HomeMy WebLinkAbout0062 GOAT FIELD LANE - Health 62 GOAT FIELD,LANE' HYANNIS
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Town of Barnstable P#
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Department of Regulatory Services
Public Health Division Date
z639. �e� 200 Main Street,Hyannis MA 02601
Date Scheduled ✓ Time Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: 57L9N-6l`-) t' 5 t P 49- Witnessed By:
LOCATION&GENERAL INFORMATION
Location Address /' `�;��.I 60 Owner's Name S GD Vl e_'rR -r_
Address
Assessor's Map/Parcel: �/� 6 Engineer's Name �5 '�
I'll I
NEW CONSTRUCTION 'R PAIR z� Telephone# 2
Land Use $ `��A L Slopes(%) L 2- Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line f ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
d-b/5 LA-.'J�C
. d
; i
Parent material(geologic) � Depth to Bedrock
C
Depth to Groundwater. Standing Water in Hole: A 2 Weeping from Pit Face N��
f j
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABU.
Method Used.
Depth Observed standing in obs.hole: _ In, Depth to soil mottles:
Depth to weeping from side of obs.hole: __ in, Groundwater Adjustment
Index Well# Reading Date: Index Well level -_. Adj,faetor Adj.Orautt 1r level
PERCOLATION TEST Date �� �► � =`", -:. ` ,.:
f Observation
Hole# Time at 4" ("0 +.i
Depth of Perc �Z Time at 6"
Start Pre-soak Time @
U u t+ Time(9"-V) - -
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site�Failed: Additional Testing Needed(Y/N),
Original: Public Health Division Observation Hole Data To Be Completed on Back---------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil• Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones;Boulders.
Co istenc ravel
L Z0*
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) g (Structure,Stones,Boulders.
(Munsell) Mottling '
Consi enc % a
' DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Cnitec 0 ve
i
' DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
i Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency, 1
Flood Insurance Rate Man:
jAbove 500 year flood boundary No— Yes
Within 500 year boundary No A Yes
Within 100 year flood boundary No_ Yes
" -Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on g` (date)I have passed the soil evaluator examination approved by the
Department of Environmenta Protection and that the above analysis was performed by me consistent with .
the required training,expertise and experience described in 10 CMR 15.017.
Signature Date ) /8 G 7
Q:ISEPTICVERCFORM.DOC
I
TOWN OF BARNSTABLE
LOCATION l y (3 �"� C� t,CA,-R— . SEWAGE# ®�>W�A
V,TLLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. S G� �y � S��S 7 AL l
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type)P
NO.'OF BEDROOMS
3 S� Ado
OWNER - -f— 1
PERMIT DATE: J '� I ,C�7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1-6 r4eet
Private Water Supply Well and Leaching Facility.(If any wells exist AI
on site or within 200 feet of leaching facility) AJ �� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist A l
within 300 feet of leaching facility) [Vo��—Feet
FURNISHED BY ����
A k-cs "S,nS�R-c, t4
Fl:l
ar\,t� a�
�--•-w r - _..�. --rf. - - -e- ,..+ti-I I. ._ ., .. _ -•
No. . 2�C�y7— ��G 1 ` l v Fee k)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipprication for dig o aY 6p5tem Cougtructiou permit
Application for a Permit to Construct( ) Repair(' Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. / ) et J k&,-f Owner's Name,Address,and
Tel.
rNo.
Assessor's Map/Parcel �C OtNY� t� V cU V f t y
Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 13-ZD gpd Design flow provided 7 gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank G U J�L�r 6X(6 ; Type of S.A.S. `� (-c„k1,Tj
Description of Soil Cn Cat y— 1.2 X 479
Nature of Repairs or Alterations(Answer when applicable) �tG(L to I)c � PrA-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date S 6y 7 d�
Application Approved by � Date 3'�-7
Application Disapproved by: Date
for the following reasons
Permit No. o�y 7 Date Issued �—eL 3-y 7
.., _.-•-•-.,rasv.+wig"+-•+.: .._ . . _ --� �-r' .3'rr"'"".""""",,,.... .,r«.:r.-.-.,;/.,:`A:.�.:... j^-:-'..-':�.=
i sZUy�— /' k' a t �' V �' Fee
No. ti
'
THE COMM Entered in computer:
ONWEALTH OF MASSACHUSETTS i
PUBLIC HEALTH DIVISION';- TOWN.OF BARNSTABLE, MASSACHUSETTS• Yes
.14
ApplicatOwfor Migpogal 6potem Cougtructionivermit
r 4 ;
Application for a Permit'
to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �UG� J Owner's Name,Address,and Tel:No.
