Loading...
HomeMy WebLinkAbout0624 BUMPS RIVER ROAD - Health 624 Bumps River Road Osterville _ A _ 144 007- ,I I II �I�CIoIVED COMMONWEALTH OF IVMASSACHUSETTS OCT 1 5 2002 EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS^TowN of BAKNSTAELE DEPARTMENT OF ENVIRONMENTAL PROTECThO�T HEALT H DEFT. TITLE 5 OFFICIAL INSPE'CTI'ON�;FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 624 BUMPS RIVER RD OSTERVILLE, MA'02655 l / oe 7 Owner's Name: HENRY WASIERSKI Owner's Address: 8 LUFF RD NANTUCKET MA 02554 R�0� Date of Inspection: 9/27/02 Name of Inspector: (please print) JOHN GRACI Company Name: " SEPTIC'INSPECTIONS 1n�' Mailing Address: P.O. BA 2119 TEATICKET, MA. 02536 , Telephone Number: 508-564-.6813 FAX 508-564-7270 CERTIFICATION STATEMENT- I certify that 1 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 SectionA'51340 of Title 5(310 CMR 15.000). The systern: 1f e ! X Passes t! Conditionally asses, _ Needs Furtl Evaluation by the Local Approving Authority Fails: Inspector's Signature: ,'' Datc. 9/27/02 The system inspector shall subm`tiopy ofthis inspection report to the Approving,Authority(Board of Health or DEP)within' 30 days of completing this inspe tion:,1f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner slia3 Wsubmit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent o the buyer, if applicable,and the approving authority. Notes and Comments 1 t SYSTEM PASSED TITLE VrINSPECTiON. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. tl� ****This report only describes eon'difiosis at the time of inspection and under the conditions of use at that time 'this inspection does not address how,the:systeon will perform in the future under the same or different conditions of use: ' ,r Page 2 of I 1 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFA_ CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A #+: _ •CERTIFICATION (continued) Property Address: 624 BUMPS RIVER RD OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI .t}�-v Date of Inspection: 9/27/02 • , Inspection Summary: Check A,B,C,D or,E/ALWAYS complete all of Section D p Y A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V-INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 rep Iac-611 Qbr repair,+as approved by the Board of Health,will pass. Answer yes, no or not determined(;Y,N ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and'over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration°or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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): .r Ic, broken ppe•(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: n/a n/a 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 _obstru'tior'is removed ND explain: n/a 1)t I Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 624 BUMPS RIVER R.D,OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI Date of Inspection: 9/27/02 ' C. Further Evaluation is Required by,.the Board of Health: Conditions exist which require ffirther`evaivation 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 Boa rdiof Health determines in accordance with 310 CM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: .S i li _ Cesspool or privy is within'50 feet of a surface water _ Cesspool or privy is witli'in'50'feet of a bordering vegetated wetland or a sal:marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in A manner that protects the public health,safety and environment: _ The system has a septic tank.:and soil.,absorption system(SAS)and the SAS is within 100 feet of 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 I 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 n/a "This system passes tithe well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is fi-ee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided'that no other failure criteria are triggered. A copy of the analysis must be attachod,to Ithis iform. 