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HomeMy WebLinkAbout0019 SUNSET TERRACE - Health 19 Sunset,Terrace ;�, -Hyannis - 7 267�;'0�1 .._. ,.;,�_��,f � - - Pow ./• � — - _ -- -_ _ - - __ __ _ _ - _ - _, - - - --- _ _ _ - _� 1 ° o { �! e o o � l: I I 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Y*evi e- Owner Owner's Name information is / i' /j�,� Qa�I�� 6 ! required for W z�' L— every page. City/Town fit 5 State Zip Code Date dinsiftection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms the �� r computer, r,use 1. Inspector: Il✓n only the tab key to move your IlMa cursor-do not use the return Name of InspectoL L U key. L Iykll D — Company Name VQ /��o Company Address� Od, 6 T,� `r4'a City/Town State Zip Code LS oa) 177r 12� ��� Telephone umbe License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was-performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails t~- a ❑ Needs Further Evaluation by the Local Approving Authority T�l 0- `- rJ co Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the jroving Atbtorit oard Y„ of Health or DEP) within 30 days of completing this inspection. If the systemlis a shared sysV% or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall Wbmit 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. 15ins•09/08 Title 5 official Inspection form:subsurface SewaJD)isoSystem•Page I of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ]—errc, c e. Property Address / I Lu✓o CI G Ile- Owner Owner's Name ,{ information is required for w t/ ,P ! ���j aNN,f �i7 D a16 7oZ �� every page. Cityrrown State Zip Code Date Ins ection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: [9-<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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / g SG kse 7� Te✓�G Ce Property Address Ile L/ G rD Owner Owner's Jame /J / information is /, /PS L! G y�N t D'd�7� �� Q,1 6 �oZ 6 /IV required for Vv // every page. Cityrrown State Zip Code Date qf Ins ection B. Certification (cont.) 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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. ❑ Y ❑ N ❑ ND (Explain below): ❑` obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 i5ins-osm Title 5 Official Inspection Form:subsurface Sewage Disposal system•Page 3 of 17 Commonwealth of Massachusetts mom Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / 9 �Uns� Property Address "elG roc Ile- Owner Owner's Name information is PS 6 a required for State Zip Code Date bfinsp4ction every page. Cityrrown B. Certification (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 indicates absent 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. i I Other: t D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ C2,,- 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 ❑ E],/ Static liquid level in the distribution box above outlet invert due to an overloaded LL�� or clogged SAS or cesspool ❑ Eq� Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow IS,ns,•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /9 -- z C � Property Address / Owner Owner's Name /f�� l n information is �' 'I required for �-��— State Zip Code Date o Ins ction every page. Cityfrown B. Certification (cont.) Yes No ❑ 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 L� tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0-�' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ I� 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ 3---- The system is a cesspool serving a facility with a design flow of 2000gpd- 0'000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 iIf 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. t5ins•OS108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �Gi' //✓O G A /!?,6 le, Owner Owner's N e /n information is es Cr N �f S �/�— (�b�,g . (O / required for every page. City/Town State, Zip Code Date Insp ction C. Checklist 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? [vj� ❑ 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? 0-' '❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): i5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17, x Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Sw o_5�� fe c Property Address Ct r0 G I/ Owner Owner's Name n� /�� required on is �es Q pa L 9, 6 �� required for C^ h f every page. City/Town State Zip Code Da a of Inspection D. System Information Description: / �G << / 4 4 &$11 *fon �6 x a 00 /l'o� �3xa�X� 0 Number of current residents: ,_,� Does residence have a garbage grinder? ❑ Yes l" No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ©'No Laundry system inspected? ❑ Yes. Seasonal use? ❑.Yes to Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No. L4,11,e Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 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: — 15ins•09r08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments r` . 