)
Assessor's Map/Parcel NyG^ t� �-U `► V t e ' —
r.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
G v�� �
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder �1Q
Other T e of Building' No.of Persons Showers
YP _ g ( . ) Cafeteria( )
Other Fixtures
Design Flow(min..required) , )�d gpd Design flowprovided 7 gpd
Plan Date Number of sheets Revision Date
Title rr }
Size of Septic Tank 1 d 0 0 (r c,.L exrS f Type of S.A.S. 1At/d ?Otl`�
Description of Soil �-�>% p(G�J� �'(5(,f s fy.J� l 5�. _ �] ��) ,tea
Nature of Repairs.or Alterations(Answer when applicable)
t
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 Certificat
Compliance has been issued by this Board of Health. r 4
Signed Date /.�
Application Approved by Date
Application Disapproved by: Date
for the following reasons
.Permit No. ;Lo V 7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the
`On-sit7JAIVage Disposal System Constructed ( ) Repaired Upgraded ( )
Abandoned( )by (-CU
at_ (�� �9 OG, (�r� L�.",1Z _ 1V t�tils has been constructed in
accordance
with the provi ions o itle 5 and the for Disposal System Construction Permit No. " I 1 dated S �3_d 7
Installer �d ��c'�"Il� Designer s 4G(G S (Gt A Le
#bedrooms Approved design flown gpd
The issuance of this pe' it shal not be construed as a guarantee that the system will n 'o�n�/ designed.
Date �2 �u� Inspector �" ✓1N. i ,
f I14
----------
n--------
No., — P" 11 ------------------.--- Fee )� —---—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
wig0.5al 6p.5tem Cori, truchon Permit
Permission is herebyanted to Construct Repair �U Upgrade Abandon
�' � ) P � ) Pg ( ) � )
System located at ('0 -�-,-2,\j UCA� P v G A jS
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 completed within three years of the date of tN pe>m C
Date 5'�3 Approved by
Town of Barnstable
Regulatory Services
$ � 1
Thomas F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601.
`4
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Dater dK a1 Sewage Permit# 00a l - z 19 Assessor's MaplParcel 2` e L 7
Designer: lnstaller: Se a n- r-7L-►uj�c
FjIC,LE S G/Wt'9ri�Y, iNC,
Address: 12 3 J-&v? !eA Address: 5
i
On F A-A,16- was issued a permit to install a
(date) (installer)
septic system at �0 2 �' ram ' _ based on a design drawn by
(address)
ST P we-" (+A-A5 P€ dated /o
. ! (designer)
i/ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved.changes such as lateral relocation of the
distribution box and/or septic tank. t
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of flie SAS or any vertical relocation of any component
of the septic systern) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
'(Installer's Signature) a
No.3USI
S O-7
(Designer's Signature) (Affix esign is Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:15eptic'Designer Cer iFicnion Form Revised.doc
i
q ie i 220• 1}7eDaration of f tans and SAecincamull r-7 u• i• , , r,� .,.: �•,n - ., � • -
The plans and specifications for every on-site system shall be prepared as follows:
(1) -Every system shall be designed by a Massachusetts Registered Professional Engineer
or a Massac�iuSetu Registered Sanitarian provided that such Sanitarian shall nnt-design a.
system designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203.
