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HomeMy WebLinkAbout0051 TRUMAN LANE - Health 1 Truman Lane Cotuit P A = 039 . 129 - - i Commonwealth of Massachusetts - � Z9 Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: "�-- forms on the computer, use 51 Truman Lane only the tab key Property Address to move your Kenneth &Joan Amelin cursor-do not use the return Owner's Name key. 51 Truman Lane Owner's Address Q Cotuit MA 02635 City/Town State Zip Code Date of Inspection: 5/4/05 Date 2. Inspector: Mike Hudson F-a Name of Inspector C= . t-a Se ticwiz Company Name 31 Midway Drt Company Address ---� 7-1 Centerville MA 5 632 City/Town State :4-i Code 508-367-5669 q Telephone Number [j"1 0 Certification Statement: 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluati n by the Local Approving Authority q11© Inspec is Signature Date 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 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. ****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. Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Svev`' A. Certification (cont.) 51 Truman Lane Property Address Cotu it MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name 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, 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: Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �y Spey`• A. Certification (cont.) 51 Truman Lane Property Address Cotuit MA 02635 Cityrrown State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection . B) System Conditionally Passes (cont.): ❑ 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: 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 Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M A. Certification (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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: Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM A. Certification (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State ZipCode Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or 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 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 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 1 Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 51 Truman LAne Property Address Cotuit MA 02635 Cityrrown State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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. G Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 6 L Commonwealth of Massachusetts Title 5 Official Inspection. Form Not for Voluntary Assessments 1 Subsurface Sewage Disposal System Form B. Checklist 51Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no"as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ❑ ® 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? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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? ® ❑ 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: ® ❑ 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)] Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2003 178GPD, 2004 200 GPD Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 8 L , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments 5.1 Subsurface Sewage Disposal System Form M C. System Information (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Home owner, Board of Health Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2,500 gallons gallons How was quantity pumped determined? Called company that did the pumping (A& B Canco) Reason for pumping: Septic systems liquid levels were abnormally high Type of System: ® Septic 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): Approximate age of all components, date installed (if known) and source of information: 27 years old, info obtained from Barnstable Board of Health Were sewage odors detected when arriving at the site? ❑ Yes ® No Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection Building Sewer(locate on site plan): " Depth below grade: 31 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A, Town provided water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of El Yes ® No certificate) Dimensions: 8.5' Ix6'wx5' d Sludge depth: 41811 Distance from top of sludge to bottom of outlet tee or baffle 21 7„ Scum thickness .10 or less Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1' 8" How were dimensions determined? measuring stick, tape, ruler,flashlight Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): System components in excellent condition, no leakage, all levels acceptable and flowing properly. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 51 truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 4/5/05 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box if resent must be opened) locate on site I( P p ) ( e plan): Depth of liquid level above outlet invert .10 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.): D-Box level, clean, structurally sound and in excellent working condition Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 12 r - Commonwealth of Massachusetts 9-3 Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form C. System Information (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code `4 Kenneth &Joan Truman 5/4/05 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: (1) 6'x10' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system J Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding, breakout, damp soil, lush vegetation or signs of hydraulic failure. Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 13 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of 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 ❑ 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.): c Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 14 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 5/4/05 Owner's Name Date of Inspection 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. I It It Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.)„ 51 Truman Lane Property Address Cotuit MA 02635 City/Town State Zip Code Kenneth &Joan Amelin 4/5/05 Owner's Name Date of Inspection Site Exam: Slope ,e V g Surface water \R© Sv s 4►cce- %-3 C�' Check cellar ��S Shallow wells n Estimated depth to ground water: 7,D ( - Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Dte ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Obtained copy of construction permit&as-built on file with Barnstable BOH ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: Reviewed topography and high gw levels of subject property location J You must describe how you established the high ground water elevation: Observed site location, reviewed plans& permits on file w/ Barnstable Board of Health, reviewed USGS water resources website for topography and ground water elevations in subject property location. Amelin-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Es TOWN OF BARNSTABLE LOCAfi&N S-I "alV- 4'll /J SEWAGE # VILL,"WE 6Dtal T ASSESSOR'S MAP & LOT D39 INSTALLER'S NAME&PHONE NO. C A$/-- �l 3 SEPTIC TANK CAPACITY /yal> 6 LEACHING FACILITY: (type) ��/ (size.) NO.OF BEDROOMS 3 BUILDER OR� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table and 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) All* Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by J �\ i t ✓\_ G' L �. � � . �>� � �� �! 6"_ g:.. _ f .-t i tea. - d 1 � I2-9 S . No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zlppliratton for 30igpogal *pgtem Congtrurtton Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No. 6-I T,p lm,0,1 A Owner' Name,Address d Tel No. Assessor's Map/Parcel 662.IV/ 2— Installer's Name,Address,and Tel. ,�No. Designer's Name,Address and Tel.No. ®";W, � 771 .glll^ 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 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil.. Nature of Repairs or Alterations(Answer when applicable) /relater �f f%G d 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 this o ealth. f Signed Date / Application Approved by Date Application Disapproved for 114 follo 'ng reasons Permit No. Date Issued No. 77- 3-73 .