19 scol�� Tevreir-lfl' Property Address zcli Owner Owner's N me jy information is ���� ,� G r1 rf�i eZ 6�� required for every page. Cityrrown State Zip Code Date of spe lion D. System Information (cont.) Last date of occupancy/use:' Date Other(describe below): General Information 6� Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sys 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins-09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's me / I n information is le /,L/� 4"h U/�4— � ©k9/oZ required for every page. City/Town State Zip Code Date f Insp ction D. System Information (cont) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer (locate on site plan): 0 Depth below grade: feet Material of construction: 0,6a5st iron 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet �erialonstruction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: � /-0 Sludge depth: C2 t5ins•09r08 Title 5 Officiat inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 -�- rev/ Property Address Owner Owners N e /n information is es �� VotG�oZ ;6 ��l required for State Zip Code Date of nspe lion every page. City/Town D. System Information (cont.) I Septic Tank (cont.) Distance from top of sludge to bottom.of outlet tee or baffle Scum thickness Q Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle C4(//C (f-- How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): (. �- �Coll vrr ,� N o C/Ck-IN 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments iPv,e,ce- Property Address iv - Gt r0 G Owner Owner's Name JJ�� / (} ) /,� information is h,s p/�- �"� ��G/oL vv required for e f �Rh every page. City/Town State Zip Code Dat of In pection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow:, gallons 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.): ' Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ms-og/o8 Tille 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 t of 17 i Commonwealth of Massachusetts 09 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / �1i1 NSA T T-evrc'C Property Address 26ie-19 C- Owner Owner's Name t—T f'D/� information is required forL4 :�every page. Cityown State Zip Code Dat of I specGon D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): v C Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note.condition of pump chamber, condition of pumps and appurtenances, etc.): ` r Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis osal System Form - Not for Voluntary Assessments 9 (�vlS.e 7 �e✓/Gi G� Property Address G✓OG� .� Owner Owner's Name l C1 information is �QS required for every page. City/Town State Zip Code Dat6 of Inspection D. System Information (cont.) Type �OO Ci It a v►t bP✓f 13 X J-��J- ❑ leaching pits number: ❑ leaching chambers number: i ❑ leaching galleries number: Elleaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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. t5ins•OM8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 ��Kse� l errG c Property Address OwnerGYDG � inform Owner's Nam g /� information is JL �C/o/ �oZ 6�02 required for rLLL every page. City/Town State Zip Code Dat f1rdpection D. System Information (cont,) 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.): I (Sins•oNo8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments / 7 -u e Property Address / L gi✓'0Gke,Ile Owner Pwnef s Na e information is aHhr required for / /�� ° every page. City/Town State Zip Code Date 6f Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where publ' water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately W Ve.r �/ a dove • 6� � `t y G3- �3 [Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address / Gt c/O c' — Owner OwniYs Name Oo� information is / — /v required for .C N✓JrJ O every page. Cityrrown State Zip Code Date ofinspe6ton D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells // xvb l � Estimated depth to high ground water: feet 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 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Check d with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: i You must describe how you established the high ground water elevation: vv► 1 v7 S �� ��e P� ��ti � , Li PA CPr 7`c c a 7- (o -1 1115 r K-ec P- 0-7 / Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ms•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 18 of 17 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address G/0 C' ` -e Owner owner' Name /n information is e Nh�f��� 0016 ` v required for every page. City/Town 011 State Zip Code Date of Inspec on E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked inspection Summary D (System Failure Criteria Applicable to All Systems) completed 9/System Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•OW08 Title 5'Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Sep - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 Ms;0t 1 ' NOTICE: "Phis Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM CAQ-t-Apr's F J41:Ny herebycertify that the en needed ian signed by me Y � P o uz;ec �5 06r concerning the property located at �JU VeC_VC,CIP. 1�' t��y t me.ets all of the fctlowmg ;�teria: • Th)s failed system•is connected to a residential dwelling only. There are no :or-i.m-_rzi3A or business uses associated with the dwelling, • Tie soil is ciass:;;ed as.CLASS l and the percolation rase is less than