Any other-agent of the owner..may prepare-plans for the repair of a -system.designed to
discharge not more.than than•2,000 gallons pet day pursuant to 310 CMR 15-203 provided
/ ttaey are reviewed by:a Massachusetts Registered Sanitarian and.approved by the approving
.(2). .Every,pIan.submitted for approval must-be dated and bear the stamp and signature of
the designer,
(3) Every plan for a new system or plan for the upgrade or expansion of an existing,system" -
which requires a variance tc a properry'llne setback distaitce, must:ttlsn reference-a plan
which bears the stamp and signature of a Massachdsetts. Licensed Land Surveyor in
accordance with M.b.L. c: 112, $ 81D;
4 Every plan for a system shall be of suitable scald•(one inch=40 feet or fewer for plot
/.' Ia)ns and one inch—20-feet or fewerfor derails of system componens). a td.Shall include.
de ction of:
(a) the legal boundaries of the facility to be served:
(b) the holder and location of any easements appurtenant to or which could impact the
h ' system;
(c} the locatiorr'af the all dwelling(s)or building(i)existing and proposed on the faclity
and'd_tifieaaari of those to be served by the system;
f(d) =the-facarion of existing of proposed impel-ious•amas,- inc'lcdng:drivw eays and -
✓ parking areas',
_ .�.. . .
e) • location anddimcrisions of th'e system (mcIudzng reserve area);
(f)• system design calculations, including design daily sewage flow, septic tank capacity
hfegnircd and proyidcd); soil absorption system capacity (required and provided); and
w ther system is designed for garbage grinder;
North arrow and existing and proposed contours;
( ):.location and log of deep observation hole tests including the date of test, cxistir.,g
ode elevations marked on each test, and he. names of the reDresent=ve of the
approving authority and soil evaluator
i) location and results of percolation tests L-icluding the aate of test:and aha names of
presentati-ve of the approving authority and soil-evaluator. .
✓(j} name and certification nuarbez-of-the-Sots-Evaluator-ef-record; ._
(k) location.of'evcry*water supply,public and private,1. within 400 feet of the proposed system location L. she ease of surface. avatar
supplies'and gravel packed public water supply wells,
2. within 250 feet of the proposed system location in the case;of tubular public
water supply wells, and
system location in the case of private waxer
3. within 130 feet,of the..pioposed
supply we11s: elated
1) location of-any-suefaee waters of the Cemmonwealtfi,rivers, borderingv eg
wetlands, salt marshes, inland or coastal banks, regulatory fioodway, velocity zone, :
surface water supplies, tributaries to stface wasz supplies,certified vt rra1 pools,private :
water supplies or•suctiati lines, gravel packed-or tubular public water supply wells,
subsurface .drains, leaching catch basins, or dry wells; and Sloe location of any nitrogen
e/. sensitive area identified in 310 CMR 15.2I5 witf:i-t which portions of the proposed
f" stern are located.
( ) location of water lines and-other subsurfat:c utilities on the facility;
observed and adjusted groun&watcr elevation in the vicinity of the system;
o) a complete profile of the system;
(p) 'a
note an the plan listing all variances to the provisions of 310 CMR 15.000 sought
-in injunction with the plan.;
ac.hm
the location and.elevation of one beark.within 50 to 75 feet of the facility
which is not subject to gslocadon or loss,during consauctiah oil the .aciItiy; :
(r) when dosing is'praposcd, 'complete design and �Pecirication of the,dosing system
reposed including.but not limited to dosing,chamber capacity (required and:provided),'
ump curves and.specifications, nuriber .of closing cycles and depth per cycle;
Sand Filter or equivalent alternative technology is required or
(s) when a RecirculatiiuD stem,including a hydraulic rotilc;
posed, a complete plan and specification for the sy g y P
�a locus Plan,to show the location of the facility including the nearest existing Me-,
thc street number and lot number, if any, of the facility. and
(Y) the materials of construct on.and the specifications of the system.
yy.
'TROY WILLIAMS `F
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection u 6,r�<r/ (508) 760-1819
CA
40 Old Bass River Roadl9`96`
South Dennis,MA 02660
Commonwealth of Massachusettsflu A-A
Executive Office of Environmental Affairs
Department of .
Environmental Protection
WIIBam F.Weld Trudy Coxe
GoMrnor .S—Vt-Y
g"Paul Celluccl Davld B.Struhs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
CERTIFICATION
Property Address: 6a 60 0-1 -.-t k L,,. `Y M.. , t �o..�.Address of Owner. h i G� G e � /�u✓�s�O/� .
