HomeMy WebLinkAbout0055 SAINT CATHERINE AVE - Health IN
- 55 ST..CATHERINES AVE., HYANNIS
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TOWN OF BARNSTABLE
LOCATION �S � 4�X 7Ggpl,'yC SEWAGE#.2ib -3 G 3
VILLAGE_A4Zk4 1S ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. ®csfi e Id 4We•1-4,,-v
SEPTIC TANK CAPACITY lSUO
LEACHING FACILITY:(type) (size) 12.29 k 3--yjF- ,I-9
NO.OF BEDROOMS T
OWNER /yI L'
PERMIT DATE: ��r0 �- 9 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _ �'�3�� feet
Private Water Supply Well Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) /V ;4 feet.
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leach' ' facility). N� feet
FURNISHED BY
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/ THE COMMONWEALTH OF MASSACHUSETTS Entered m com ter:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplitation for M18t1Dsal *pstrm (COnstCuttion Vermit
Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System [�j Individual Components
Location Address or Lot No.5S".f T C41rE4e-.", 1 sd v Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 2 9/ 6 .7
Installer's Name,Address,and TAI.
No. Designer's Name,Address,and Tel.No.
'$a�srr</d SAAo4A..j .>erw,v_e Arc ,eo,v%
SA.ibL,-t c ik ✓i 4 4'dv Z o/b •2G 37 J�.r/7v�<c!� r�-73 Z/7 7
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building �1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) —�T d gpd Design flow provided gpd
Plan Date l r Z o—a J Number of sheets / Revision Date kAOoy-G
Title
Size of Septic Tank Oe(J2' ,nq 400 Type of S.A.S. 64;,4�4e,_f 37 6c1Xt2__20 X g=;LJJ_l'
Description of Soil_S lae—/d 1jo^
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
S' d Date /1 7 Q
Application Approved by 1A Date
Application Disapproved by Date
for the following reasons
Permit No. U / —
)ate Issued u'9
-------------- - -r
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No. Fee /Od
THE COMMONWEALTH OF MASSACHUSETTS Entered in canp�ter:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,-MASSACHUSETTS Yes
20plitation for disposal Opstem Construction permit
Application for a Permit to Construct(. ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System L']Individual Components
Location Address or f,ot No.SSS 7 CATi-K-r— Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 2 9/ 6 3
Installer's Name,Address,and Fel.No. Designer's Name,Address,and Tel.No.
h 5t-f-/d YAn,a-r-•y Sc�V„ �e ��(-
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5ra•n �c� A ���' 20/b ��,s�s� d'33 Z/ 77
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(W)
Other Type of Building _ sal/ /e No.of Persons Showers( ) Cafeteria( )
Other Fixtures
j Design Flow(min.required) gpd Design flow provided gpd
Plan Date 2 u --o Number of sheets / Revision Date tioiv-e
Title
Size of Septic Tank E6X,S7.. /_P9 Type of S.A.S. 37 oV r 1'Z.21i x 7-. h
r Description of Soil S� /"lQ,01
Nature of Repairs or Alterations(Answer when applicable) P 44
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°
S' do �30 �/�`.,"'"�'�_ Date // 6 g
Application Approved by I/ nl. S Date -/o w g
Application Disapproved by Date
for the following reasons
Permit No. .?0 C b Date Issued / (�
-- - - ------'-- -- - - -= = - = ----- = - -THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
-- Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired()e ) Upgraded( )
�
Abandoned( )by 3OuS�i P �� L-1, re o,c rc e C
at �5 C,q %/ �iw e. /i'"y //Y-114/7ia has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. '(-�� dated U�I
Installer Designer -
#bedrooms Approved desig 'flow
tdesigne
gpd
The issuance of thi permit shall not be construed as a guarantee that the system will fimcttod. �/Date � { � � �) � Inspector >. ,J
No. .2 00 0) �3 (� � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS -
Z[Sposal *PSttm Construction i3ermit
Permission is hereby granted to Construct( ) Repair(Y) Upgrade( ) Abandon( )
System located at
u�s,2aAl1/.5
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction rust be completed within three years of the date of this permit.
Date (o Approved by \ U.
Town Of Barnstable
N� f"E r Regulatory Services
P
Thomas F. Geiler, Director
i a Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
�J r
Date: . 1Z-1z0z) !.
