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HomeMy WebLinkAbout0054 CROSBY CIRCLE - Health E54 OSBY CIRCLE'OSTERVILLE 6 019 �t r f l f ; l Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System-Form -Not for Voluntary Assessments °M 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer, use 1. Inspector: ©a Q f) only the tab key to move your MICHAEL DEDECKO cursor-do not use the return Name of Inspector key. COMPASS REALTY DEV CORP Company Name _ P.O. BOX 2384 Company Address MASHPEE MA 02649 City/Town State Zip Code 508-221-5603 Telephone Number 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 ❑ Falls71* i ❑ Needs Further Evaluation by the Local Approving Authority € , 1/26/07" ; spector's Signature Date ' The system inspector shall submit a copy of this inspection report to the Approv ng Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate iregional 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. ` 281OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Paget of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Ford Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 54 CROSBY CIRCLE Property Address " GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code I Date of,lnspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: LVJte 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 4 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 ' 1 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C � _ I 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 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. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,3 of 15 I� Commonwealth of Massachusetts Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M ,•'' 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is OSTERVILLE required for MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate."Yes" or"No" to each of the following for.all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ L(� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name - information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): , Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.] ❑ 15//' The system is a cesspool serving a facility with a design flow of 2000gpd- / 10,000gpd. ❑ fi—// The system fails. I have determined that one or more of the above failure. criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 arsurface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No f ❑ �, Pumping information was provided by the owner, occupant, or Board+of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ 9 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) L�' ❑ Was the facility or dwelling inspected for signs of sewage back up? L1t1 ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15' L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. Cityrrown State Zip Code Date of Inspection 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): �� Number of current residents:" — Does residence have a garbage grinder? ❑ Yes M_ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E�`No Laundry system inspected? ❑ Yes D-IN"o Seasonaluse? ❑ Yes Er-No Water meter readings, if available(last 2 years usage (gpd)): vo Sump pump? ❑ Yes VNo 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: ' Last date of occupancy/use: Date Other(describe): t 281 OLD MEETINGHOUSE•08/05 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont) General Information 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? ype-rnSysY�mr:°---' l� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records,'if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes N?/No F 281OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information fo is OSTERVILLE required for MA 02655 1/26/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan):, Depth below grade: feet Material of construction: ❑cast iron M 40 PVC ❑ other'(explain): Distance from private water supply well or suction line: �d V'"'j feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): l � Depth below grade: feet i Material of construction: concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1f tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 1. Distance from top of sludge to bottom of outlet tee or baffle VL Scum thickness NL Distance from top of scum to top of outlet tee or baffle 