Date of Inspectlon:5�13/y6 / 'T- (If different)
Name of Inapectoy� /.�r r s
n -7
Company Name,Addceea In Telephone Number. Ovk �vrcJ
c 33
EKG CA-130✓G,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage-disposal systems. The system:
,Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signet Is Date:
The System Inspector shall submit a oo of this inspection report to the_Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A B,C,or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:/1/4�
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination is all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved,
by the Board of Health.
(revised 11/03/95) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addrem /C
Owner. Ko.✓�S b¢v
Date of Inspection: y
B)SYSTEM CONDITIONALLY PASSES (continued)
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):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(a). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: IV117
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment. /
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT•.
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
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 leas than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Addcesx
Owner.
Date of Inspeotkon: ✓ S Sc✓y
DI SYSTEM FAILS: NI9
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to
failure. determine what will be necessary to correct the
— Backup of sewage into facility or system component due to an 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 IN 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 Soil Absorption System, cesspool'or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
— Any portion of a cesspool or privy is within a Zone I of a public well. '
— 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
eoliform bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:N/4?
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
— 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 11 of a public
water supply well)
The owner or operator of.any such system shall bring the system and facility into full compliance with the groundwater'treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
i
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (, a GmK s :e/,,A
Owner: K, l-I s 6,17
Date of Inspection:
S1/3 /'1,
Check if the following have been done: -
Pumping information was requested of the owner,occupant,and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been reeeiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
1l As built plans have been obtained and examined. Note if they are not available with N/A.
V The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
ZAll system components, excluding the Soil Absorption System, have been located on the site.
d,[The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction,dimensions, depth of liquid,depth of sludge, depth of scum.
lzlThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
ZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION
Property Address 6 02 Gmt'-4-�'
Owner.
Data of Inspection: I�
RESIDFNTIAU FLOW CONDITIONS
Design fio—._22 plloaa
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): V4-7-5
Seasonal use(yes or no): A/6
Water meter readings, if available:
164, s
� moo
Last date of occupanry: v Gt cc.��,-� C, rh 6 In S
COMMERCIAL/INDUSTRIAL• N1,,q
Type of establishment:
Design flow:_-- allona/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yea or no)_
Non-sanitary waste discharged to the Title 5 system: (,yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: _
8YE m pumI�ed as PaA of inspection. (yes or no) A.10
If yes,volume pumped_: gallons
Reason for pumping:
TYPE F 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)
Other(explain)
APPROXIMATE AGE of all components; date installed (if)mown) and source of information: L �� 7
Aff
Sewage odors detected when arriving at the site: (yes or no)
i
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address; b a
Owner. K 0.✓ $ bc,i�i
Date of Inspection: s //3 IF6
SEPTIC TANK
(locate on site plan)
Depth below grade:.�� /
Material of construction: ✓concrete_metal_FRP_other(esplain) `
Dimensions:
Sludge depth:_ �,• s
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: rr
/V /r
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) Car. �-- � 6 C.-P f44_7- CA-c%_( v c_ c¢_ �o'r a /e-
6REAS9 TRAP:±14�
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP—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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
i
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner. Ko - S 6
Date of Inspection: 5113
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction _concrete_metal_FRP_other(e:plain) -
Dimensions:
Capacity: gallons
Design flow: ¢ 1lons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: lGU
Comments:
(notg if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) 1-5 sh Sys
G uA
PUMP CHAMBER: Nl/-9
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
I
(revised 11/03/95) 7
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addeeaec •Z �jo°��-�j�-/�
Owner. /Cw 15 wg
Date of Inspection:
SOIL ABSORPTION SYSTEM(SASr t�
(locate on site plan, if poasrble;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Tope:
leaching pits, number: Dh
leaching chambers,number._
leaching galleries, number
leaching trenches, number,length:
leaching fields, number,dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condi ' n of vegetation,etc.)
a
CESSPOOLS:
(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 constriction:
Indication of groundwater: _
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRFVYN/,
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic-fsilure, level of ponding, condition of vegetation,etc.)
_f
(revised 11/03/95) g,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Ownec: 5
Date of Inspection:
5 //,3 �� L
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�k.
5`I '
sf'h- .