„ ar Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migpoga[ *pMem Con!5truction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ©'Complete System El Individual Components Location Address or.Lot No. y� Owne ' Name,Address d Tel.No. s'r ion Cq�'�J� Assessor's Map/Parcels�C� ' Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No. 771 -f399 t 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 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs orAltera 'ons(Answer when applicable) /► eG��q' s'P���G' �i�/r� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y thiss -o -ealth. / Signed /4� Date Application Approved by Date — �— 7 Application Disapproved for tY follo ing reasons Permit No. Date Issued f Q THE COMMONWEALTH OF MASSACHUSETTS 673 J�7 BARNSTABLE, MASSACHUSETTS (tertificate of QCompliance THIS IS TO CE , that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by per/ dC_e C4olg�. at 5r r/G1l�1l� CC G1/ has been constructed in accordance .' with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will fu tion as designed. Date Inspector 7_ " N o. /7 Z_;�) 03�—IZf Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS i a Migpogar *pgtem QCongtructton Permit y Permission is hereby ranted to Construct( )Repair( ✓Upgrade( )Abandon( ) System located at J TX W,14/7 a and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction(must be eejcompleted within three years of the date of this permit. Date: lk.. Approved by IrJ a NOTICE: This Form Is-.To Be Used For-the-Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) nerebv certify-that the application for disposal works construction permit signed by,me dated concerning the property located at ,�7_/ r440 7W )q, GGD7`Gff meets all of r following criteria: !' ere are no Wetla.Zds within 00 feet of the proposed saotic system /7f,er 2 are no priiai2 Weil,'s uhln 50 i2et Of _he _•ropos2d_epiic system t!' rtle Ob52^:2d aroundwaiei:abbe is C:.LI 27221,.oejoV, Cni- ^017 JI i72 T._2�C 2 _SC �'ti2r2 '.S 0 ]CreaS ;ri ;?0tv and;or 1a1J' r, rent) c1 _ ieszea J: SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a`sketch plain of the proposed system.Also if the licensed,installer posesses a certified plot plan this plan yshould be submitted]. 61 a w6i, -r.¢ t$ •f.. s+Y" cF _ *..� d' rs+y+'e'• aw„'`�; �C£�+ t f .s,�. `T 4c,p ?V Z S��� �. ^{" a,�,y, a��t�.§ �;;}'`. "`.�;� ( �� „k"CF,. *;, �'P:'''e. t� c as �.•y�•3,�g�.�V43.A�e-_ - ','Y e _ Y A'� 3'', '�'K 4r'�'2 �-as �..��.r��'°. 't�Y�� ����'�•,..c�„;` r`} �.,-�Ms.Ft•'i���S.:s �� �'iw��A�. h�`S"' �'�+-h;:� 'M�:i���.. � ��� Y;... s r �h. S '-x�� pf.Y>�'�,d���� x -� �:, a,�at� �`"�'�€ � �=.;� y''�.'..� �$;,��i'�� "'��•.-,ae�°�.� �._xa����"�i;� n:a��"� is ,.� _, _,� LOCATION SEWAGE PERMIT NO. 7 / VILLAGE INS TA .LLER'S, . NAME i ADDRESS 13 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7 h �} �j 30- ��'� ` , �l� I Y ', ' '2 �111 Jul'�i�� ( ib 't� Uill1fi�l mac. 44, W F' .h, :y,,t���; OL O-V\ I'l, tie oh �eXf A JNk- a � � A44 R 2 LE 2 ;.� 7o1y� 440 BORTOLOTTI CONSTRUCTION, INC. R HEtin ,Fp 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02( 8` 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: J� Date Of Inspection / Inspector's Name: _ Owner's Name and Address: I CERTIFICATION STATEMENT: 1 Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate.and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance,of On-Site Sewage Dis- posal Systems.Tlyz'system: v Passes Conditionally P Needs Furtl - Ev ua io► he Local Approving Authority Failure Inspector's Signature ` Date: ��l� The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with'Thirty (30) Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY . A) SYSTE PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria m defined in 31.0 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: ' One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. [["'not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic'Tank is Replaced with a conforming Septic"Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): _ 1 _ SUBSURFACE .SEWAGE- DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION (continued) Broken pipe(s) replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than lour times a,year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of'I'he Board Of Health): -Broken-pipe(s)-are replaced Obstruction is removed. C) FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Ilealth in order to determine it' the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELLTH DETERMINES THA'I'I'HE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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'1'HE730ARD OF 11EA,L'I'If (ANU PUIILK" WATEII SUPPLIER, IF APPROPRIATE) DETERMINES'THAT I'IIE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS TI-IE PUBLIC 1.HEAO H ANU SAFETY AND THF, ENVIRONMENT: ` The system has a Septic Tank'and Soil Absorption System and is within.100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply: The System has a Septic Tank and Soil Absorption System and is with a Zone l of a Public Water Supply Well. The System has a Septic'Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well, unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this,delermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload 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 clog- ged SAS or cesspool. T , . 