Designer: ���T,� �v`��"I Installer:
Address: . Address: ��` �-C_, _
On 0 Zou —Iwas issued a permit to install a
(dale) (installer)
septic system at. . based on a design drawn by
(address)
—Di1V 1 W106OL4, R5 dated to Z ZD0
(designer)
I certify that the septic system referenced above was installed substantially according to
=t1ie design, which may include minor approved changes such as lateAl relocation of the
distribution box and/or septic tank
r.
I certif}...that the septic system referenced above was installed with`'major.changes
s. greater than'10' lateral relocation of the SAS or any vertical relocation of any component
of the septi`,,system)but in accordance with State&Local Regdiat ons. Plan revis oza or,
certified as-l; lt`hy designer to follow.
"°0'"As
_ z =dAVID �y.
(Insta 's Signature) B• Cn
�
h9ASON rn
Flo.1,066 s
sgN�TAR�I'�
(ll er s Signature) (Affix`= i er's Stariip Here).
PLEASE RETURN TO BARPNSTAUtE'PUBLIC.HEALTH DIVISION. C RTIF+'ICATE
OF COMPLIANCE WELL: NOFM': SSUED: fiJN',ITI; "BOTH'':3TII&jF4RM AND"
BUILT CARD ARE RECEWED ft THE.BARNSTABLE PUBLIC RED DIVXSIOIY
THANK YOU.
Q: Health/Sepric/Designer Certification Fora
APPLICANT:
ADDRESS: 4Tr 13Zil- -I E 4YE
DESIGN FLOW: gpd
REVIEWED BY: -
DATE:
N/A OK NO
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)] i ►/
Locus Provided 310 CMR 15.2204(0]
Plan proper scale?(1"=40' for plot plans, 1"=20'or fewer for
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for /
upgrades]- i not, a variance is required 310 CMR 15.412(4)] I�
Location of impervious surfaces (driveways,parking areas etc.)
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)]
Location and dimensions of system components and reserve areas
[310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(f)]
daily flow
septic tank capacity(required andprovided)
soil absorption system (required andprovided)
whether system designed for garbage grinder
North arrow [310 CMR 15.220(4)( )]
Existing and ro osed contours [310 CMR 15.220(4)( )]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)
Names of soil evaluator and BOH representative [310 CMR /
15.220(4)(h)and (i)] 1/
Location and date of percolation tests (performed at proper J
elevation?) [310 CMR 15.220(4)(i)] 1/
Percolation test results match loading rate? [310 CMR-1 5.242] ,
Certification statement by Soil Evaluator 310 CMR 15.220(4)0)1
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Location of every water supply,public and private, [310 CMR
15.220(4)(k)]
Address � ���Itw�
t
Sheet 1 of 7
within 400 feet of the proposed system location in the case
of surface water supplies and rayel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case].
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)]
Water lines-and 6th6f§bbsufface utilities located [310 CMR
15.220(4)(m) if water line cross see 310 CMR 15.211 1) 1 )
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR15.220(4)(o)]
Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2)or as LIZ
approved for an upgrade under LUA at 310 CMR 15.405(1)(k))
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103 4)
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103(3)]
Benchmark within 50-75'of system [310 CMR 15.220(4)( ))
Materials specifications noted? [various sections of 310 CMR
15.0001
System components not>36" deep(unless Local Upgrade
Approval or LUA requested) 310 CMR 15.405(l(b
Address —4t6 C L� Sheet 2 of 7
r
Size OK? _[310 CMR 15.223(l)]
Inlet tee located ten inches below flow line 310 CMR 15.227(6)]
Outlet tee 14" or 14"+5"per foot for increase ft depth [310 CMR J
115.227(6)] V
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)]
Note regarding instal.lation on stable compacted base [310 CMR
15.228(1)]
Separation between inlet and outlet tees (no less than liquid 4 V" I
depth) 310 CMR 15.227(2)
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or perm ifted for
upgrades under LUA [310 CMR 15.405(1)(k)]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and n d-
o the box 310 CMR 152228 1 and 310
) [ ( )
CMR 15.232(3)(0]
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" (b 7/07) [310 CMR 15.228(2)]
Access to within 6 " of grade - one port for system-s<I_OOOgpd, '
two fors stems>1000 gpd 310 CMR 15.228(2)
All at-grade covers secured to unauthorized access? [310 CMR j
15.228(2)] 1/
> 10 ft from building foundation [310 CMR 15.211(1)]
Buoyancy calculation Required/Done 310 CMR 15221(8)]
H-20 Where appropriate? 310 CMR 15.226(3)]
Setbacks from resources 310 CMR. 15.211)
Required when other than single-family dwelling or flow>1000
d [310 CMR 15223(1)(b)] ✓