3. Other: n/a t r L Page 4 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �.a PART A CERTIFICATION(continued) Property Address: 624 BUMPS RIVER RD.'OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI,1;, Date of Inspection: 9/27/02 . D. System Failure Criteria applicable to all systems: You must indicate"yes"or"nb"to'each of the following for all-inspections: Yes No _ X Backup of sewage into;facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of ekffluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , Is 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 'h 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 NO PUMPING INFORMATION. X Any portion of the SASt cesspool or privy is below high ground water elevation. X Any portion of cesspooWor.privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cessp6ol�or priJy,is within a Zone 1 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�s less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEP certified laboratory,for.(oliformt.bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this for:m:I _ (Yes/No)The system fails. I:liave determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system,failsj,he system owner should contact the Board of Health to determine what will be necessary to correct the failure: ,; r E. Large Systems: 4; ° To be considered a large system the..systein 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 systerns in addition to the criteria above) yes no i X the system is within 400 feet of ai 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 11 of a publi'water supply well If you have answered',iyes"to any question in Section E the system is considered a significant threat,or answered .,yes" in Section D above the faigq,�yslcni.lids laded.The owner ur operator of any Itu'1;e system Considered a siknificlini Ihrcnl under Section E or failed under,Se,ction D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. a 'v , Page 5 of 1 1 ;,,;" OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURF'ACt,;SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` CHECKLIST Property Address: 624 BUMPS RItVER RD OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI Date of Inspection: 9/27/02 Check if the following have been done,,oY.ou must indicate "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 Were any of the system components'. omponents pumped out in the previous two weeks lit _ X Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection '? t X Were as built plans of the,system obtained and examined?(If they were not available note as N/A) 40 v t. X _ Was the facility or d%Mli6' ih p'e'cted for signs of sewage back up X _ Was the site inspected,for sigrs of break out'? X _ Were all system components,excluding the SAS, located on site'? IV X _ Were the septic tank,m;anholes 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 ? X _ Was the facility owner(and,';occ.upants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems;' The size and location of the5oil Absoi•ption System(SAS)on the site has been determined based on: Yes no X Existing information For example,Ya~plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue"approximation of distance.is unacceptable) [310 CMR 15.302,(3)(b)] ' a l ` '! ,r F is I :r f .1; Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 624 BUMPS'RIVER RD OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI Date of Inspection: 9/27/02 ' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)'!3. TNiunber of bedrooms(actual): 3 DESIGN flow based on 310 CMR1S.203 (for�example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system (yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):,NO t Seasonal use: (yes or no): NO ; Water meter readings, if available(last 2 years'usage(gpd)): tea- U2'00 U Sump pump(yes or no): NO Y. Last date of occupancy: n/a .!; COMMERCIAL/INDUSTRIAL ''t` Type of establishment: n/a Design flow(based on 310 CMR 15.203;):-n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5`system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records ,T Source of information: NO PUMPING INFORMATION Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons- How was quantity pumped determined? n/a Reason for pumping: n/a 4 TYPE OF SYSTEM Y `; X Septic tank,distribution box,soi'l�absorption system _Single cesspool _Overflow cesspool _Privy is� _Shared system(yes or no)(if yes,attach,previous inspection records, if any) _Innovative/Alternative technology.�Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): n/a F Approximate age of all components;date installed(if known)and source of information: 5 YEARS 0Y OWNER ? ,: Were sewage odors detected when arriving ai�'tf a site(yes or no): NO a , 6 Page 7 of I 1 ? OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 624 BUMPS RIVER RD OSTERVILLE,MA 02655 Owner: HENRY WASIERSKI Date of Inspection: 9/27/02 ti BUILDING SEWER(locate on siteplan)` Depth below grade: 14" Materials of construction:_cast iron =40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,�ev.idence of leakage.,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 8" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a fs"agtconfirmed,by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500 GALLONS t,' , F•=, Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outiet,tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/axM'; Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a t Comments(on pumping recommendations—inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage' etc., n/a d� K !t.i t, 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 624 BUMPS RIVER RD OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI Date of Inspection: 9/27/02 TIGHT'or HOLDING TANK: (tank must tie pumped at time of inspection)(locate on site plan) f Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensiions: n/a ' Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A r Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float swatches,etc.): n/a DISTRIBUTION BOX: X(if present``inu'"be,opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND, PUMP CHAMBER: _(locate on site plan) t: Pumps in working order(yes or no): NO 1 Alarms in working order(yes or no):NO . Comments(note condition of pump chamber;condition of pumps and appurtenances, etc.): n/a i,ti, „ • r t Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 624 BUMPS RIVER RID OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI Date of Inspection: 9/27/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: 0 FLOW DIFFUSERS jeaching chambers, number: 4 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a 3, ! innovative/alternative system ,-,Type/name of technology: n/a Comments(note condition of`soil, signs`of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): DIFFUSERS ARE STRUCTU'ftALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. THEY WERE EMPTY AT TIME OF INSPECTION. BOTTOM IS AT 5 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool:,n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):'°NO Comments(note condition of soil,signs of hy;_. draulic failure, level of ponding, condition of vegetation, etc.): n/a , az PRIVY: (locate on site plan). ;h Materials of construction: n/a 4 Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a ,3 n Page 10 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 624 BUMPS RIVER RD OSTERVILLE,MA 02655 Owner: HENRY WASIERSKt Date of Inspection: 9/27/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. '•,,x _ R Ft (3ac ., L Ry . 1. I ! �. Y• i A Z� P AC L15 r 1 B 33 is i a 1• Page I I of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION(continued) r Property Address: 624 BUMPS RIVER RD OSTERVILLE, MA 02655 Owner: HENRY WASIERSKI' Date of Inspection: 9/27/02 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet' Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS;database-explain:'%n/a you established the high round water elevation: You must describe how Y g g I HAND AUGER- 12+ FT. `t i ti TOWN OF BARNSTABLE LOCATION �j o� t��ipS rr2�`Ir �z SEWAGE # T 1,U p gar VILLAGE ASSESSOR'S MAP & LOT /,IV oa� INSTALLER'S NAME&PHONE NO. KC4NM h1 c4117G)VFAU �BJ/Zh�'S f�lc��a7'ist SEPTIC TANK CAPACITY /5-0 0 (2;&1_[o 415 LEACHING FACILITY: (type) !'/ac.✓ D:Flu,ers (size) /o'.r 3 9" mrory1t NO.OF BEDROOMS J BUILDER OR OWNER ��P ja/�AW PERMTTDATE: •.�� `9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 9 t Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ,16A)F Feet_ Edge of Wetland and Leachi g Facility(If an wetlands exist within 300 feet of leac g fa lity) eyfi4 Feet Furnished by - ; r j , � t l�rcir o� I'�o�S�. � . , �� �� � � . � � i �ti `.6� � k � i l�� o / F r " THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Mizpozar *pztem CowAruction Perron Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. (0 2—+ '``OM P 1 V Owner's Name,Address and Tel.No. e RL� 1DeV8 X Assessor's Map/Parcel i 4+ 067 M/ PiP=- Mr+ �9 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. tJ RK�S C60,A\hq 161J pe of Building: Dwelling No.of Bedrooms 13 Lot Size sq. ft. Garbage Grinder(�) Other Type of Building RES . No. of Persons Showers( _ Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 s stem in operation until a Certifi- cate of Compliance has been issued by t 's Bo d �Health> Signe z Date _a ^4 Application Approved by ,v Date Application Disapproved or a following reasons Permit No. Date Issued TOWN OF BARNSTABLE LOCATION SEWAGE # 7 VELL;AGE , 0,5 Atup cor, ASSESSOR'S MAP& LOT /4y 00 INSTALLER'S NAME&PHONE NO. iC rt ,Jz 4, SEPTIC TANK CAPACITY—_� —0 LEA PHING FACILITY: (type) /-'!owg ens (size) /o' r 3 9 .mrorv/( NO,OF.BEDROOMS � 5rae. BV]L:DER OR OWNER PERMTTDATE: Iy COMPLIANCE DATE: Separation Distance Between the: Maaunum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Privat . .eW at er Supply W ell and PP Y Leaching Facility (If any wells east onsite or within 200 feet of leaching facility) Edge.of-.Wetland and Leachi g Facility(If an wetlands exist Feet within.300 feet of leac ' g fa ,,hty Furnished by Feet 4 �a j Bch i � J � � `. � � • v u. >;v i - ,. •« _ . ,Y. .-��.yr- ,.✓ ... .. � ��...r' , *, ••- •_•.y, .,.,^••', '-N` •I F D THE COMMONWEALTH OF MASSACHUSETTS : Entered computer: Yes PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS Application for Oi5ponl *p.5tem Congtructio,n Permit Application for a Permit to Construct X Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 0 KO- -/De V/9_oy 300 rpLMoU F i-I P-D /44 Assessor's Map/Parcel �6 M 1+3 H,PCL M f4 .O 2(.4— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. cj2K�S C.GaAVOT 16tJ Type of Building: Dwelling_ No.of Bedrooms Lot Size sq.ft. Garbage Grinder( �3) Other Type of Building RCS_ No.of Persons Showers(7 Cafeteria( ) Other Fixtures �. Design Flow �gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maint finance 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 s stem in operation until a Certifi- cate of Compliance has been issued by this Board of Health., ` Signed', 4 C , Date Application Apg oved by `�-- -o-- '- Date '. Application Disapproved or efollowing reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certificate of (Compliance � J THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired ( )Upgraded( ) Abandoned( ).by,_ FIIC44-xo g! at � `"°` �:: cie- has been constructed in accordance with the provisions of Title 5 6d the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not 3be construed as a guarantee that the system ll fu. n�ction as designed. Date ^ T ! Inspector ————— --------------------------------- No. a Fee THE COMMONWEALTH OF MASSACHUSETTS 1 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wigogal *p.5tem Construction Permit Permission is hereby granted to onst ct( Repair( Upgrade( )Ab d System located at S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: - Approved by • i i THE�OA�D COMMONWEALTH F�-iEALTH Ts 7 OF... ..........t4.*....... . Apphration lar Bitipaaiittl aar�) or 1aaatilrurfion rani# Application is hereby'made for a Permit to Construct ( Repair ( } an Individual Sewage Disposal S stem at c •................... Q. ••••••-._••.•.•.• o tion-•/? ddres I or Lot No. Q tp/ Ln.&........... j Q �(� ner tAd r F. t . . ........... ---- ------ ..... . . ...... ................. ....................... a Insta ler ddress d Type of Buildin Size Lot............................Sq. feet. U Dwelling ' No. of Bedrooms----............. ..._.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ...................... No. of persons...............--_---------- Showers ( ) — Cafeteria ( ) a Other fixtures -------------------- - - --------------------- Design Flow..................... ....__ _._ gallons per person per day. Total daily flow..............__......................gallons. WSeptic Tank 4-Liquid capacity/ -gallons Length................ Width_.............. Diameter................ De nth ------......--- x Disposal Trench—No..................... Width,..�.-. ..._-------- Total Length--------._--........ Total leaching ......... ..........sq. ft. Seepage Pit No.___./............. Diameter leo�--1�v_.... Depth below inlet------._____.__.... Total leaching ire 4:f?..2.---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------- ---------------------•-.................