15, . f�vt Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? � 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 IL Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information isequired for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection 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.): ow CD U Grease Trap(locate on.site plan): Depth below grade: feet k .. Material of construction` ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain); 2810LD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of.15 Commonwealth of Massachusetts W Title 5 Official Inspection Form, - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan)` Depth of liquid level above outlet invert OW�Y �� 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.): �X_ _�_Vu�9Utic l Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: `` ❑ Yes ❑ No 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: u Type. ❑ leaching'pits number: leaching chambers number: ❑ leaching galleries number: ❑ leaching 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.): 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i_ r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °- 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owners Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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' El Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids_ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): G . N 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. It 5- 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 CROSBY CIRCLE Property Address GAIL ALBERTINI Owner Owner's Name information is required for OSTERVILLE MA 02655 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar - ❑ Shallow wells Estimated depth to ground water:., feet Pleas 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) ❑ Checked with local Board of Health - explain: . ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: D u y.rC 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 . TOWN OF BARNSTABLE LOCATION �� C��S��/�'//��� SEWAGE # VILLAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.k/�Z1eP1,4­'1 ef:�&!5 77/`93J•i SEPTIC TANK CAPACITY f LEACHING FACILITY: (type) Lb4l (size) 1 x 3 ` NO. OF BEDROOMS / f BUILDER OR OWNER PERMTTDATE: ZZ2 /�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by V7 �J f u „J Q 14-^2- z �2 q0 3 TOWN OF B/ARNSTABLE,,,, LOCATION J 7 ��dy�/f y�Jf�`� ""'SEWAGE # VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. ��� � SEPTIC TANK CAPACITY. - LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNER 610 01 PERMITDATE: ° Z/ZO��� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) " Feet Furnished by } v J No. _ / s ; Fee _ THE COMMONWEALTH"6_MASSACHUSETTS Entered in computer: <r Yes UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprtcation for ;Bigo5ar *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7I ?3�7e Type of Building: - Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building s No. of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Design Flow `�D gallons per day. Calculated daily flow 43 30 gallons. Plan Date qQ Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. O17491 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 system in operation until a Certifi- cate of Compliance has been issued b is o 10 ealth. -- Q Signed Date Application Approved by _ Date ?!L;r Application Disapproved for the following reasons Permit No. Date Issued �l No. ( Fee f En in compute r THE COMMONWEALTR16F �0"ASSACHUSETTS Entered o puce. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETM 0[ppYication for Mioozar *raem Cone;truction Permit \ Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. �J Owner's Name,Address and Tel.No. 77 C� ��Ile, ,, C/'105�� Assessor's Map/Pazcel/ / OS�/) l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 771 Type of Building: ,?; Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building L:J e e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /& gallons per day. Calculated daily flow 330 gallons. Plan Date ! / qQ Number of sheets / Revision Date Title Size of Septic Tank DO /6 Type of S.A,S. S Description,of Soil Nature of Repairs or Alterations(Answer when applicable) /T�/Z� ✓�G�Jh Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued bWhis000fiHealth. .