First compartment 200%daily flow; Second compartment 100%
daily flow 310 CMR 15224(2) and(3)]
"U"pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15224(4)]
Address `�"`��� Sheet 3 of 7
rl5
cated atleas! ten feet from any water line? [310 CMR
.222(2)sposal piping at least 18"below water line (when water and
sewer cross, see 310 CMR 15.211(1) 1 ) V
Cleanouts required/provided ? [310 CMR 15.222(8)]
Thrust blocks s ecified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)
Proper pitch on all runs?(.005 within gravity-distributed trenches
and beds) 310 CMR 15.25](9) and 310 CMR 15.252(2)(c)]
Siphonproblem/ leachfield below pump chamber)
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified?(not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)]
Materials specified 310 CMR 15.251 5
P specifies various
( ( ) p sous pipe
types allowed)
Stable compacted base [310 CMR 15.221(2)and 310 CMR /
15.232(2)(a)
Splash plate or baffle tee required on inlet/provided?(when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)]
Riser if deeper than 9" [310 CMR 15.232(3)(f)]
Inside minimum dimension 12" 310 CMR 15.232(2)(b)]
Minimum sum 6" [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)]
Capacity(emergency storage above working=design flow)?[310 ✓.
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20"MUST BE ✓,
TO GRADE [310 CMR 15.231(5)]
Service components accessible (not too deep,with piping,
disconnects accessible) LIZ
Alarm floats -alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag /
mode. [31'0.CMR 15.231(6)and (8)] ✓
Stable Compacted Base [310 CMR 15.221(2)]
Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)]
Address L-5T. C491�rAz/Kx— Sheet 4 of 7
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR /
15.240(1)] 7�
Required separation togroundwater? 310 CMR 15.212A
Aggregate specified as double washed [310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241] 1/
Inspection ports specified and within 3"final grade? [310 CMR
15.240(13)
Breakout requirements met?(No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole (if>2000 gpd must /
Lz
be to grade) 310 CMR 15.253(2)] l/
Aggregate 1 minimum-4'maximum. [310 CMR 15.253(1)(b)]
2'sidewall credit maximum [310 CMR 15.253(1)(a)]
In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)]
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)]
100 feet-maximum length [310 CMR 15.251(1) a
Minimum separation 2x effective depth or width whichever J
eater(3x if reserve between trenches) [310 CMR 251 1)(d)]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
minimum 2 distribution lines 310 CMR 15.252(2)(a)]
Maximum separation between lines 6' 310 CM R15.252(2)(d
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)
Aggregate depth below discharge pipes 6" minimum, 12" /
maximum. [310 CMR 15,252(2)( )] V
Separation between beds 10' minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only 310 CMR 15.252(2)(i)]
r
Address / ` ��� / 'k ` ' Sheet 5 of 7
WIN
Pressure Dosed System'? Provided pump and piping
calculations as re uired 310 CMR 15:220 4 r) Y
Pressure dosing required on all systems>2000gpd or alternative
systems undeWftnedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system -make sure jet is directed as not to
scour soil interface [Guidance Document]
Inspections once per year(systems<2000 gpd)or quarterly
(>2000 dgood to note on plan 310 CMR 15.254(2)(d))
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)? ]/
Impervious barrier and/or retaining wall ? Guidance Document
Impervious barrier installation must be supervised by
designer [310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)] .
Side slope not exceed 3:1 ? 310 CMR 15.255(2)
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document] " I
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [3,10 CMR 15.255 (2)(e)]
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge J
to scour soil interface
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for ✓'
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applidant submitted a coy of a maintenance
Are the variances listed on the plan ? [310 CMR 15.220
(4)( )
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)
New construction or increased flow proposed - [Refer to 310
CMR 15.414]
Address c75T C4-7AI&Oc/ 'E
Sheet 6 of 7
1
4
91 WE
Is the system in a Designated Nitrogen Sensitive Area(Zone I1 for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)] ✓
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(l)] V
Pumping to septic tank? [ 3]0 CMR 15.229
Shared System 310 CMR 15.290
-
i.
F
Address Sheet 7 of 7
r/�, C��I u�� � _ .
Town of Barnstable P#_ a
Department of Regulatory Services
aru3I, :� Public Health Division Date a2 0
9� t639 `6�MASI
200 Main Street,Hyannis MA 02601
i°lED►M'l�
Date Scheduled Q s jWt
Time Fee Pd.—
Soil Suitability Ass-ssment for Sewage ispt
l
Performed By. Witnessed By; (nv �N ) Dl
LOCATION& GENERAL INFORMATION
Location Address Owner's Name
5S S c CA4-Gt ev ,,-e 4V2 i 731(( McNAMA J -
Address S 4-Yk.e
Assessor's Map/Parcel: Z q 1 o t,3 Engineer's' DAu2 tht< o V1
s Name
NEW CONSTRUCTION REPAIR �. Telephone# 9-3 `L( ? 7 r
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft IIrinking Water Well ft
Drainage Way ft Property Line ft Cther ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&.perc tests,locate wetlands in proximity to holes)
- �wo `b
7
Parent material(geologic) ,-C4 Depth to Bedrock `w
Depth to Groundwater. Standing Water in Hole:° Weeping from Pit Nce Lg44-
Estimated Seasonal High Groundwater ly
DETERNIINATION FOR SEASONAL HIGH WATER TA13LE
Method Used:
Depth Observed standing in obs.hole: in,. (Depth to soil mottles: in,
Depth to weeping from side of obs.hole: .in, Oroundwater Adjustment ft.
Index Well# Reading Date: _ index Well level ��-Adj,faetor,_ Adj.Groundwater Levei Observation —
PERCOLATION TEST bate_ Time
Hole# Time at 9"
Depth of Pero Time at 6"
Start.Pre-soak Time @ Time(9"- ")
End Pre-soak G
Rate Min./Inch AN71
Site Suitability Assessment:. Site Passed �,Siteiled: 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:\SEPTICVERCFORM.DOC
DEEP"OBSERVATION HOLE LOG Hole.#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
on iste cy,% ravel)
13 C i C5 ,
2,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consiste %G vel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
I Consistency,
Flood In"surance Rate Maa:
Above 500 year flood boundary No Yes .
Within 500 year boundary No,ZYes r=-
Within 100 year flood boundary No�,�Yes
Depth of Naturally Occurrin>?Pervious Material
Does at least four feet of naturally occurring pervio s �jaterial exist in all areas observed throughout the
area proposed for the soil absorption system? _`""""' U�
If not, what is the depth of it turally occurring pervious matertal?
Certification '
I certify that on L (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed y me consistent with .
the required training, pe 'se rid experience described in 310 CMR 15.017.
Signature Date 1-0t°
Q:\S.EPTICVF-RCFORM-DOC
TOWN OF BARNSTABLE
LOCATION 13 5 S-- l(Vs SEWAGE #
VILLAGE ASSESSOR'S NTAP& L 3
r
INSTALLER'S NAME&P96t NO.
SEPTIC TANK CAPACITY
LEACHNG FACILITY: (type. d (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
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 �C.,
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I
j-� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
�� w 8t
Property Address: 55 ST. CATHERINES AVE. HYANNIS c
Name of Owner RITA WIECHELS �•5
Address of Owner: SAME
w
Date of Inspection: 6/8/99
Name of Inspector:(Please Print)JOHN GRACI 23 1 7 y
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 999
Company Name: nla d TO�FggRNs �+
Mailing Address: n/a �'d 1FIOQ'T
Telephone Number: n/ate
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:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passe code 310 CMR 15.303.My findings are of how the system is
Needs Further Ev at' n By the Local Approving Authority performing at the time of the inspection.My inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:6/9/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
THE PASSES TITLE V INSPECTION.RECOM MEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:618199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
S. SYSTEM CONDITIONALLY PASSES:
n(a 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is 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 complying septic tank as
approved by the Board of Health.
nLa 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
nta The system required pumping more than four 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: . RITA WIECHELS
Date of Inspection:6/8199
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 the public health,safety
and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS 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 free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa_(approximation not valid).