or equa to -n:nut:s per inch. The applicant may use historical data to conclude this fsc; or may :Driduct pre!irnwar;, tests at the sire without a health agent present • There :s no increa.e to flow and/or change. in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen I feet aonve the maximum adjusted groundwater table elevation. fAdiust the nundwa;er table using the Frimptor method when apphcablel Please complete the following: �. "fnp of Grouno Surface E!zvatiun (using GIS infotmna!ton) 6` G.w' l<var.on _ ad,ustment for 'nigh G.W. RcNCF EETWEEN > and 8 DATE: s!a�z 3asec iron t^c atove r.formation, a repair permit wil! be issued for �edr^oms dd w)nal bedrooms ze authorized to the future without en,tncerec =s_X.tem plans. --- — z 1-.uh!r,:Oci Pucc.tm7 Permit Number: Date: Completed by: h HIGH GROUNDWATER LEVEL COMPUTATION Site Location: \0VC1SQ_ �2C1' Q Lot No. a - Owner: �dh(1 ��C��C�R1�1 Address: n Contractor: ��`Y;\�i T nlj►KODME06 \ Address: �('fl0 ipr Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. ..................................................... ._ ................... .Date v month/day/ ear STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well................................................. OWater-level range zone...................................................... C STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well mon h/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 28) determine water-level adjustment .......................................................................................... 1 STEP 5 Estimate depth to high water by subtracting the water• leve'I adjustment (STEP 4) from measured depth to water level at site (STEP 1) ........:...... 8,(� .................................................................. I; Figure 13.—Reproducible computation form. 15 TOWN OF BARNSTABLE _ LOCATION ����-�'� �/�/-.�t-e3 SEWAGE VILLAGE ���',�� � ASSESSOR'S MAP & LO1T�, INSTALLER'S NAME&PHONE NO/0"LL p SEPTIC TANK CAPACITY 6 -G� e � LEACHING FACILITY: (type) (size) 7 7 NO.OF BEDROOMS BUILDER OR OWNER -PERMIT DATE: 0 COMPLIANCE DATE: Separation Distance Bet en 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(1f any wetlands exist . ' within 300 fee_LA f le c n li Feet Furnished bye *7 1 0 - -� q11.2- � i i COlf1`10"WEALTH OF XLI�S.SACHL SE.7 Q _Na '_ EYEc TnT OFFICE OF : l•_IliO� VL 'i DEPARTMENT OF E-N7WROI\: -TE-\-1,)LL PRO_ECTZO TITLE 5 OFFICIAL INSPECTION FORtiI—NOT FOR VOLL-2-N-TARY ASSESS-NIENTS SUBSURFACE SEWAGE DISPOSAL SYSTENT FORZI PART A CERTIFICATIO-N Property address: ON---ner's\ame: ✓�'✓I Rv�! _ Olvner's Address:—L C4*7S� 7:�-- Date of Inspection: - ame of Inspector:lplease print) Compan-,--ame: .4—/G!//p _ :`Iailin;Address: a Telephone\umber: p _ L{c� d, CERTIFICATION STATUVIE\T c'7y w I I certify that I have personally inspected the sewage disposal system at this addr._s and that the mfo_.�:arc- below is true, accurate and complete as of the time of the inspection. The ins rioa.va_: e— —,a training and experience ir.the proper Rmcaon and maintenance of on site.se-wage disposal as L � ._. approved sN stem inspector pursuant to Sect' 15.340 of Title 5 3 to 1 am a DFaP Q ( 10 CMR 15.000). The sys. Passes _ Conditionally Passes T� . w Needs Further Evaluation by the Local Appro-via`_q- ho G�i Fails M. Inspector's Signature: Date: //h The system inspector shall submit a copy of this inspection DEP) repo t to the Appre�:�nQ_�uthe-- �o,rd .,—T,�:..� �_ within 0 days of completing this inspection.If the system is a shared syst o � - gpd or greater. the inspector and the system ocher shill submit t em o-ha. a -t�_s_ _to;<ai' '. DEP. The orig he retort to he apnro^bate repo nal c- ._e final should be sent to the system owner and copies sent to the buyer i`anahcab?e. authority. - - Votes and Comments `C-**This report only describes conditions at the time of time. This inspectio inspection and under the conditions of use at ti�at n does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6115;'2000 Pace 1 Page 2 of 1 1 OFFICIAL INSPECTION FORAI—NOT FOR VOLLT T_A.RY ASSESS?NIENTS SUBSURFACE SEWAGE DISPOSAL- SYSTEINi INSPECTION FORM P!-1RT"A CERTIFICATION(continued) Property Address- J(�4v1� Owner: RO Date of Inspection: . / Q Inspection Summary: Check A,B,C,D or E/.0 AYS complete all of Section D A. Syste sses: I have not found any information which indicates that anv of the failure criter_a described,L ;10 CN_>R 15.303 or in 310 CNMR 15.304 exist. Any failure criteria not evaluated are indicated belo Comments: ��70ne m ConditionallyPasses: or more system components as described in the"Conditional Pass'section need to be retD.lac-ed or repaired. The system; upon completion of the replacement or repair; as approved by the Board of_Heahh. will Hass. Answer yes; no or not determined(Y.\\D)in the_for the following sta-emen-s. ""not lea_e explllain. The septic tank is metal and over 20 Vears older or the sepric tank(whether metal or not)is s-rucarall.: unsound; exhibits substantial infiltration or exfrltsation or tank failure is irr.