-............... Date-------------------------------------- ,� Test Pit No. 1................minutes per inch Depth of "lest Pit-------- Depth to ground water...........-.-.-....---. Li, Test Pit No. 2................minutes er inch Depth of Test Pit.................... Depth to ground water......-.._...._..-..... 9 ---------------- ------- .................................................................................................................... Descriptionof Soil------- `----------------------------------------------------------------------- ------------------------------------------------ x W ......•-••-•---------•-•---- ----- - - - ------------------------------............-•••••••-•••••_--•_------------------------------------•---------------------------------------_ ....._..••...... VNature of Repairs or Alterations—Answer when applicable..............................:................................................................- ------------------------------------------------------•------------ ....................................-------------. ------------ ----------------------------------------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary.C©de--^The undersig_uoA fur her agrees not to place the system in operation until a Certificate of Compliance- �fs-h en issued b th health. igned- • ••....••--- =-•-•-- ---------_•_-••-__. TDa e Application Approved By........_ = •.•-• ............. i t 7�... Date Application Disapproved for the following reasons---------------------------•--------------------------------------------- ................................. •••••-••••••••-••••••••-........................ _•••--•-••••••••••••••-•-•••-••-••_•••••••••-••••••••-__•-••---------------------- -------- -------------------------------- / Date Permit No.---••--------------------------------------------------- Issued----f-� '�-- -----� 3-----•---- D to No.._ �r _.. Fz��.. ,� ....... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD F HEALTH 1 Aplifiratinn -fur Bbipviittl Worko Tnn#rnrtion Vanift Application is hereby made for a Permit to Construct ('°" ) or Repair ( ) an Individual Sewage Disposal System at: .............' d r ........ ......---- 'f - - --• -•--------------------------------------- Loct�ation ddressn { or Lot No. rT_ _. _.....� _.'� _A. _....._..._. .` ,. s?✓fit _o.�,d kA4_l-�l________________ _ __ .:__.____ r rier dr s Installer Address d Type of Buil(in Size Lot----------------------------Sq. feet U Dwelling=No. of Bedrooms--------------- _.......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.--_•-•-..__-__-__-____----- Showers ( ) — Cafeteria ( ) ;? d Other fixtures' -F ---------- ----------------------------------------------------------•-----------------------•-......_� -- -----------•--•------- ` W Design Flow_____________________ _______ __gallons per person per day. Total daily flow--------------------------__--_-__. .-._..gallons. WSeptic Tank-�Liquid capacityj_��_ZZ--gallons Length---------------- Width................ Diameter__.---..--_____ D ) 1 x Disposal Trench—No..................... Width-_ Total Length____________.,__.__ Total leaching 1r z.. sq. ft.. w� See a g e Pit No..._. . Diameter I 4... .... Depth below inlet____________________Total leaching tre.> ,'t '�-sq. ft. P 4....••_.._.. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test-Results Performed by--,------------ ----------------------------------------------------- Date------------------------------------.... Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water____.____`_..._.__._.... (i Test Pit No. 2---------------minutes er inch Depth of Test Pit.................... Depth to ground water-_-_----_-_____-___-_--- R'+ DDescription of Soil----------------'"" --- `------------------------------------------------------------ ------- ------------ -------------------------------- x V --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------.. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 boa d,of health. tgnedy # f a raj ' a j r Date Application Approved By-•--- ''; ter' .: .x t l� � p � a c � �--• �,,.-- _. 7 � Date. -- Application Disapproved for the following reasons. ------ -------- :----------------------_.---- --------- --------- ----------- •---•----------------------------------------------------------------------------------------------------...