3) OTHER
nLa
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:6/8/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nta.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
_ 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:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
I
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:6/8/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:6/8/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:34.Q g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):4
Total DESIGN flow: 44Q
Number of current residents:l
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): MQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):_LQ
Water meter readings,if available(last two year's usage(gpd): Wa
Sump Pump(yes or no): MQ
Last date of occupancy: n&
COMMERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: Wa gpd(Based on 15.203)
Basis of design flow: nLa
Grease trap present:(yes or no):JM
Industrial Waste Holding Tank present:(yes or no): LLQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ
Water meter readings.if available:Wa
Last date of occupancy: n&
OTHER: (Describe)
D&
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SYSTEM WAS PUMPED TWO YEARS AGO,INFORMATION FROM OWNER
System pumped as part of inspection:(yes or no):YES
If yes,volume pumped 1590 gallons
Reason for pumping: MAINTENANCE
TYPE OF SYSTEM
X Septic tankidistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1985
Sewage odors detected when arriving at the site:(yes or no): 111Q
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:618/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2.6..
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
nLa
Dimensions: L 10'6"H 5'7"W 5'8"
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: L"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:6
Distance from bottom of scum to bottom of outlet tee or baffle: 1L
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nta
Dimensions: nLa.
Scum thickness: nta
Distance from top of scum to top of outlet tee or baffle:jada
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
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.)
nLa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:6/8/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: WA
Capacity: Wa gallons
Design flow: nta gallons/day
Alarm present: NQ
Alarm level:jiLa- Alarm in working order:Yes_No_ NO
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND, SYSTEM IS FUNCTIONING PROPERLY
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nta
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:6/8199
SOIL ABSORPTION SYSTEM(SAS): $
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: ONE LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: j3&
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nLa
overflow cesspool,number: nLa
Alternative system: nLa
Name of Technology: -n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY SAS SHOWS NO SIGNS OF FAILURE PROBED AREA IT IS DRY
CESSPOOLS: _
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: n&
Depth of scum layer. Wa
Dimensions of cesspool: n&
Materials of construction: nLa
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
)I&
PRIVY: _
(locate on site plan)
Materials of construction:nLa Dimensions:nta
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:618199
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
e
d
�o
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 ST.CATHERINES AVE.HYANNIS
Owner: RITA WIECHELS
Date of Inspection:6/8/99
NRCS Report name: nLa
Soil Type: nta
Typical depth to groundwater: Wa
USGS Date website visited: nLa
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
- Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS AND VISUAL-12+FEET
revised 9/2/98 Page 11 of 11
LOCATION SEWAGE P RMIT NO.
INSTA LLER'S NAME A ADDRESS
vow
® U I L D E R OR OWNER
� \IF,cvAu-,Lz,7 ! , J I N &L:L�t-� �
GATE PERMIT ISSUED
DATE COMPLIANCE IS SUED � �
�LI-7l� P r
t;
.a
ly
� 1
y 1
� � L
V � M
tq
cnr� 2 �
1
R ! �
No....... 6•�/ Fm$..............................
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F.....................-.......-........-"-"-----•-"--.._...-...-----•-•---.-....._...-•--•-
Appliration for Elispos ai Vorks Tatuitrurtion ranfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
... .. ..__e'..._. :a,r�, ._.• ..��................... ............•----,---------... ............................................................
Location-Add;ess or Lot No.
........ :' .`. ........
ll�.IS...�...•��.5........ .............: ....................... ...................................................
Ownr-�j 1 Address /�
•---
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling`''=No. of Bedrooms.__-_` __________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No, of persons____________________________ Showers — Cafeteria
0.' Other fixtures ..---------•--- ---•--•-•••••-• -
W Design Flow...............��� _..............gallons per person per day. Total daily flow........(4-_44-P�_....__.____...__.__gallons.
WSeptic Tank—Liquid capacity__ gallons Length-----10..... Width.....to...... Diameter................ Depth__q__!F.....
Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No--------k........... Diameter____________________ Depth below inlet.....7A.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation.Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................
--•----------------- .............................-..........................................................................................................
0 Description.of Soil.........................................................................................................................................................................
x
U ---•••••.._.:...........................................................................................................................................................................................
W --•-••••-•--•----------------•-••••-•--•-•••••---•-----••--•--•-••--••----•--•----•---•••-•-••-•-•-------••--•••------------------------------------•----------------------------------••••-••--••••••--
UNature of Repairs or Alterations—Answer when applicable_____ ?4 __._"� _k�- �,•___._._�� ,O�___..-____..
f G,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL U 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 boar .