DEPTH TO GROUNDWATER -
Depth**to groundwater: — feet :- - -; `" adjusted high grotuidwatcr level fi '
fv+'"1 � i "��J•t
method of determination or roximation:
N aPP •- - ��:,.�'- a.>y -G���1 y lip ��r.-duo ` �' �',�: ._.�?""F5 ' -
)h I
.ate..r ,.� �j•.:.. ..
TOWN OF BARNSTABLE g
LQCATION, ;2 /66a T 1/CA R14. SEWAGE # "O? ✓75 0
V-..LAGE�_ a/�. ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /b
LEACHING FACILITY: (type) (size) 54"
NO.OF BEDROOMS
BUILDER OR OWNER
!.4
PERMIT DATE: 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility) Feet
Furnished by�� W` 1 °"4 Sf16g2 ��
__/
_� to
v I'i
C�
r' 9
� ��
c'b
c��
i
.-_ .
LOC TION. SEWAGE PERMIT NO.93
VILLAGE
1,NS'TA LLER'S NAME i ADDRESS
'5 • p��s cy
B U I L D E R OR OWN ER
DATE PERMIT ISSUED 3
DATE COMPLIANCE- ISSUED ! Z
� � ��
n � O
� �, '�`. _
��
,:�
` ' M1
V/
'I
� I
47-1.11117", 7
A
I :-T'1 :ON5
R 1,A
'LE V DE-SIGN C T�
ACCESS:]COVERS IN-
INSPECTON WINIMUM
' GENERA L�WOTE,,�
U_ t�W, WITH- A E
N IER R
D
'DES I 61V"FL.0 W.
I N�Ek f4i 6V� PTtC TANK: � 97- L
PORT _
F0iiSH"15RA _ , ', .: : � ,� " , , *
3 MAXIMUM COVER " - t_ .", L ., , "''
A;,
INVERTJN V 15 1. BOX
'TO
THIS PLAN�'IS'FOR THE, DES,IGN AN01 'CO#S TRUCTI 0&;.'
STI'�,
-3,�BEDROOMS,A T I
IV 'PEASTONE-.
BD.:� PER
N VER T 'BtDRO
/IV 2�� OF
L t ITI, OM EQUALS JJO G.'P.D.,
.:OF THE SEWAGE,D' SPOSAL' SYSTEM ONLY
r,'l N ACH' HAYBER.-�,,. 7.2, -
INVER'
4' C 9
IAM PIP
/2.�7 D I A DA TUM SASSUMED
:VERTICAL'
'NO GARBAGE OR NDER FOR BENCH'MARKS
2. '
- : 95.2
BOTTOM OF,LEACH �CHA
97.3 I'� ' a I, ., 11 1 , i � , I , 71 ,�:, : , , I SET,1: SEE,'S I TE �PLAN.,
E WASHED �STONE
,DO&BL'
2
24'
OAS
I I 1 '95. TED GR 0&ND:.,�,WA TER
'97 ;47 ADUS
,1 11, 1 1 SEPTIC TANK PEo
a FF4 til RED:
NIA
AFF4
T
3. ALL
L OBSER VED_GROUND WATER: -660 GAL. CONS RUCTION METHODS,AND"'MATERIALS AND
:,NFILITRATOR 330 G,P.D
3 X 200V
'TEST�,.HOLE,, MA f N TENA NCE"OF,�I*HE- tPTIC S YS TEWSHAL L
EXISTING 90,1:
-CHAMBERS W14STONE AROUND 8 TTOM ,'OF' 2,
D-BOX SEPTIC TANK PROVIDED: 1000 GAL. EXISTING
T11
P., :* OCAL
1000 AL" 12 x 2-0 1 'x 24d� E-�15�A ND L'
ONFO�
A
SEP f I'C TANk: 6 CRUSHEDSTONE OR SOIL ABSORPTI N's 80 RD 'OF PEAL P411REGULA TIONS�.