'Liquid depth in cesspool is Tess than 6" below invert or,available voluu�e-is less than I/2 day llow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - "'9t1I3SU E,RFACE!SEWAG DISPOSAL SYS TFM INSPFC TION FORM - PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high grou►.►dwaler elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a Public Well. Any portion of a cesspool or 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for cohiform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is.10,000 ggd or greater(Large System)and the system is a significant threat to.public health and safety.and the environment because one ormore of•.the following conditions exist: The system.is,within,400.Feet of a surface drinking water supply .. lie 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 ll of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B y ,CHECKLIS 1 z., ._. ._ Check if the following have been done: _AZPunping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ZAs-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for,signs of sewage back-up._ , 1'he system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ ` t/All system components,excluding the Soil Absorption System,+have been-located on site. 'rhe septic,tank manholes were uncovered,opened,-aan'd the inter►or of the septic tank was in spected'for condition of baffles or'tees,material of construct ion,'dimensions,depth of Liquid, depth of sludge,depth of scum. I'he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _ 3 _ SIJBSIJRFAC'E'SEWAGE,DISI'OSAI:. SVS`I•EM=INSPECTION FORM PART B CHECKLIST(continued) V`I'I1e facility owner(and occupants,if different front owner)were provided with informalion oil the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SVS`I'EM INSPECTION FORM PART C "SVS`I'EMANFORMA`I•ION" - FLOW CONDITIONS RESIDENTIAL: Design Flow:3 3y gallons Number of Bedrooms:s Number of Current Residents:- Garbage Grinder:/Jb Laundry Connected`I o Syysten Seasonal Ilse: /Uj0 Water Meter Readings,if vailable: Last Date of Occupancy — COMM ERCIALANDUSTRIAL:. ' Type.of Establishments u• . DesignfFlow: gallons/day' Giiis6'frap Presents (yes of no) Industrial Waste Holding Tank Present: ` Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL NFORMA`I'ION PUMPING RECORDS atiy soul`cc of`inf(irmatioii: 9 System Pumped as part of inspectio If yes v lume pumped: gallop Reason for Pumping: TVPEjQF SYSTEM: Septic'1'ank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared.System(If yes,attacli pievious'inspection records,if any) Other.(explain):. - - ROXIMATE AGE of all co onen ,date installed(if known) and n�rce°of info m rmation: Sew ge.odors det cte when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade:T Material of Construction: ✓concrete metal FRP Other (explain) Dimisions: 'X ' Sludge Depth: Scum Thickness: Q Distance from top of sludge to bottom of outlet tee or baffle: D .` Distance from bottom of scum to bottom of outlet tee or baffle: /0 Comments: (recommendation for pumping,condition of inlet and outlet tees or es,de th of liquid level in relation to utlet invert, structural integrity, idence OX leakage,etc. AA R GREASE TRAP,:I � C/Jl'iPC� � Depth Below Gr dg e: Material of Construction:_concrete_metal_FRP. Other (explain) _ Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: y„ Comments: (recommendation for:-putiiping,condition*of:iniet and outlet tees or baffles,depth of liquid., level in relation to outlet invert, structural integrity, evidence of leakage; etc.) .; TIGHT OR HOLDING TAN Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: allons/day Alarm Level: r Comments: (condition of inlet tee, condition`of alarm and float,switches, etc.) - DISTRIBUTION BOX: 1/ Depth of liquid level above outlet invert: Comments: (note if 1 Cl and distribution is a al,evid ce of solids carryover.evidence of leakage into or out of 0,7 box,etc.) PUMP CHAMBER -1 ui is in working ord r: Comments: (note condition of pump chamber,condition of pumps and appurtenances,,etc) `. -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Co nts: (note condition of soil,si ns of hydraulic failure 1 vel of poll ' ig,condition of vegetation, —il CESSPOOLS ' Number and configuration: Depth-lop'of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) r . :' ,.