---•--------------------------..`----------------------------------------------------------- Date Permit No. ---------------- Issued------------------------•-•----••-•----•--•- Date THE COMMONWEALTH OF MASSACHUSETTS /41�1 ' BOARD F HEALT r!4 ! P } (9rdifira#r of Tam;41'ttnrr S IS CERTIFY the In ewage Dis s Sy tem structed ) or Repaired ( ) j f) jnstAler hf f f,` has been installed in accordance with the provisions of Article XI of The State Sanitary ode as described in the application for Disposal Works Construction Permit No---------- 32................. datcd.__,:?� �' ,f..- �......... p THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSY� UE® AS A GUARANTEE THAT THE SYSTEM 71 L FUNC ON SATISFACTORY. ,y DATE 7 Inspector-•-- THE COMMONWEALTH OF MASSACHUSETTS /t14f BOARD OF HEAL No....:t!... FEE......................... rkii To din$ rrmit Permission is hereby granted- - - .��........ ........................................................... to Construct ( o Repair ( an Individual gee D•sposal S em , at No. y �Xr Cy�t__�s:'�!°$rJC^4.4'4._.-, _. F_ ^`" Y.�'�_'.i.. . ?y.?__...___ ------ s..._e_'__ .._•____________________ __ _____ _ Street r- as shown on the.applic on for:Disposal Works Construction Permit�' o.------ •� ........ 14- /1313S -:- ------------------- Board of Health DATE........� --'--- - ---------------------------------------- FORM 1255ARREN, INC.. PUBLISHERS \ Town of Barnstable P# Department of Health,Safety,and Environmental Services �VV Public Health Division Date q� 367 Main Street,Hyannis MA 02601 HAt i.r i639 �� G d rEnrra+�AM Date Scheduled c�S- 9' Time //:3Q Fee Pd. /06. Soil Suitability Assessment for Sewage Disposal } Performed By: C&/-o /y.1—- /�B S�le` oe, Witnessed By: LOCATION & GENERAL;INFORMATION Location Address Owner's Name Address J;©l01Ct011_"®a71_2 409? /r/ %9 � Assessor's Map/Parcel. Od Engineer's Name NEW CONSTRUCTION' ✓ REPAIR Telephone# tLi Land Use ,oJl9d— / Slopes(%) /.S�a Surface Stones � �ssrbrl � Distances from: Open Water Body NL4' ft O /V® ft Drinking Water Well V/W ft Drainage Way A11W ft Property Line /y/ ft Other ,[1,/� ft SKETCH:(Street name,dimensions of lot,.exact locations of tes, s&pert tests,locate wetlands in proximity to holes) Ej o` � o0 4 \7 a i Parent material(geologic) dU�G�IASh OO�llifl Depth to Bedrock yl Depth to Groundwater: Standing Water in Hole: /P//l Weeping from Pit Face Estimated Seasonal High Groundwater /%� belad OK F q f re-s 7-4,r GW bETERIVtINATIOIV POQYt SASONAIJ HIGH VVATtt TAE Method Used: 6rvvpl elle .maw' Depth Observed standing in obs.hole: in. Depth to soil mottles: ti/IV in.t Depth to weeping from side of obs.hole: ti/ in. Groundwater Adjustment A/4 ft. Index Well# d(I# Reading Date: ti! Index Well level y/ Adj.factor 41* Adj.Groundwater Level V1,4 PERCOLATION TEST DateviTime %resort Observation Hole# _ Time at 9" _ Depth of Perc (BJ Time at 6" Start Pre-soak Time @ Time(9"-6") Iy/%rJ End Pre-soak �sy — Rate Min./Inch Site Suitability Assessment: Site Passed ko�' Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-� Copy: Applicant S DEEP.OBSERVATION:HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Gravel) O-9 A to /e AlI — e 3 OrP-� o rt?s L o0 2 e ry ,area! 10 YK 6.1fLe,osG A7 7e ;,,w 36 -�� G ��✓�u�� o e2 6 b "Loose DEEP OBSERVATION HOLE LOG Hole.#` d2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) O - 4 .u/ lOo.V a -- A;-,-.able / O /0 5 LD©S e Fire ra -90 C, a 'e 6 6 Lars e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistent %Gravel EP OBSERVA DE TIONHOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No t/' Yes Within 100 year flood boundary No +✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yee 25-;,It be ca��r�.�/arie �o � '7 If not,what is the depth of naturally occurring pervious material? Certification I certifythat on date I have passed the soil evaluator examination approved b the OC T. /p'9. (date) p Pp Y Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature Gra��� � _ Date 4��=;Z LOCUS: GENERAL NOTES: —�, - w 1. THE SYSTEM COMPONENTS AND CONSTRUCTION SHALL BE IN ACCORDANCE WITH THE STATE OF MASSACHUSETTS SANITARY CODE TITLE V, AND LOCAL o BOARD OF HEALTH REGULATIONS. 00 SI TE 2. CONTRACTOR SHALL NOTIFY DIG-SAFE .PRIOR TO CONTRUCTION AND BE RESPONSIBLE FOR ALL I, 1; ROUTE 26 o UNDERGROUND UTILITIES. 