0 YS TEM',PtOU RED:
COMPACTED BASE
DES�I GN PERC..RA Tk, 5'.MINIINCH
4. � � ,ALL SEPTIC SYSTEM�COMPONFNTS L ia�A TED NDER
$0 1 C' TEX7URA L CLASS I
OT TO SCALE - To VEHICULAR TRAFFIC-OR GREATER
:E ::N AREAS SUBECT
PP OF:'/ L
0.74 GPDISF
EFFL UE`NT LOADING RA TE
THA N 3
446 S.F. REQUIRED
330 GPD'1 IN DEPTH, SHALL 'BE CAPABLE OF Wt T141
�:O.74, GPD�Sr
S,
OA
STANDING H-20 'WHEEL L
PROVtDED:"3 i NP L TPA TOR. 30�0
PIPE SHALL-,BE,SCHEDULE 40 OR
CHAMBERS W14 ' STONE AROUND. A-512 S.F. ALL, SEWR
Q
378 'GPD
S.F. i 0.74
6. SEPTIC TANK,'AND D BOX SHALL BE REINFORCED ,
TA
SO IL TES T P T DA PRECA$T--CONCRETE'AND WATERTIGHT. ,_�D-BOX
BE� WATER TES TED TO CHECK FOR LEVEL WHEN TH RE
ND I CA TES
ND ICA TES �7
WA TER 6A TE
�PERCOLATION 'OBSERVED MORE THAN'ONE OUTLET.
GROUNDWA TER,
p
A E3 TES T
-DIG-SAFE
7. BEFORE CONSTRUCTION CALL
TP
'0 TP #2 THE 'LOCAL WA TER:DEP T.
0
19
FOR LOCATION OF UNDERGROUND _UTIL TIES,
UP 23911 HORIZON' :- TEXTURE COLOR - ORIZO
76o 100.7 0* 100.6
68' 0
LOAMY IOYR LO'AMY 10YR 8. SEPTIC SYSTE14 INSTALLER SHALL.,NOTIFY THE
iguy VIRE
CONSTRUCTION
SAND
guy WIR SAND ,
DESIGN ENG I NEERTWO DA YS PRIOR, TO
.0 3' ........
. ............. ......... .........
100.1,5 6* /00. / OF THE SYSTEM TO ALLOW FOR
�CHEDULING OF THE
LOAMY IOYR LOAMY /OYR
SAND 513 513 CONSTRUCTION INSPECTIONS.
Iry SA ND
CATCH PASIN N NK
............ ......
24 ...... ........... ......... 98.7 24-— 98.6
LOT : 6 3-INFI L TRA TOR 365 9. , EXISTING LEACH PIT Te BE PUMPED DRY AND
MED COARSE IOYR
MEa-'COARSE IOYR
BACKFILLED.
CHAmBERs w14,
1'\4367 S. F. I STONE,AROUND SAND SAND 616
616
+
101.95 T P*2
im, CORNER OF SULKHEADI
IiL
42
rp.I
G
100.7
NO WA TER NO WA TER
120
EXIS ING
Y�STING .90.7, 126-
TANK
I Tr
DA TE.- APRIL 17. 2007
4k
UA
TES T 8 Y:, STETHEN HAAS
WITNESSED' BY: rDONAL6 DESPARA S
+
0 f
PtRC RArE:, '( ,2 MINIINCH
f10
A.
CIVIL
............
NO,354
Eo�
102
- 15'W
76
E_,P T 0 D L A IVE- "A P .2 4 c5
' 6'2 OOA TF P A R 4��E
T-,TR V Ll_ �E
77A 's L. ::�F
A R S
-PARE-D F_OR
LEGEND ,
0 C8 CONCRETE' B 0 UND
W
WATER
LINE
y T S CA-L E
HYDRAN
N C
A S U FR V E Y N
L E,
GASI,L-I NE
E, G
OHW— 0 VER�WEA D WIRES
6 u t el 6 A
L GH 'P0S
p
"0.2-6 75
�E Y ca r rnc> u t h, NAA
-ELECTRIC LJ N
UNDEROUNDr
ER UND
GRO 508
TE'LEPHO'NE r NE*
T UND L
LINE,
CTV
r ION' '
SPO T EL
,7F 40,4
OUR
S TI
—40 NG'CO T
TOUR
PROPOSED'CON
0 40
1/ 0
40 W CHECK
CF W, r
026: FIELD CrWZEEK�` CALC: SAHICF
IVA p OB IVO
D
t