__ - �'^---'— -.. _ . .�._..�. _ _ ',...__..... ..__.. "l f -!', s f err a+,:- .i_s.tS:I -e{_ vi5 ., s}'n r• . -6- - SURSURFAC,E SEWAGE DISPOSAL SYSTEM INSPECTION FORM ~' PART C' SYSTEM INFORMATION (continued) SKE TCl1 OF SEWAGE DISPOSAL SYSTEM: 'Include ties to atleast two permanent references,landmarks or benchmarks. Locale all wells within 100 Feet. DEPTH TO GROUNDWATER: Depth to groundwater: 7-1 eet Method of Determination or Approximation: A lvwmv-A-01/—n'm 5 l/ lec?lB4%c'�J� - 7 - TOWN OF BARNSTABLE LOCATION T7lGlr� SEWAGE # 7. u ASSESSOR'S MAP VILLAGE INSTALLER'S NAME&PHONE NO. 7✓? — SEPT`1C TANK CAPACITY / oU LEACHING FACILITY: (type) (size) JC�d NO.•.OF.BEDROOMS 3 ` BUILDER OR� WNE CG�/yl PERMIT DATE: -COMPLIANCE DATE: Separation Distance Between the: S Feet Marcum Adjusted Groundwater Table and Bottom of Leaching Facility Private 1?Vater Supply Well and Leaching Facility (If any wells exist / Feet on;site.or within 200 feet of leaching facility) /v Edge:of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by eat 6 bt9 ' sg 6 L644T•t0N SEWAGE PERMIT NO. V1•ILAGE C v TIP (' I N S T A LLER'S NAME & ADDRESS -y c � (*o .9 B UILDE R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 1 _ _ ' ^� �. ..-� .-. _ � --�� '�1� �� .., , - ., TOWN OF BARNSTABLE L CATION Jr 1 _OrVA"d t' LAI SEWAGE # �'1171 !;75.LAGE 6,�y t 4 1j ASSESSOR'S MAP & L_OT ! ISTALLER'S NAME&PHONE NO. ! SEPTIC TANK CAPACITY LEACHING FACILITY: (type) D T (size) G NO.OF BEDROOMS .3 BUILDER OR OWNER re-0 Aa#� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6+ Feet Private Water Supply Well and Leaching Facility (If any wells exist N on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist A/ within 300 feet ofleachin f ci 'ty) Feet Furnished by iT r.✓ � uP Eirri j 51 "t vAla�t hvvi 'paL� jA I A 3 97'6 Qr 2 51 yoo 3 a 2 431, 83 37 S (7 No............IIy . Fxs....�ets............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH W.144.............OF......�A.-�2 .,F'T .1. 4 ._.................... Allpfiratijan for Uhgaaaal Works Tlauldrnrtiun Frrmit Application is hereby made for a Permit to Construct ( Q-er Repair ( ) an Individual Sewage Disposal System at: _. - rn/�a�/ �---••---.D_s..... ........................zd 7........_......------.--••---•--.. ..............� -...z .... ---- o tion-Add0.ress or Lot Now i �ltll. .....•,--, ..................... Address a ..............:.... ..._..._... Installer Address Type of Building Size Lot.A?3t.Va_O_._..Sq. feet U Dwelling—No. of Bedrooms......... .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building 7:, No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. . dD Mik---•---•-----------•-------------------------------------------•-•---.-.------ -•-------- w Design Flow..........&0-------------------------gallons pe per day. Total dail flow..............3.3--0...............gallons. WSeptic Tank—Liquid capacityl400•gallons Lengths TS4." Width-_4r.S/0'biameter................ Depth...sr=.. " x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.................... q.:s ft. Seepage Pit No.......f........... Diameter.../OX- .. Depth below inlet.6,05 1`.... Total leaching area.....?:4 7sq. ft. Z Other Distribution box Dosing tank '-' Percolation Test Results Performed by.... �ll� ]�- G��,,�t�.-------- Date.---/ -���7-�--------.. Test Pit No. l..a(.Zr...minutes per inch Depth of -Pit..r¢¢ Depth to ground water________________________ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-••••-----------------------••--••••.......................-----------..............------.................-----------......-----•--•--------.....---•------ Descri tion of Soil....A1. a...........I-evo.P..�.�U��-� .... � .�=._.3_.G.°....., .�-FO/ v ........... '-..........