--iinent. Svstetn .tit!pas rsnecvo if ; existing tank is replaced with a complying septic tank as approved by the Board of Heart . *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Gel.cif care of Cor n_ :lance indicating that the tank is less than 20}rears old is available. r \-D explain: Observation of sewage backup or break out or hi_h static ivater level in the d,stri bu;ion box due to obstructed pipe(s) or due to a broken. settled or uneven distribution box. S�,-stem,�% 11�zs in;pec . i= approval of Board of Health): - broken pip.e(s)are replaced obstruction is remo-ved distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obsiucted pi_e!S). .n= _•_..;-2- pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed \'D explain: •rir�.� � to cr�onrinn T=n..�� �,'1:;nnnn � .. Page 3 of 11 'OFFICIAL INSPECTION FORA?- NOT FOR VOLU T—RY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTE-1 INSPECTION FOR-Af PART A CERTIFICATION(continued) Property Address: ,l S��'lS2T or Al �f e Owner: ,�G�o Date of Inspection: C.- Further Evaluation is Required by the Board of Health: /' Conditions exist which require further evaluation by the Board of Health in, orde-r To de,e­_-e i�_�e.s_;°:r=m is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance pith 310 C.-IR 1>.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=0 feet of a surface Rater Cesspool or privy is within 50 feet of a bordering vegetated-%vetland or a sai: nar:h 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 tithin 100 et e surface water supply or tributary to a surface eater supply. The system has a septic tank and SAS and the SAS is Rithin a Zone i ofa public Rate=Sin i The system has a septic tank and SAS and the SAS is within 50 feet of a private w-a-er _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or-o-e .=om a private water supply well**. Method used to deternune distance "This system passes if the well eater analysis;performed at a DEP cemt`ed iaborato�. for col b= bacteria and volatile organic compounds-indicates that the v ell is free from pollution. -on.:_tha-facil:�:and the presence of ammonia nitrogen and nitrate P.itroaen is equal to or less than d nnm.arc ided-' a no ot-,er failure criteria are triggered.A cony of the analsis must be attached to this fo'n . 3. Other: T rim tncnont1n1 T=n.,.,_ l l Lllnnn 'f Page 4 of 11 OFFICIAL INSPECTION FORN7—NOT FOR V OLUNT_IRY ASSESS--NIEN TS SUBSURFACE SEWAGE DISPOSAL SYSTE-NI INSPECTION FORM PaxT,A CERTIFICATION(continued) Property Address: Slit hfe T e�/lq L 141 —�7 Owner: z A RO C Date of Inspection: M// ;,'6---:� A System Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each dithe following for all inspect,.ons: Yes \o/ ,Back-up of sewage into facility or system component due to overloaded or cio_-ed S.kS or.-;;poor Discharge or ponding of effluent to the surface of the ground or surface water; due to ar: averioa ed er ciogcred SAS or cesspool v Static liquid level in the distribution box abo\--e outlet ini et?due to an o-,-erloaded of clogged S_-kS or sspool _ Liouid depth in cesspool is less than 6`�below insert or available,'olume is Ter `hban day l v t�Required pumping more than 4 times in the last year NOT due tc clogged or obst cted pit:;s:f. Numb e- iof times pumped v` r/ Any portion of the SAS;cesspool or privy is below high Around water elevaro-n. f�Sny portion of cesspool or privy,is within 100 feet of a surface,;pater supply or u`_buTan-to a ;ur'a•re ater supply. lv nv portion of a cesspool or pri,,v is within a Zone 1 of a public-w-ell]. An^ portion of a cesspool or privy is within 50 feet of a private water supply wel: y portion of a cesspool or privy is less than 100 feet but greater than 50 fee--from a private �z ater supply well with no acceptable water quality analysis. (This system passes if the well Rater anah-sis. performed at a DEP certified laboratory-,for coliform bacteria and volatile organic compounds. indicates that the well is free from pollution from that facilits-and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than;ppm,provided that no other failure criteria are trig(yered. A coPy of the analysis must be attached to this form.l /y (Yes/-No) The system fails.i have determined that one or more of the above falltire cr*teTia exist as described in 310 Cyr 15.303:therefore the system fails. the system owner s tould contact t e Board of Health to determine what will be necessary to correct the failure. E. Larae Systems: To be considered a large system the system must serve a facility,with a design flow of 10.000 gpd to 15.000 gpd. You must indicate either"yes'or"no' to each of the following: (The following criteria apply to large systems in addition to the criteria above) the s �srem is ,yithin 400 feet of a surace drinking water supply the system is within 200 feet of a tributary to a surface drinking water vs s.pp1 — the Svstem is located in a nitrogen sensitive area(Interim Wellhead Protection_fie_ Zone II of a public water supply well if vou have ans,vrered"yes"to any question in Section E the system is considered a sic�i= es"in Section D above the large system has failed.The ow;,er or operator of anv Igrc; significant threat under Section E or failed under Sectionh D shall .adA.