- Signed �+ �-�''~ Date Application Approved by ly Date l� Application Disapproved for the following reasons Permit No. Date Issued ` --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER IFY,that the On-site ewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by f&Zeg4,el at S" IV Cross/ rli^e e D_2&OLI —42? has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �!9—�1' dated i Installer Designer .--. �' � n C, The issuance of this p/e tt s/C!halll not be construed as a guarantee that the systemlw'11"function as designedL/Irf�Date /11 / r`1 Inspector �t t (�/1j/ . /L.. ✓' r) I � No. � / — ---------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS 116 ,v J 7 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS xlizpozar *p! tem Cou5truction Permit Permission is hereby granted to Constru9t( )Repair(P )Upgrade( )Abandon( ) System located at cro-5 b y C//G X:? 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 a t.Date: / c /0 / Approved by i Town of Barnstable P# Department of Health,Safety,and Environmental Services EVE Public Health Division Date 3 1111, Q, 367 Main Street,Hyannis MA 02601 • BARNBI'ABLE, MAB& 1FD MAt",� Date Scheduled / / Time Fee Pd. - Soil Suitability Assessment for Sewage Disposal Performed By: 1,lDz> S. Witnessed By: -Dot W� 1✓110F_e-,�1, 1 LiATION&GENERAL IlVFORIYIA ' ON Location Address Owner's Name r�pr, j ��,� lam'l�� G-�VS 0516- 9 L.4t Address GIA1153 ' GttZG� C oe,_E►2Vil LE,rv1 Ar Assessor's Map/Parcel: MATS V-t(p I Engineer's Name atet NEW CONSTRUCTION REPAIR Telephone# gq(p Land Use S1T_-.)[=�A.YrIA-t.r Slopes(%) Surface Stones Distances from: Open Water Body pD ft Possible Wet Area t4Aft Drinking Water Well _0 ft Drainage Way l g y � 2:� ft Property Line Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) o - F-k isT. P�2LN- I nwE LuN r GRQSt-3Y C t Parent material(geologic)GyL4e_i. -L_ !J Depth to Bedrock > I ZCa�� Depth to Groundwater. Standing Water in Hale:Q ACE P_.�2(0l i Weeping from Pit Face 14 w,41✓ ` Estimated Seasonal High Groundwater ...............................................................:.......................:,y..,.....,......,...:.::.,:.........:....:........::...:.:.. .....,......;..,..........»............::.:>:>a ;:`:.::.:; I 1 't't+ lei. € 1 S1✓A ON GM.'V tA' FIR T Method Used: _ Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment _ ft. Index Well# __._._..,Rrading.Date;- Index Well level.,,._._ ,Adj:factor_ Adj.Groundwater Level 22: . t .............. . .... .. . :: :: i . : ;;; :: : TNTE........................ .�a Observation Hole# Time at 9" Depth of Perc /_d�l p � r Time at 6" Start Pre-soak Time @ ®.,D0 Time End Pre-soak or WA-Tce- Rate Min./Inch Site Suitability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant . DEEP O�SEVTIQN HOLE L0;1C I ©Ie#. ...................................:........:. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Bouldere& Consistency. Gravel) o s S 1._EL DEEP:QSSERYATQN.:HtDL�E L�CJ Hole .. Depth.from Soil Horizon Soil Texture So1l Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,°°Gravel) .... I1EP f BSEVA 'I(3Nf)T Ebb ... . .: Tole#.. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) DEEP OBSERAT�Gb1�I kIfLE]Lt�G ���# .. ... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Gravel) Flood Insurance Rate Map; . "-2-5 o6 o r v 0 Above 500 year flood boundary No ----Yes Within 500 year boundary No_ Yes ✓ Within 100 year flood boundary No_ Yes A--13 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? `F S If not,what is the depth of naturally occurring pervious material? Certification I certify that on 1 / (date)I have passed the soil.evaluator examination approved by the 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 ; ' /' L Date 1 LOCUS: DEEP OBSERVATION HOLE LOGS l�ol2l'N- DEEP OBSERVATION HOLE If1 DEPTH FROM SOIL SOIL SOIL COLOR SOIL TOP OF D.O.H. t CM,2h SURFACE In. HORIZON TEXTURE (MUNSELL) MOTTLING OTHER y- T.b - 2 '� i.aN IOYR 2 NO W ea Cjc %.55 20 ^- e1 g S N Y IQ 51 F'1�IA (\I MPAIum •� 6�rtt 90 3-9 •-• 12-G ° C I SAAD 2.5 "/ / x T06_ •3 CRIPH FNP DRt17r*}�' T tU BOTTOM OF PERC AT: 64" TIME: 10'.00 A.M. �/' RATE: < 2MIM./InIGH DATE: 'I25191 C W.E O�_ �� /''� . ..' .'�� r3Al( � PERFORMED BY: RICHARD JUDD WITNESSED BY: P•MI0KANr>t1 %4PCIO"" �� 45,g tOt3 DEEP OBSERVATION HOLE 12 q7,q �� oP� a5.AS- '_qZ DEPTH FROM SOIL SOIL SOIL COLOR S011 .