Signed :. - -- --- ......... .._. ��- ``�.
Date
ApplicationApproved By--•-•-- /L- -----------------------•--------------....--------.._.......---••----•-•. -•--••-••-----•-•---•--------••--••-•---
Date
Application Disapproved for t e following reasons---------------•------------------------------------------•------•-------------------------------•-----
Permit No.... y:... 7!------------------------------ Issued...............
71
No..................... FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........................---................OF.......................................--................................................
Appliration for Uhipos ai Vorkfi Tonst.rnrtinn rrmft
*;
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
on- ress �, `,, n or Lot No.
(Xl "�-+C
_ ...........
---•--------------•--------- -......_.S).3.__..._..----- G' ` s - �--- ...
......... .
Installer� Address
UType of Building /, Size Lot............................Sq. feet
Dwelling—No. of Bedrooms____.•-_•_---�__-•_•---------------------Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e of Building ............... No. of ersons............._.......__.____ Showers
YP g ------------- P ( ) — Cafeteria ( )
Othextures ...---•••••-•••••••-----•------••----•••••••-•••••••-•'-----•-•••••••-••--•------------------•--••-
W Design Flow........ -------------------•--___---gallons per person ear day. Total d sly flow.....4��......................__ lons.
WSeptic Tank—Liquid capacitylr�Pallons Length...._.__...... Width..____..... Diameter________________ Depth_ .___..
x Disposal Trench—No..................... Width.................... Total Length......._....__..... Total leaching area....................sq. ft.
Seepage Pit No...1_ -- Dia meter..................... Depth below inlet._....T ..... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,.� Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.........................
4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
RS ....................................
-----------------------
-----------------
__...............................................................................
0 Description of Soil........................................................................................................................................................................
x
U •-••••••••••-•-•-••---••••••---•••-••••---•-•••--•-••-•••-•-••••-••••-•-•••-••--•••-----•......•-••-•---••--•---•-•••••••--•••••••...------••••••-••••-••--•-••••••••-•-••--•-••--•--•••-•-•••--------•.
x -•••-•-••---•--------••--------•-•••-•-•----------•----•--•--------•••-••••••--•-•......................... 1� i
U N tur of Re irs or lter tion —Ans eyw en a livable_ 1L-7t_.________l_ _-. X.. ...........
Lle(
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ued by the boardd d lth.
- - Signed..... ( .. -•
Date
�
Application Approved BY-----------'--'--�=-•--------------------------------..._------•----------•---•------------------ ---------------------------•-----------
Date
Application Disapproved forte following reasons:............................................................................................ --••••-••••-••-•--
•-••-•-•••••••••••••.........••••--•-••••....._...•••---•---..._...•••-••-•---•••--•----•--•-••...•-•••-•'. ......:...............••------•••----•--•---•-•••---•••-------•-•--••••---------•••••-••--•--
Date
PermitNo...... ...........................••__ Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
A.
fch ..( ..........................s4'Y......Crrtgitt�ea..........
�u�t�� ��t�e f,
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O
t° .--......k
Installer
at••••-•-••-••...•-••-•_r .f 1'............................................./...
has been installed in accordance with.the provisions of TITL j of The State Sanitary Code as described in tlig.
application for Disposal Works Construction Permit�tiTo:`._. ` _ ----_____________ dated_ ..____7_._J' ..
a�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A CUARANTEE'THAT THE
SYSTEM WIL FUtjdTION ,SATISFACTORY.
DATE.... . � � Y
In-....._... --- •.................... Spector___ --------•-----
THE
..
COMMONWEALTH`OF MASSACHUSETTS
BOARD OFF HEALTH
vtc.�, � r✓s,Gr..�� .
...........................................OF.............. k<...................--------...............................
No......................... � FEE........................
Disposal Works Toots ion ramit
�Q'a e l`'� /�..l ✓i rS
Permissionis hereby granted-----------------------=� ..................................................................................................................
to Construct ( ) or Repair (✓J"an Individual Sewage Disposal System
at No...--_-• .em y-- ........� �: ..G 0,147 f.ic <a_ `° f r`. p I-�• ---...
a 4._ Street .'/-
as shown on the application for DIssposal Works Construction 'Permit No..................... Dated...........r...._....__......._......