• u g - —p` the syste_. acc�.r�a-,e -=_- _ : 15. 04. The system owner should contact the appropriate regional office of rile Depal,nieS - •-.-, �n c»nnn 3 Page 5 of 1 1 OFFICIAL, INSPECTIO\ FORM—'SOT FOR VOLUNTARY ASSES S-N ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PECTTO- FOR .PART B CEIECKLIST Property Address: S� h� Owner: �Or�p fi Bate of Inspection: ZZZ7AO6 { Check if the folio-,ving have been done. You must indicate"yes'or"no"as to each of the folio -r: e`` \o/ ��umping information was provided by the owner; occupant, or Board of Heals: - ire%ere any of the system components pumped out in the previous two:reeks :' vHas the system received normal'floa-s in the pre-,°ions Two Reek period Have large volumes of water been introduced to the system recently or as pa.-L of this 4-.,e on VVere as built plans of the system obtained and examined?(If they were not available r_ete as j 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? V Wcre the septic tank manholes uncovered; opened;and the interior ofthe tan:;its-cec,ed for t_e con", :o^ of,the/baffles or tees;'material of construction;dimensions;depth of liquid, depth of sludge and death of scurn Was the facility ov.mer(and occupants if different from owner)provided« th itfot:~ta-di n on the^-r- oger maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has beer de,ermined based on: Yes o /Existing information.For example; a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue _p '_o = =0-o- is unacceptable) [310 C\TR 15.302(3)(b)] Tirlc incncrrin r'nrm 4it C/711lin - i Page 6 of l l OFFICIAL INSPECTION FORT—\OT FOR VOLUNTARY ASSESS:fE-TS SUBSURFACE SENT-AGE DISPOSAL SYSTE_A1 INSPECTION FORM PART C Q SYSTE3IINFOR-'IATION Property address: / -.5 Cit ee//G C i.f o✓ Owner: 120c Date of Inspection: LOW CONDITIONS RESIDE\TI•-AL / Number of bedrooms(design): Number of bedrooms(actual): o� OOY� aoZ� DESIGN flo:v based on 310 Ci 15.203 (for example: 110 gpd x_of bedrooms): �30 \'umber of cut-rent residents: Does residence have a garbage grinder(yes or no): �V Is laundry on a separate sewage system(yes or no);yp if yes separate inspection recut e<dl Laundry system inspected(yes or no):AV Seasonal use: (yes or no): IN,ater meter readings. if available(last 2 vears usage(gpd)): Sump pump (yes or no): I Last date of occupancy: COSMERCIAL/ENDUSTRIAL T%.7e of establishment:. Design flow,(based on 310 C%4R 15.203): rd Basis of design flow(seats/persons/sgft,etc.): y Grease rap present(yes or no):_ Industrial waste holding tank present(yes or no): \on-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings; if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 11(--e J f 4Ev-7 �tgOV Was system pumped as part of the inspection(yes no): If yes; volume pumped: gallons--How was quantin,pumped determined?_ Reason for pumping: TYPE,�SYSTEM _Septic tank, distribution beY, soil absorotion system _Single cesspool _Oyerflo�t cesspool Price Shared system(yes or no) (if yes; attach previous inspection records; if any) _Innovarive.Alternative technology. Attach a copy of the currer-t operation and irai:ten-mce c -ac= - obtained from system owner) _'Tight tank -attach a,copy of the DEP approval —Other(describe): Approximate age of all components; date installed(if hoar)and source of infoa on: «ere sewage cdors detected wh.-n arriving at the site(yes or no): Tito \ tnC!'�PI`41/ln �,lYm �/t-;nnnn � Page 7 of 1.i OFFICIAL INSPECTION FORM-NOT FOR VOLI.-NTARY ASSESS_ 1.ENTS SUBSURFACE SEWAGE DISPOSAL SYSTE'NI INSPECTION FORM PART' C Q SYSTEM INFORMATION(conxinued) Property Address: / 7 _5�r0-ire Owner: �� p Bate of Inspection: 7 BL:ILDI\G SEWER(locate o�site plan) Depth belov=,wade: Nlaterials of construction:_L_,G �t iron --4T1VC other(explain): Distance from private water supply well or suction line: Comments (on condition of joints;venting,evidence of leakage;etc.): SEPTIC TANK: _(lam ocate on site plan) Depth below g*ade: � Material of cons-maction:_vEoncrete metal—fiberglass -.Dolvethv_lene other(explain) If tank is metal list a(ze:_ is age confirmed by a Certificate of Compliance( Tes or no):_(a-ach a cc of certificate) Dimensions: _ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:--� Scum thickness: i Distance from top of scum to top of outlet tee or baffle: G �/ Distance from bottom of sour to bottom ujl_et tee or baffle: 12 _ Hoyt-were dimensions deterrined: 19 2 MA 2ri/CQ Comments (on pumping recommendations.inlet and outlet t e or baffle condition. structural irtegrn. fie io level; as re ated to oylet inver,�, evidence of leakage, tc.): u �o �I cle� ct� �rl i✓''I2 Gi N Gn s O y r h , GREASETRAP:/locate on site plan) Depth below grade: _ Material of construction:_concrete_metal fibe_giass_poivethvlene other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition. smut tu_ai -ems as related to outlet invert; evidence of leakage; etc.): 8of11 OFFICIAL INSPECTION FOR.i•I-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTE-Z INSPECTION FOR J PAk2Z' C SYSTEM INFORT'IATION(conr:med; Property address: / _N,og /Qv�,-G C� Owner: �OI /{e c Date of Inspection:. // O TIGHT or HOLDING T K:�y (tank must be pumped at rime of inspection)(locate or,site plan) Dept below grade: \laterial of construction: concrete metal_fiberglass_polyethylene ot±e_lexrLL!: Dimensions: Capaciry: gallons Design.Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: v Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOA.: �(ifent must be.opened)(locate on site plan) Depth of liquid level above outlet invert:��✓���- Comments(note if box is level and distribution to outlets equal,any e-,zdence of solid_ can:v over. an_.'evidence of leakage t o or out of bo,-, etc.): PUNIP CHAMBER: / (locate on site plan) Pumps in working order(yes or no): Aiatms in working order(yes or no): Comments(note condition of pump chamber.condition of pumps and appurtenances. etc.": i T;:lo t cno�r;n �n 41,�lJnnn $ Page G of 11 OFFICIALI\SPECTIO FOR�'VI—�OT FOR i��OLU\TAR1`ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I\SPECTION FORM FART C SYSTEM INFORn•I_ATIO\(continued) Property-Address: �e;i Aac Date of inspection: �/ O SOIL ABSORPTION SYSTEi\I(SAS): (locate on site plan.excavation not required) If SAS not located explain why: Type leaching pits. number:_ 0 �©O �G �/p C��v� �P✓ leaching chambers. number: -f leaching galleries,number: r leaching trenches; number; length: W �/ leaching fields; number, dimensions 7` J Ae"?e overflow cesspool; nurnber: innovative,%alternative system Type/name oftech.iolow: Comments (note condition of soil, signs of hydraulic failure;ievel of ponding, damn soil, condirio'n o ,,-ege ration. etc.): CESSPOOLS: (cesspool must be purnped as part of inspection)(locate or,site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth ofsolids layer: Depth of scum laver: Dimensions of cesspool: '-laterial_s of construction: Indication of uoundwater inflow(yes or no): Comments (note condidon of soil, suns of hydraulic failure;level ofponding. condieo-2 o ve?etat or? :::.is PRIVY: (locate on site plan) -Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure;level ofpondinr. condition T:'i, Page 10 of 11 OFFICI4.L.. INSPECTION FORAT—NOT FOR VOLLITA Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEMI\SPECTIO\ FORM PART C SYSTEM INFORMATION(continued) Property-Address: / J L! C� Owner: c Date of Inspection: Q( SKETCH OF SEWAGE DISPOSAL SYSTE 1 Provide a sketch of the sewage disposal system including ties to at least mo permanent reference landmarks or benchmarks. Locate al -ells v ithin 100 feet. Locate«-here public water supply enters the builei__. 3 --r I / cZ f1 o2 gc� — d,9 n . Page 11 of 11. OFFICIAL., INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ! SPECTION FORM PELR"I'C SYSTEM I`TFORIMATIO\(continued) Property Address: Sly hSG 1" ev�R�� a,a is o✓ /�/� Z3:-.rner: Bate of Inspection: SITE E_XA-M Slope Surface water Check cellar Shallww ,wells Estimated depth to ground grater 1� feet Please indicate(check) all methods used to determine the high ground water ele-vat or_: Obtaine system design plans on record-If checked,date of design plan rep ieR ed: O' n-ed site(abutting propem/observation hole Mthin 1�p reet of SAS) Checked-with local Board of Health-explain: Checked-,sith local excavators; installers-(attach documentation) Accessed L.-SGS database-explain: You mustf�escrib how-you PP-tablis d the high gr and water eievation: C� 1�6 P L !/1 O P1 T`-1c C fn cno�tinn L Town of Barnstable OF tWE�pw �. Regulatory Services • - Thomas F. Geiler, Director BARN96ABLE. 9� MASS. Public Health Division ATEo �° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: i Designer: FT)04C0 \ Installer: C Address: �•L3: j6 (�a Address: Cn .>:Pc_&�0�1C.� '1 On Mmac)*2Lw�, a was issued a permit to install a ( at ) (installer)tA,we LRgcrrS septic system at \121k ls on SQ-�T�1M C?-, i based on a design drawn by (address) 9_ncmz n-\,4c\ C6dated // (designer) ? 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. I certify that the septic system referenced above was major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. H OF F.dq q c CAR�i?EN G, st ler's Signature) �� E. U CW t,V �" a No. 1181 ra `o K ST0- IIT s� . .aN (Designer's Signature) (Affix Design's ii 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: Health/Sepiic/Designer Certification Form Town of Barnstable OF IHE Tp� o Regulatory Services , Thomas F. Geiler,Director * &1RN' BLE. ► 9 MASS- Public Health Division i63.9• �0 ATED �A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: GQ Designer: Eno Installer: Address: e765U Address: On �was issued a permit to install a ( at ) (installer)M,IJsE LP►B#15 septic system at A &3n Sg� T5� CC CR_, l J�based on a design drawn by (address) notcm" �3c6dated (designer) 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. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. � ,ZN OF MgSs, c , o� CARMEN ZG . st ler's Signature) E. SHAY No. 1181 � a (Designer's Signature) (Affix Desi i 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:Health/Septic/Designer Certification Form C� TOWN OF BARNSTABLE LOCATION �7 - SEWAGE # VILLAGE — ESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO"Ad A SEPTIC TANK CAPACITY '�d LEACHING FACILITY: (type)c:;�- (size) L3J( 27 NO.OF BEDROOMS j �� BUILDER OR OWNER 0-6( L�"1 PERMITDATE: S 0 8" 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 fee f le c n rli Feet Furnished by':w c Ewl No. .may �a . i FEE C V COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. APPLICATION FOP DISPOSAL SYSUM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) -)KComplete System ❑Individual Components Location Owner's Name Map/Parcel# Address asr 1• Lot# -A 3 Telephone# Installer's Name - _ I ku Designer's Name Address Address Telephone# Telephone# 54R — 9 G 021;&-Vo Type of Building \\f�L ,- Lot Size sq.ft. Dwelling-No.of Bedrooms ram\ l �C1 - ) �� Garbage grinder (/VrV�f} Other-Type of Building r V CsN E No.of persons Showers (V,Cafeteria ('Vf Other Fixtures LAupatw? , KiTCair-4 rjk, LAutipp,Y Design Flow(min.required) 330 gpd Calculated design flow Design flow provided AZj,�S gpd Plan: Date q ��`]T�� Number of sheets Revision Date !— Title CC7'1�se SE PT\C c�.s-\Se.M Description of Soil(s) _ Q�\CYN Soil Evaluator Form No. Name of Soil Evaluator C1SNAY Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITi!5 and furth to no to place the syst per tion until a Certificate of Compliance has been issued by the Board of Health. Signe �� Date © " V Inspections �w No. CXi 3 r�^t 1 ' X I FEE Ste... Board of Health, n t )c' MA. APPLICATION F®R`DISP®SAI SYSTEM CONSTRUCTION IO PERMIT !. S Application for a Permit to Construct( ) Repar ',•UpgradeO Abandon(g) „ Complete System ❑Individual Components id. ` Location P C2 Owner's Name -. Map/Parcel# ^ , ` Address I-,Ul k Lot# Telephone# O Installer's Name _ Al K Tlr Designer's Name14� " Address , Address ,? _ at R , �VN Telephone# _ Telephone# Type of Building 1l` CCU\T1,7 t-Sr'T i(�L. L;ot Size V t ('4 sq.ft. Dwelling-No.of Bedrooms -7t spa Garbage grinder Other-Type of Building g E No.of pays ns � Showers (V,Cafeteria (YJ{ Other Fixtures LiriQ PrrrA>-S s Tr C`N n)1- 3 tou��DRY Design Flow (min.regilired) gpd Calculated design flow esi i�flored gpd Plan: Date ` (~'a Number of sheets R ate •J'� Title t"r� �PC� 'F o7\c Description of Soil(s) . [ '. `>� Soil Evaluator Form No. Name of Soil Evaluator �w�1r�'r�� !:t- iY Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthetLagu to n to place the syst per lion until a Certificate of Compliance has been issued by the Board of Health. Signed !° Date Inspections No. FEE s t a Board of Health, & o15�,O,, CERTIFICATE OF COMPLIANCE Description of Work: O Individual Component(s) O Complete System The undersigned,hereb certify that the Sewage Disposal System; Constructed ( ),Repaired (4-t7pgraded ( ),Abandoned ( ) by: 11 y- L. at 1 Su..W.l T ra -: e4A t r- has been installgd in accordance with thp>rovisio o_ 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application Nod 4 Zi dated r-. ,°l O 1 . Approved Design Flow ,(gpd) Installer Designer: Inspec Date: ')r� The issuance of this permit shall'not be construed as a guarantee that the system will function as designed. No. �� " C7 "a FEE COMMONWILALT14 OF MASSACHUSET$� Board of Health, &> r-,-I<, , MA. . DISPOSAL SYSTEM CONSTRUCTION CTION PERMIT Permission is herebygranted to; Constr>� Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at `'"�4. a � Ct _ '� v� +'t►" S '�` '' as described in the application for Disposal SysteConstruction Permit No. dated Provided: Construction shall be completed within three years of the dat'e of`lhikp trait ,A11 local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date / i`/� Y Board of Health--, - _ SECTION A -A ALL OUTLET PPES FRM TW "NOTE: TO BE 4" SCHEDULE 40 P.V.C. asrnreulroN Box p, de+t g NOTE. ALL PIPES ARE U PROFILE' VIEW OF:LEACHING SYSTEM 1D' min. from SET LEVEL FOR AT LEAST 2 FT. 12• CONCRETE COVER , r P 5 t house to septic tank t t ~� Existing Foundation s Septic tank coves moat be ,+ -,i-.- •, �-5"��• -v... � � C " a .. 2 ' w within 6 ML of finished grade : ! m / I Ia,JK.t Lti.oB.d AY"tr " /' "- KNOCKOUTS _ • Grade over Septic Tmk- 99.50 Grade over D-Box- 99.00 ----Grade over SAS- ELEV- 9&75 of /s I/� /w%bt Aw"ewv . a In 12" INLET 'O � • >, 4 0 OUTLET , S 0.02 HOLE H-1O •{ .. ,.: ... ..: .-...- :- .� j M,de�Fa/< fi 1!ttlA4et.l er S"0.10 Top of SAS-Elev.=95.75 p DiST...BOX 3• Maximum covey.' '� Ott CREA , . ` 3 .� 15 NEW TER S- O.Ofd per foot A-- /� 0 C3 4" SCH- 40 Co 0 1,500 GAL / M o o n o C 3 0 0) SEPTIC,TANK u1 65 o C] o o ;• SE � PLAN SECTION , CROSS SECTION 0 : O0 -1 1 16 20 o Effective Depth 2 lhats B B.5' 1T a rn H 0 � pvc TEE g a � a � ., • , 1 w"sell. REQUIRED n o 4 19 4 FULL FOUNOQION-, n u� - C To REDUCE m A rn WATER vt:Locm _ 3. 3s r7 : 3 HOLE'H-10 DISTRIBUTION BOX. prtsdr , ,,s �1� SmIIt8t m � na D-Box •: N 1 u .--d rn z5 "; I 6 In.of 3/4'-1 1/2 d > > i Effective Length NOT TO SCALE i3dm -.< SYSTEM PROF LE compacted atone m o m 12 N .: - ' k'd, r M1F?f.� .;; c > d o - 020A3PmdM tt @Pi7Vi at fsa" y °rtk Effectivt Vldth T Not to Scale c > - SOIL ADSORPTION`SYSTEM (SAS) > i i o - c c . 