• • , _- "q4 ' • /__ SURFACE in. HORIZON TEXTURE (MUNSELL) A(OTTLkVG OTHER �� i ' •i� ��'/,. q6-.. `n °P'-- 91.1 OM AL COVEC TOP OF D.O.H. 2 i i ,, jam" •�•�' PROPoSf0 S.A.5. (2)S,S'LX4S'WX2'P - �/ (Wto)LEACH•CHAMKEKS BOTTOM OF PERC AT: TIME: I p sr�uce. RATE: DATE: G W.E O PERFORMED BY: RICHARD JUDD WITNESSED BY: / 1 O S►Iep KEFER TO�CP DESIGN DATA: QM1 O Cp W 1. REQUIRED FLO �_ BEDROOMS X 110 GPD/b �.R. 3 GPD 2. SEPTIC TANK CAPACITY.- 330 GPD X 2 = C000 GPD \\I �� ItP,15004AL..CH-lb) � USE (1) 15C,0 GAL. H-Io SEPTIC TANK SEPTIC TANK y$.8�- 3. LEACH FACILITY DESIGN: \ �l ��� �47 SIDE AREA:_ ZC?51 12.6)X2 x0.'f$ErPPISLE. 1 11•81 ` � Aa°'S BOTTOM AREA: .. _. 25XI2.1&X0.7+(TPD/S.F. = 21�6.90 TOTAL In 34 A.fog L \ rep eq:IcaIA rerP) (50©± S.F. �- GPD PROVIDED > � GPD REQUIRED REFER To TO ----�!r�1 RESERVE AREA - 100X LEACH CAPACITY USE.(Z)5.5't_X4.%'w;KZ'0 LEAWCHAMP5EiLSCN-10) W/4'0FSToNE A►ANC- ENDS i SIDES ,�� '�-AGP ��, 100.0 ESTIMATED HIGH GROUNDWATER CALCULATION NA (USGS/CCC METHOD) \ ourssn� coy, INDEX WELL: f ZONE: S DATE OF READING.--DEPTH TO GROUNDWATER: � � EXIST. 3 13.F• PORCH qq�.� p, ��P�N�FM�Ssgc , 99.4 DWELLiNt �d� ti�N GROUNDWATER LEVEL ADJUSTMENT: RICHARD 1%°'� T.O.E � 101,1a•S iAa J. ACTUAL GROUNDWATER LEVEL O SITE: ELffi r ESTIMATED (MAX) HIGH GROUNDWATER LEVEL: EL- t �''" JUDD,JR. GENERAL NOTES: No. 1125 1. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN CONSTRUCT1dM HDTr-S: ` �`��/STER`4o t : ACCORDANCE W IT OF THE SANITARY CODE & ANY L WAS14IN41 MA0A NE P1.UMr�I�Tp \ � ��5^NIrARIN APPLICABLE REGULATIONS. C0#4kF .'r'T'a P'ROP+aSMtD 5Y5' ,. 2. PRIOR TO BACKFILLING THE INSTALLATION, THE SANITARIAN 2. EARSTERk1 LEAC.N CRAM(P5-MK MUST M%JE". & HEALTH AGENT SHALL BE NOTIFIED FOR INSPECTION. 10J3sECTI014 PaRT W/'IN 1•x"OF J. ANY ALTERATIONS TO THIS DESIGN MUST BE APPROVED BY 3, A ZAII�EL..Ale00 EFE~'WENT FI+-rEK THE SANITARIAN & BOARD OF HEALTH, IN WRITING. IS Rv_c?vlfr'EA• /I/r, 1 4. SYSTEM IS NOT DESIGNED FOR A GARBAGE GRINDER. 5. THE INTALLER IS TO VERIFY THE LOCATION(S) OF UTIUTES, �°CoNTt�AC:�Q'!;5 AS-L,u1L.,T MU N R IN RT PRIOR TO CONSTRUCTION. STATE INkAT THE SEP''�'4 TM•i \K. 5 16 �AVEQA,Faj CESSPOOLS) A D SEWER INVERTS FI rr'!"I� w 1 �+�1 EFL-�F;'NT' � IwTEir, 6. ALL UNSUITABLE MATERIAL WITHIN 5 FT. IN ALL DIRECTIONS I I -4 FROM THE SOIL ABSORPTION SYSTEM SHALL BE REMOVED & REPLACED W/CLEAN. COARSE SAND. � oFSS9CyG Z ALL FILL MATERIAL UTILIZED FOR THE SOIL ABSORPTION I .. (aE SYSTEM SHALL BE CLEAN, COARSE SAND FREE FROM ° TERRY DELETERIOUS MATERIAL AND SHALL HAVE A PERCOLATION RATE o. OF LESS. THAN 2 MIN./IN. BEFORE & AFTER PLACEMENT. N v 3NER y 8. EXISTING CESSPOOL(S) TO BE PUMPED AND BACKFILLED PER , tt o.38721 TITLE 5 ABANDONMENT PROCEDURES P• �I1'DdtANT' ° � 9. DURING INSTALLATION. THE CONTRACTOR IS RESPONSIBLE TO ' 0� 4 9q•2 %aL I_^ 5 PROVIDE A SAFE EXCAVATION AREA. OAS MAI 10. GROUND COVER OVER SEPTIC SYSTEM COMPONENTS SHALL r pQPR QI } ✓ ✓ NOT EXCEED 36 KR 9PK FND 11. ALL GRAVITY SEWER PIPE SHALL BE 4" DIA. SCH 40 PVC V UNLESS OTHERWISE NOTED. THE MINIMUM SLOPE OF 4" DIA. I SCH 40 PVC SHALL NOT BE LESS THAT 0.01 FT/FT f 12. WHEREVER SEPTIC LINES CROSS WATER SERVICE LINES OR J1 WHEN WATER SERVICE LINES COME WITHIN 10' OF THE PROPOSED S.A.S. - PIPES SHALL BE CLASS 150 PRESSURE PIPE & SHOULD BE PRESSURE TESTED TO ASSURE WATER LEACH CHAMBERS TIGHTNESS. COORDINATE WITH LOCAL WATER DEPARTMENT. RIChOrd Judd, R.S. T.o. EON. NOTE - RAISE Nu COVERS To 500 GAf_L ON DRY WELLS 775 Freem on's Wo�y WITHIN 6" OF FINISHED GRADE ACCESS PORT Brewster, MA 02631 EL. 10 .1 EL.g9. D FINISHED GRADE » ' (508) 896-9316 '' 98. 3" MIN. 3" MINX. 2 LAYER OF 1/8 TO 1/2" WASHED STONE LEGEND: TITLE,' 54CROSPYC►RCLE 9" MIN, OUTLET PIPE TO 36" MAX. OSTERVI LLE � NIA ® 975!? 9T�40 T ., ------' � EX/STiNG CONTOURS BE LEVEL FOR 2 FT. MIN. 4.97 �� PROPOSED CONTOURS OWNER: H. M�lN l�\f C R OS B Y ME q7 o o cn o 0 0 WATER 0 o Ga o 0 o EFFECTIVE DEPTH o GA S Sra,a,- RF_QuIrFD u UNDERGROUND UTILITIES REVISIONS: \-GAS BAFFLE q(o3O U�1D�R G�sa r1,Ef'S • OVER DIG' g4.3D P-87 T 1540 AL. •:,,: :.;.. ..:;. •�- EST HOLE SEPTIC TANK L =P� ZI 3/4" TO 1/2" WASHED STONE I STONE MAP: I I t!p PARCEL: 1cl TO BE INSTALLED ON A LEVEL STABLE STONE LENGTH = ('j BASE 6" CRUSHED STONE REQUIRED DATE: 4/l/91 SCALE: I"_" 20' PROPOSED SEPTIC SYSTEM PROFILE NOT TO SCALE DWG NO.: 1*i-3S