1 3
Ax.
U �� 1_ , Bo
„
=d of
DATE------------------7_...�_..._..---'---.......-........•-•--•--=.........
a. each FORM 1255 HOBBS & WARREN, INC., PUBLISHERS `,
LOCATION SEWAGE P RMIT N0.
V I L L A G E
�� >✓ Wit\dv 5 C
I N S T A LLER'S NAME i ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED � 2�
DATE COMPLIANCE ISSUED
t'
is a3
ZVI
t
Z� i
ASSESSORS MAP : �/' a�.:� ),, ..
TEST HOLE: LOG`
PARCEi.. : y V > lV :
SOIL EVALUATOR:FLOOD ZO[4i
_ 1) The installation shall comply with Titk: V and"9 own of Bourne Board of
REFERENCE � D / �. DAT - IID I Health Regulations.
1 ,� '
PERCQl. SAT ,� ) The installer shall verify the location.of utilities, sewer inverts and septic
A
x7 , 7
/ f �� components prior to installation and setting base elevations.
ltr �' �� ' TH*..1 TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/0"per R)ot. The first _
two feet out of the d-box to the leaching shall be level.
Lok
I t t /A l C-Lf f i 4) This plan is not to be utilized for property line determination nor any other
c. A -- purpose other than the proposed system installation.
5) All septic components must meet Title V r--)eci+ications.
6) Parking shall not be constructed over H 10 cum septic onents.
P P
-- i � -----�--- �LOCATION M A f 7_ d ) The property
perty is bounded by property corners and property lines.
0") The property owner shall review design considerations to approve of tot-: a
design flow and number of bedrooms to be considered for design. 12eceipi. 'b
-,7� �
() .� .��,.-I( of payment for the plan and installation based on the plan shall be deemed
I `` approval of the design flow by the owner.
)) The existing leaching or cesspools shall be pumped and filled with material
,r ¢ `� �� t per Title V abandonment procedures. "Those within the proposed SAS shall
`fal {p be removed along with contaminated soil and replaced with clean sand per
Title V specs.
10)System components to be 10 feet from water lime. Sewer lines crosslog the
water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
_ SEPT IC SYSTEM DES I G N applicable. The proposed SAS is being 'installed below the water service
line. The line is to be sleeved as aforemeritioned and maintained in place.
FLOW ES I'1 MATE 11) If garbage grinder exists it is to b,; re,,,-oved and is the responsibility of the
owner to ensure such.
_J.. 1
E3EDI:OOMS t : I GAL/DAY/$EDROOM - �I` GAL/DAl -)The installer is to take caution in excavation around the gas line if such
exists.
.�D,OQ SEPTIC rA1V K
13)The installer shall verify the location, quantity and elevation of the sewer
in s l exit he &,vell or to the
_. � j.__._,, ._ �.. _,• __ _.._-_ _ ___ -- �� exiting t ing prior installation.
GAl /UAl' x D v - GAL
— - - -- SE. GAL SEPTIC TANK (_cc lf;
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SOIL ABIORPT I O! SYSTEM
rrt.1.40:t> n C)\"A
SIDE AREA Zk t �y.
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�; I BOTTOM AREA: , '�C t2��_--r, `� � t^t
61
C SYSTEM SECTION v
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LEACl ItNG
(1.,29,WX36.48'LX 1.9'D) 633 FT2 SITE AND S .WAGE PLAN
_� ✓ .j; �' Bottom:(12.29'X 36.48)= 448 ft2
Sides:2(12.29'+36.48)X 1.9'= 185 ft2 LOCATION : 6AT�fA W F,, -AV
TOTAL LEACHING AREA CAPACITY
-HLf L M�
(AREA X RATE) 468 GAL./DAY i
RESERVE LEACHING CAPACITY PREPARED FOR : �`J�(,>,-�1 ��4�'
RES N/A_
PRO VIDE-(8)-H-20 ADS ARC-50 UNITS WITH 4 STONE z l
ALL AROUND/N AN 12.29'X 36.48'X 1.9'TRENCH FORMATION SCALE: `
DAV I D B . MASON P'. r DATE : ID ZD
Z DBC ENV I RONMENG� C L'c I GN S
z -- EAST SANDWICH . MA
3 DATE HEALTH AGENT ( 508 ) 833- 2 177
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