500 - C H-20 LEACHING UNITS / WIGGINS PRECAST 6 In.of 3/4"-1 1/2' o GENERAL NOTES compacted stone m Not to Scale NOTE; ALL COMPONENTS MUST HAVE RISER TO WTHIN 6" BELOW GRAD 1. Contractor is responsible for 'Digsafe notification S E Bottom of Teat Hors t oev.=87.5o and protection of all underground utilities -and pipes. vObs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank and distrt tion,;box shall be set level on 6" of 3/4"-1 r-T 2' stone. 3. Backfill should be clean sand or gravel with no ' stones over 3" .in size. PERCOLATION p n t p O n l TEST 4. This system is subject to' inspection during installation f_E l\ V LA 'V I G by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance Date of Percolation Test: MARCH 29. 2004 S e__/ 1 v s� T T�� ,g �+ with Title V of the Massachusetts state code, the approved plan Test Performed By- CARMEN E. SHAY, R.S.. C.S.E. 1`-� s and Local Regulations. Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) 6. If, during installation the contractor encounters any, Excavated By. SHAY ENVIRONMENTAL SERVICES, INC. 40 FOOT RIGHT OF WAY soil conditions or site conditions'that are different Percolation Rate: Less Than <2 MPI ------------- --- --- ---_ _ _----_-----_----- 98 from those shown on the soil log or in our design -_-_ installation must halt & immediate notification be --- made to Carmen E. Shay - Environmental Services, Inc. L I z i 7. No vehicle or heavy machinery,shall drive over the t septic system unless noted as H-20 septic components. Test Hole i I S 85d 145' 30" W No. 1 I 8. Install Tuf-rite gas:baffles or equals on all outlet tee ends. DEPTH SOILS ELEV. i 105.00' I W 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. 1 3 I 10. All solid piping, tees & fittings`.sholl be 4" diameter 0 Loar,y 98.50 i ' TEST HOLE 1 1 Schedule 40 ,NSF PVC pipes with' water tight joints. Sand ELEV = 98.50 W 11. Municipal Water is Connected to The Residence and'Abutting t0 VR 3/2 W i GRAVEL I L*I _ Properties Within` 150 Feet. As 8.00 t I i .� ^ Loamy o I DRIVEWAY Sand Y M i 1 I 10-M 5/6 I I i ►�- i ^I THE PROPERTY LINES ARE APPROXIMATE AND 11"- 42" B, 95_00i i I_. ;�-1z COMPILED FROM THE SURVEY,PLAN GENERATED BY Medium I - b ;f '� BEARSE & KELLOGG OF BARNSTABLE, MA ENTITLED Sand <t t i EXISTING 6 •' °j O "HEMEON DEVELOPMENT IN HYANNISPORT, MA -PLAN BOOK 85 PAGE 105 io rx>/4 o j 2 BEDROOM 20 5� "� '.*-i DATED JANUARY-1948. IT SHOULD BE USED FOR NO PURPOSE ._ 42' 132 C, I HOUSE OTHER THAN THE SEPTIC SYSTEM INSTALLATION. 2' f0.25 EXISTING CESSPOOL TO BE PUMPED DRY & LOT #36 99 ---' T_..-- ---i #f0 ------ ------------- -99 REMOVED IF FOUND TO BE NECESSARY TO INSTALL NEW SEPTIC TANK. i i NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE I----- -------' FROM THE EXISTING CESSPOOL TO BE DISPOSED DECK OF AS PER BOARD OF HEALTH SPECIFICATIONS. NOTE: NO WETLANDS ARE PRESENT WITHIN 200 FEET OF PROPERTY. d NEW 1500 gal. O PROJECT BENCH MARK ASSESSORS MAP 267, PARCEL 061 Perc 1 o Septic Tank 0 TOP OF FOUNDATION Depth to Perc: 44" to 62" 0 0 ELEV. = 100.00 (Assumed) LEGEND Perc Rate- 2 MPI (assumed) .� Nt Groundwater Not Observed o 104X1 DENOTES PROPOSED No Observed ESHWT `` ADJUSTED H2O Elev. - None ------ SPOT GRADE 100---- ---- SHED ------ -- 100 DENOTES EXISTING -- LOT #37 X 104.46 SPOT GRADE 10,875 Square Feet +/- PL PROPERTY LINE 102.17' 96P PROPOSED CONTOUR N 85d 44' 20" E - - - - -97 EXISTING CONTOUR DEEP TEST HOLE & 3-24• DW1 ACCESS MAM40LM PERCOLATION TEST LOCATION +0' -6' 6 FOOT STOCKADE FENCE films•_.'.•.-.+'�3��L _� -.a•.._..\ ~`-• = LOT #38 - 1 m LOT #39 n LOT #40 INLET INLET CE4 rOUT P LOT PLAN iF THE ACCESS COVERS FOR THE SEP11C TANK, �.:,_..r.T. -. = DISTRIBUTION BOX AND LEACHING COMPONENT OF PROPOSED SEPTIC SYSTEM UPGRADE R'S• ? ; SHALL BE RAISED TO WITHIN 6" OF STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PREPARED FOR PLAN VIEW INSTALL TUF-T1TE E E BAFFLES OR EQUALS V 0 H N C A D I G A N ON ALL OUTLET TEE ENDS 3-24" REMOVABLE COVERS 11 I AT I/•/t- 19 SUNSET TERRACE 3' mh clearance - . ,3 aLFt Y - INLET 8'mhT�_mim Inlet to outlet a•mh -' - - - OUTLET HYANNISPORT MA mkt. L.Tgiii�bvel - 51 r - _r �$ 5 Calculations E g _ 4'-0•min. Design u ins lgald depth Number of Bedrooms: 2 Equivalent to 220 Gal./Day �(t'L OF MASS PREPARED BY: i. minimum per Title V) o�G e Grinder: No N Garbage (330 gdp . t•-.�. -.'.. 'r- : r. - - .:- 'i , _. Leaching Capacity Proposed: 330 ' �j u - - ••`•K' '� 9 P Y P Gal./Day Minimum (Min.' Per Title V) � RlYl E1 Y l� . A�llA 1o'-Cr s-6' Septic Tank ; - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. S ENVIRONMENTAL SERVICES, INC. CROSS SECTION END-SECTION SOIL ABSORPTION AREA: Using percolation rate of Q min./Inch 0 20 40 50 Bottom Area: 0.74 gal/sq.' ft. 'x 300sq. ft. = 222.00 gallons �o P.O. BOX . 627 Sidewall Area: 0.74 gal./sq. ft. x 148 sq. ft. - 109.50 gallons GtST � EAST FALMOUTH MA 02536 TYPICAL 1500 GALLON SEPTIC TANK Providing: ® 331.50 gallons sANITAR�P�'' TEL/FAX 508-548-0796 NOT TO SCALE , Use: (2) PRECAST 500-C UNITS,` HAVING A 2' EFFECTIVE DEPTH, _ "- TO BE USED WITH 3,5' OF WASHED STONE ON THE SIDES AND ' SCALE: 1"=20' SCALE: 1 =20 DRAWN BY- CES DATE. APRIL 5, 2004 (H--10 LOADING) 4' OF WASHED STONE ON THE ENDS. PROJECT#SD552 FILENAME: SD552PP.DWG SHEET 1 OF 1