3 ELEVATIONS ARE BASED ON BENCHMARK AS SHOWN. L ��o $ 4. PIPING SHALL BE SCHEDULE 40 PVC. 5. SEPTIC COMPONENTS SHALL MEET H-10 LOADING p y�y "U"S RryER ,,AD UNLESS OTHERWISE SPECIFIED OR H-20 LOADING - srRF tREEt UNDER DRIVEWAYS. ' _K `ram• >>� i i Pp 6. INSTALL D-BOX WIRISER & COVER TO 12 INCHES BELOW GRADE. r r . 7. D—BOX EXIT PIPE TO BE FITTED WITH INVERT r r I LEVELLER CAPS. Af4VJI a 8. D-BOX TO BE INSTALLED ON MIN. 6" CRUSHED EDGE OF DEPRESSION Q STONE BASE. e •1v;-iiV,� ELEVATION = 10.00 .C: ti. 9. ELECTRIC AND TELEPHONE SHALL BE OVERHEAD. MiLN k No L s EGEND: \\ LOT BOUNDARY PRECAST CONCRETE _ � �� ' o G GAS IC, TELEPHONE FLOW DIFFUSERS, \ o �' -ET- ELEC 4' X 8' EACH ` F � o' r' w WATER22- \ 39' 4 ------ -- -- LIMITS OF SEPTIC SYSTEM �� 2 '• �� >< O o- \ f 15 CONTOURS - - - - - - EXISTING - ----------- ---- i Ncofo N oo \ LOCATION UNKNOWN, (151 PROPOSED CONTOURS - � \ CONTACT GAS COMPANY s L\ \ &, HYDRANT 6 oeoo�E tiz\ rc ��� '� TP-1 TEST PIT, LOCATION & NUMBER i I 1\No; REVISIONS: SEPTIC SYSTEM DETAIL ,6$ i 5 �6pp wir er sP���'tP 4GIL�Fc� �I!/�97� ,' i 66 jo ' APPROX. LOCATION, CONTACT WATER DEPT. FOR DETAILS TITLE: 1 E LE SITE PLAN & .SEPT C SYSTEM DESIGN 1 'o BUMPS-RIVER ROAD, OSTERVILLE, MA BENCHMARK-TOP OF " C.B. EL. 26.70 2° yb 0 OWNER: GREGORY DEVAUX 26- o. 300 FALMOUTH ROAD, UNIT 14E p19 28 �1 Is)- �R ?,0 r / MASHPEE, MA 02649 CJ ENGINEERING / B\30P R 0 " E�'a�% ® " dgc 48 GULLY LANE, SANDWICH, MA 02563 30 cAR LYN y� (508) 888-4975 J. C 40 80 vy �o G' OYLE N� 34531 MAP: 144 PARCEL: 007 SCALE: 1"= 40' T�� � DATE: 317197 SCALE: AS SHOWN Z, DWG NO.:CJ14/624BUMP1.DWG SHEET 1 OF 2 f DESIGN CRITERIA: SOIL TEST LOG PERC TEST P-8886 DESIGN FLOW. " 1 SOLID PVC, FIRST 2' TO BE LEVEL, TP-1 TP-2 3 BEDROOMS AT 110 GPD = 330 GPD SOLID PVC, S=0.02 SOLID PVC, S=0.02 REST AT S=0.005 DEPTH HORIZON DEPTH HORIZON SEPTIC TANK = 1,500 GALLONS GRADE = EL. 29.8 GRADE = EL. 29.5 NO GARBAGE DISPOSAL , 0" 0" TOWN WATER NO WATER SUPPLY WELLS WITHIN 400 FEET 2)t : ---------------- o 0 0 o NO WETLANDS WITHIN 100 FEET ° ° SANDY LOAM q SANDY LOAM q 3 5 'f . SIZE OF LEACH FIELD REQUIRED: 6 4 9" 8" DESIGN PERC RATE. 2 MIN/INCH 4 7 REQ'D.AREA = 33010.75 = 440 S.F. PROVIDE INLET TEE OR 8 C FINE TO 0 FINE TO 0 NEW SE@TIC TANK BAFFLE IF S=0.08 FT/FT MED.SAND. MED.SAN.D - AREA PROVIDED: AA — (10'+1) X (39'+1) = 440.0 S.F. 13" 12, FINE TO Bw FINE TO Bw EFFECTIVE LENGTH = 39' + PROPOSED SEPTIC SYSTEM — PROFILE EFFEcrivE WIDTH = 10' MED.SAND MED.SAND NOT TO SCALE 36" 23" FINE TO FINE TO MED.SAND Cl MED.SAND Cl 77 70" MEDIUM MEDIUM - SAND C2 SAND C2 120" 120" SYSTEM COMPONENTS* ELEVATIONS** ' SOIL TEST CONDUCTED ON 2125197 BY CAROLYN J. DOYLE AND 1. TOP OF FOUNDATION ..........................................I....... 27.00 - i WITNESSED BY BARNSTABLE BOH AGENT JERRY DUNNING 2. INVERT OF PIPE AT FOUNDATION ............................. 23.50 NO GROUNDWATER AT 10' (EL. 19.50) \j MIN. 3" TOPSOIL. \j 3. INVERT OF PIPE AT SEPTIC TANK INLET .................. 23.29 \\/ TOPSOIL \\ SEE ATTACHED PERCOLATION TEST s ORGANIC MATERIAL & �� FORM FOR DETAILS ' 4. INVERT OF PIPE AT SEPTIC TANK OUTLET .............. 23.12 /j BOULDERS, IN COMPLIANCE \/ j WITH 310 CMR 15.255(3)), \\j ENGINEER TO VERIFY 4' OF SUITABLE 5. . INVERT OF PIPE AT D—BOX INLET ........................... 22.77 \\ COMPACT TO 907. DRY \\/ MATERIAL BELOW THE PROPOSED SEPTIC REVISIONS: \\/ - \\ 6. INVERT OF PIPE AT D—BOX OUTLET .......... DENSITY SYSTEM AT THE TIME OF EXCAVATION. 22.60 / 2" LAYER OF 1/8-1/2" DOUBLE WASHED STONE 7. INVERT OF PIPE AT DIFFUSER INLET ......................... 22.55 7 8 a. BOTTOM of DIFFUSER .................. F 21.55 \% TI TLE: SEPTIC SYSTEM DESIGN \�/ 3' 4' 3' \� 624 BUMPS RIVER ROAD, OSTERVILLE, MA H 9. BOTTOM OF AGGREGATE .......................................... 20.55 \j/ \\j OWNER: GREG DEVAUX 300 FALMOUTH RD., UNIT 13E 3/4-1 1 2 DOUBLE \\� MASHPEE, MA 02649 WASHED STONE \\/ *LOCATED ON SECTION & PROFILE \i. \ 9 4pv ®f �'�*^: CJ ENGINEERING' N GI NEERI N G N<K<_</\�< � 48 GULLY LANE, SANDWICH, MA 02563 **BENCHMARK = TOP C.B. EL: 26.70 SECTION A A CAROLYN Ili;; (508) 888-4975 J. SEE SHEET 1 of 2 TYPICAL SECTION DOYLE H NOT TO SCALE No.34531 MAP: 144 PARCEL: 007 DATE: 3/7/97 SCALE: AS NOTED r� J° .3J��97z DWG NO:CJ14/624BUMP2.DWG SHEET 2 OF 2