-ci,
.^.--
ee
\v; CCC II fr
ft
�b O u
- 00 'f� \ ` ` I tL
I
1
of. -
j
Vr.2F PREPARED FOR
I ' '
G Ocrv' 3��eld/
SLV Yi-
}1-
0
i
Central Construction Company, IIII
I Coll
Steve Devlin •1-�rsident
261 Blackthorn Drive•Marston Mph,MA 02648.508A20-1340
SCALE - !
0
tot—
_ DATE DWG NO.
DESIGN
' CHECK
DRAWN
F
JOB NO. SHEET O
SYSTEM PROFILE
TOP OF NOT TO SCALE
FOUNDATION FINISH GRADE FINISH GRADE OVER
EL. 77.7 FINISH GRADE OVER FIN
EL. 76.2 SEPTIC TANK 76.0 DISTRIBUTION BOX 76.0
FINISH GRADE
OVER TRENCHES 76.0
_ - A RISERS TO 6" `9
OF FINISH GRADE ,
PRECAST CONCRETE i
r 500 GALLON DRYWELLS
�'o '•o. �•,c� b'
' 3"MIN. RISERS TO 6" s b' H-10 REINFORCED
:�10 MIN.SLOPE 1% OF FINISH GRADE OUTLET PIPE(S) LEVEL LOADING
13"
t
6" j B MIN.SLOPE 1% o FOR 2'( MIN.1% SLOPE TRENCH LENGTH = 25'-0"
n BEYON17
r __" MIN DRYWELL LENGTH - 8'-6"
13"MIN. 14" 4
74.20 74.00 �L. +
`°' MIN. 6' SUMP
-o� o - 73.75 73.G5 v7348
PVC OR CAST IRON TEES 73 4$
,, 'I X <"' ����r,.� +d�.�=�i0 f r ' �;Ib� `,o7r :� .; ,.Q� i �s �•/�
GAS BAFFLE ��''{���7b° •:fo, ; b fir,
_j DISTRIBUTION SOX1. '/° .':, a -'
1500 GALLON W = MUM INSIDE DIMENSION 12" 3/4 - 1-1/2 DOUBLE `
> MfNi, " "
OUTLET INVERTS 2" BELOW INLET INVERT r 3/4"- 1-1/2" DOUBLE 3
o< a 4 WASHED CRUSHED
- :0, PRECAST CONCRETE _a MINIMUM CONCRETE WALL THICKNESS 2" 8' WASHED CRUSTED 4'
=_o . ;i STONE ,
BSMT.FLR. o:- " H-10 REINFORCED INSTALL ON COMPACTED LEVEL BASE STONE
ELEV. 70.2 o - BOTTOM OF TEST PIT
OJ a•r
�,o;1• �,o'+ ,r, r. + +o,l I r ,,
°di.a� \tr' f':1+ °l Oc'� o• r.' O r n. i '•r f .,�f,. •r f ,r f i P , ['r ',0 /'
-
I—IONTRENCH SEC
�, �
NOTE: EXCAVATE TO =C= STRATUM 1N ORDER TO
SEPTIC 1 AN K REMOVE ALL =A= & =B= IMPERVIOUS MATERIAL
INSTALL ON COMPACTED LEVEL BASE WITHIN 5' OF THE SAS. REPLACE WITH CLEAN,
CLAY-FREE SAND 19" MIN. 3" OF i/8"- 1/2"
4" DIAM. 36" MAX. DOUBLE WASHED
PEASTONE
Ij
o
:i�, �.r °- 3/4" - 1-1/2" DOUBLE
14$" 5'-2" WASHED CRUSHED
1 TRENCH WIDTH STONE
13'-211
/ GENE€SAL NOTES: NUMBER OF TRENCHES 1
NUMBER OF DRYWELLS 2
1. ELEVATIONS SHOWN ARE BASED ON ASSUMED
2. ALL PIPESN THE SYSTEM MUST BE CAST IRON
LIJ
OR SCHEDULE 40 PVC.
- 3. 1 SEA] TH AGENT/CAPE & ISLANDS ENGINEERING P- 2{�
I MUST BE NOTIFIED WHEN CONSTRUCTION IS PERCOLATION RATE: < 2 MIN./IN
COMPLETE PRIOR TO BACKFILLING. WITNESSED BY: J.CONLAN
4. ANY CHANGES IN THIS PLAN MUST BE APPROVE® BARNSTAB_E BOARD OF HEALTH
BY CAPE & ISLANDS ENGINEERING AND THE BOARD
OF HEALTH. DATE: APR.9,1985
I�
/ 5. MATERIALS AND INSTALLATION SHALL BE IN of PITS 1 &2 EL.75.0 DESIGN DATA
160.00, �� COMPLIANCE WITH THE STATE SANITARY CODE LOAM
�_J___ /� / [TITLE V]AND LOCAL APPLICABLE RULES AND
_j /^ _ / REGULATIONS. 24' NUMBER OF BEDROOMS 3
,N , 3p0p' 6. NORTH ARROW Is FROM RECORD PLANS AND IS GARBAGE DISPOSAL NO
s' o p ! / NOT INTENDED FOR SOLAR ENERGY PURPOSES. SUBSOIL DAILY FLOW 330 GPD.
2� l °°° �o' 3 ROPOS 1 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. SEPTIC TANK REQUIRED 1500 GAL.
p��QR�GO ___ I 8. FLOOD ZONE C [NON-HAZARD]
36" i SEPTIC TANK PROVIDED 1500 GAL.
M LEACHING REQUIRED 330 GPD.
/ �L.74.7
l w J �,K�pORC \ ` I SOIL ABSORPTION SYSTEM CALCULATIONS:
y.�l2�T II MEDIUM SAND
SIDEWALL AREA= 152 SF.
152 SF. X .74 G/SF. _ 1 1 2�GPD.
2200 BOTTOM
X 0R74 G/SF.� 243 GPJ.
GAGE \ Q'
t LEGEND 144" NO GROUNDWATER EL.63.0 LEACHING PROVIDED = 355 GAD.
52 PROPOSED CONTOUR
SINGLE FAMILY RESIDENCE
-—-52-—- EXISTING CONTOUR
PROPOSED SEWAGE DISPOSAL SYSTEM
OBSERVATION PIT
PREPARED FOR
Jr,wir'Y e�,
4
/ ❑ DISTRIBUTION Box CENTRAL CONSTRUCTION
° O SEPTIC TANK •, QC o,�ef�� HSE.NO. 602 LOT 3' PUTNAM AVENUE
I COTU IT,MASS.
SOIL ABSORPTION SYSTEM
oaF~
PLAN NO.102601 SCALE- AS NOTED
RESERVE RESERVE AREA �Oli JF ;,9y�s � FILE NO. 175BA DATE: OCT.26,2001
Q vdO� �'r SEPTIC FILE NO.70 PCS FILE.- PUTNAM AVE602
22.26 PIPE INVERT ELEVATION cHA R ,
_ P CAPE & ISLANDS ENGINEERING
PLOT PLAN
38 14 3 602 0 - 0 � �F��Sr`�t"';�; '` 800 FALMOUTH ROAD, SUITE 301C
SCALE: 1 30 MAP
++ - > > > MASHPEE,MA 02649 (508) 477-7272
- SEC PCL LOT HSE , w w s }` - ��