&L.FRnV--------, ..VID.......................................................................... w VNature 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 H1,LZ 5 of the State Sanitary Code-The undersigned further agrees not to place the system in operation until'a---Certificate of Compliance has been issued by the board of health.. is Sig r ...` �/ :Y�Hr�s.�.P✓ Date Application Approved B �i,✓ _ � .y...................... ........................................ PP y--•-- yam . Date - Application Disapproved for the following reasons----------------------------------------------------------------•------------•-:-................................ ......-•.....................•---.................-•----------------......----:_....----•---•---•--•-•...------------------------------------------------------•--------------------------------•------- Date PermitNo......................................................... Issued-....Ja: �, --................. A Date No........... Fmc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF....... ................. Appliration for Disposal Works Tonstrurtion "Jprrmit .Application is hereby made for a Permit to Construct ( LJ-16r Repair an Individual Sewage Disposal _System at: ........... .......... ....... .................................. ............................... ,L-.C ati o -Address or Lot No. ......R&1eC4A.&A1;7j;�._V ". .W. . ............... . ess .......... ......... Installer Address Type of Building Size Lot.. .?,o...f!?A..-Sq. feet Dwelling—No. of Bedrooms...............,..................__....Expansion Attic Garbage Grinder ( Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( Otherfixtures ----------------------------- -1--&6iM4, -------------------------------------------------*------------------------------**..." Design Plow.............&.0................ PFA=per day. Total daily flow.............-x33.0..............gallons. 1:4 'Septic Tank—Liquid capacity./04?..gallons Len gthgg.:76... Width.0.1/ " Diameter................ Depth..S.:75...' Disposal Trench—No..................... Width_...._......._.._... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No.......I........... Diameter-M..,cr.7. Depth below inlet.6...!F.r.. Total leaching area...Z.62..sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by .......... Date..? ......... 14 1-� Test Pit No. 1....miew.1—minutes per inch Depth of T/eFt At Depth to grown��Waterl/............... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._................._... ............................................................................................................................................................. 0 P Description of Soil....XV.-.6... ....... ....... .......rourjlay.�_y----------------------------- ------------------------------------------------------------------------------------ - 6........ ......C4.as ......d-ZA-0......T.&A ---- .............................................................................................................................................................. ............*- ------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: i"If The undersigned,agrees to install the aforedescribed Individual Sewage Disposal System in, accordance with the provisions of TI Tly 5 of the State Sanitary Code— The undersigned further agrees not to place the system in I operation until a Certificate of Compliance has been issued by the board of health. C-,-32C Signpd.._...... ................... Date -------------------- ........................................ 0 , W, ApplicAion Approved By......!;;;12 / e.I Date Application Disapproved for the following reasons:................................................................................................................. . ...............................................................................2...................................................................................................................... k Date PermitNo....................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 4�_L_, . BOARD 6F/-PEALTH ......... ......OF............ ........................................... (Intifiratr of Toutpliaurr THIS IS TO CERTIFY, That the-,Individual Sewage Disposal System constructed (A or Repaired by........................................... ------------------------------------ at ........... .. .......... Installer has been installed in accordance with the pro isions of tT'_ 5 of The State Sanitary Code as described in the 2 applicationn . 4 �T " -M$ -or Disposal Works Construction Permit No.FK..XX..'71.................... dated......;;?j - ------------------ TAE"'ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN6TION SATISFACTORY. DATE............................................................................... Insp-'ector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ?V7 ..... 1. .. .....0 F................ . No...... . ....................................... L FEE.... . Disposal Works Tonstrurtion "Vrrmit Permission hereby granted...s�...t............................................................................................................ .. 105,-or Repair an IndivOal Sewage Disposal S,-_ .0 to Construco, yo terry . ............... ...........a ,I V_ I r I/ K_1�7AXI` -4 - ............ as shown on the application for Disposal Works Construction Permit-No. ... ..... Dated.......................................... ............ix . ....C; Kith- ry . ......--------- DATE.................................................................................. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS IN OWE R AY A-33.06 . - -- - - 7y. g7. - - - 10 \ \ I ILIIA ILI w /O/ /00 _P_.RbPOSE IS* B bR l —� -98 N 97 J _l , / � O � 7006 Gaz:--`- /o_lD/AA _Box 7 pO;o_FCJTURE I xnAw /oN < , LEACH/N_G_P_l___T 99 1 /60.oo _ LOT 2( NO T 5 : CX l S7_1"C 19/vp 1=-//Vi9( �,�,9DE5 u2•E55E/�T/�9LL Y THE �;'�N_�Y �`.T.. ��`tki OF RICHARD RICHARD n` DAMES ;� ! JAMES �^ O'HEARN -+I O''HEARN - No. 27871 v No. 694 v LEGEND �yF�iSTEF��oe' EXISTING SPOT ELEVATIONS O,A � S#7Rv�� - SRNITFr�F� LL EXISTING CONTOUR- - - 0 - - - - FINISHED SPOT ELEVATIONS O.0 ' FINISHED CONTOUR 0 PROPOSED PLOT PLAN APPROVED: BOARD OF HEALTH SCOT U I T_ , --MASS. c; ; _ AGENT _.LOT" 27 EISENHOWER DRIVE t I CERTIFY THAT THE PROPOSED R ✓. O'HEAPiN, 1/VC, RLS, RS EUILDING SHOWN ON THIS PLAN 191 MAIN ST. (RTE. 28) CONFORMS TO THE ZONING LAWS WEST DENNIS, MASS . OF BARNSTABLE M1AS DATE -�6 76 Is /' 3 _.. �C3 NO_ 78 -Z67 CLIENT MCL-,T i DA E EviS i c nt%D L �:D SURVEYOR I nR. g\' : �, r/I_ ; HE t= T / CAE Z ___ s` SOIL TEST INVERT ELEVATIONS NOTES= DATE OF SOIL TEST INVERT AT BUILDING 96.5 FT ALL WORKMANSHIP AND MATERIALS WITNESSED BY R 4' INLET SEPTIC TANK 96'•S FT. SHALL CONFORM TO D.E.Q.E. TITLE 5 PERCOLATION RATEZ-z �41N./INCH OUTLET SEPTIC TANK 95. 3 FT. AND THE TOWN OF �,92�SM2642 RULES AND REGULATIONS FOR SUBSURFACE OBSERVATION HOLE I OBSERVATION HOLE 2 INLET DISTRIBUTION BOX `05 7 FT DISPOSAL OF SANITARY SEWAGE ELEVATION = ✓7. D ELEVATION-_ OUTLET DISTRIBUTION BOX ems. FT. eA _a INLET LEACHING PIT 9S• 0 FT. yv00rncown4 BOTTOM . LEACHING PIT 89.o FT. 6,. DESIGN CALCULATIONS _ 36 NUMBER OF BEDROOMS .. . . . . . . . . . . . . . . . . . . . 3 GARBAGE DISPOSAL UNIT.. //ONP TOTAL ESTIMATED FLOW ( iv GAL./BR./DAY x 3 BR.).,. 330 GAL./DAY cL,e..g"v M,60. '.. REQUIRED SEPTIC TANK CAPACITY. . . . . . , . . . . . "y_ GAL. ACTUAL SIZE OF SEPTIC TANK TO BE INSTALLED... . . 20a GAL. LEACHING AREA REQUIREMENTS _ /44 " �� = 86.0 SIDE WALL AREA 2•EGAL./S.F. i BOTTOM AREAS GAL./S.F. 7SL -L_Vi9TE2=�FN� v !TFr�F17_ LEACHING CAPACITY ( BOTTOM +SIDEWALL GAL. 57x 5'X4o RESERVE LEACHING CAPACITY. . . �`{9 GAL. =s .. .? 20 FT, . t T0P OF '"-FOUND. 4" SCH. 40¢, ELEl, 9 /OFr CONCRETE CLEAN SAND 1 . COVERS PVC PIPE CONCRETE- 77 MINI PITCH COVER 1 1/8 PER. FT. 3�� 12�� MAX. 2% MIN.. PITCH P�A" OFM4v H���`ZOF RICHARD RICHARD y% N z 2n LAYER OF I/8�- I/ZII JAMES n; -"�- DAMES �1 FLOW LINE O'HEARN \ O'HEARN " r �— WASHED STONE ` No. 27671 O y ?1 X. 611 v :•� —l-O Z /9, • o o n o n n '9 FC/S7F- Qq' F��ST�.t 4n CAST IRON - 0 3/4 - 1 !/2 ,y r PIPES- MIN. PITCH , , = oa n WASHED STONE SUR\1E, = SAMITk �' 1/4 PER FT. DIST. o - f- PRECAST. LEACHING BOX �p�,� V o w p. ° BASIN OR EQUIV. � W n t ° w v L�r 27- E/5 E�/�owE2 ,�z J000 GAL ; MASS .. SEPTIC G ,ter BA2i✓sr�r3 ar.,.r L S R S TANK /0 ,-r D/.9. M//�/. R. J. 0 HEAFdN, INC., R , 191 MAIN ST. (RTE 28 ) WEST DEENNIS , MASS . PROFILE OF GROUND WATER TABLE JOB NO. 267 CLIENT A/ 7cZ,9U°HL/N SEWAGE DISPOSAL SYSTEM NOT -TO SCALE DATE 71ZO/-78 SHEET 0 OF 2