The URL can be used to link to this page

Home My WebLink About0166 EBENEZER ROAD - Health 166 Ebenezer Road PF Osterville A= 122-075 r Commonwealth of Massachusetts Title 5. official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M 166 Ebenezer Rd Property Address Forrest Owner Owner's Name / information is Osterville ✓ Ma required for every 8-28-17 page. Cityrrown State Zip Code Date of Inspection 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. mb Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town . State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal s stemi at this address and h 9 P Y 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 ❑ Needs Further Evaluation by the Local Approving Authority 8-28-17 InspectoP Ignature Date The system inspector hall mit a copy of this inspection report to the Approving Authority(Board ` of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10;000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 ,(d �/S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Septic in good working order. tank in good condition with baffles in place Dbox good and leaching in new condition 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•3113 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 Y 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8_28_17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 pipes)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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wr 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. Citylrown State Zip Code Date of Inspection 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 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 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 %day flow t5ins•3113 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 M , 166 Ebenezer Rd Property Address Forrest Owner owner's Name information is required for every Osterville Ma 8-28-17 page. Cityrrown State Zip Code Date of Inspection, 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 tributary to a surface water supply. ❑ ® 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 conform 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 16,000 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 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. t5ins•3113 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 M z ' 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Cisterville Ma 8-28-17 page. Cityrrown 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 ® ❑ 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? ❑ ® 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? ® ❑ 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osteryille Ma 8-28-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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: t5ins-3113 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 wM 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner 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 System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): t5ins•3/13 Title 5 Official lInspection 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 M 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-2g-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: tank origanal to house DBox and�leaching updated 2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on.site plan): Depth below grade: 21 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 24+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑,fiberglass ❑ polyethylene ❑other(explain) 1000 gal H10 in good condition no visable cracks, Decay or leaks Center cover has riser in place If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal f Sludge depth: less then 1 t5ins•3/13 Title 5 Official 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 , t 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma . 8-28-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching. tank was pumped spring of 2017 as maintenance Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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-3/13 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 �,M s 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping rec ommendations, in let and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): baffles in place 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 t5ins-3/13 Title 5 Dfficlal.lnspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): good condition. no carry overs or cracks was upgraded in 2011 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: infultrators inspected through 4 inch observation port at ground level. no standing water in chamber and sand was clean and dry. septic is in very good condition t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma page. Cityrrown StateDate o Inspection Zip Code Date of nspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1)25'x11.6 infultrators ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. City/Town State Zip Code Date of Inspection 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.): t5ins-3/13 Title 5 Official Inspection Forth: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 r 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. City/Town State Zip Code Date of 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 public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Op I 3 ® 61 _33 3 t5ins•3/13 Title 5 Official Inspection Farm: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 166 Ebenezer Rd Property Address Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 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 high ground water: 30' 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: town GIS maps Date I ❑ 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: town GIS maps indicate area over septic is el. 50 bottom of leaching el.45 pond across street has el of 18.83 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 166 Ebenezer Rd Property Address . Forrest Owner Owner's Name information is required for every Osterville Ma 8-28-17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high.groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. �O l I II� : FeeV1 THE COMMONWEALTH OF MASSACHU Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTAB J SSACHUSETTS 2ppliLatlon for Iona[ *pstem ConetCULtlon hermit Application for a Permit to Construct(4-�— Repair(4)-11pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No /66, r_-gP`(1/!= /=r Owner's Name,Addr s,and Tel.No. Assessor's Map/Parcel 41 I Z Q -=.07 --�_, Installer's Na e ddr s,and Tel.No. 5-d Z -2?0^77s2 Designer's Name,Address,and Tel.No.5-og- JO,3e/o1�'� I �rNrv$ Da�rHi./� Fyy Type of Building: Dwelling No.of Bedrooms 119, Lot Size sq.8. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A 01-f] gpd Design flow provided � � gpd Plan Date Number of sheets ', Revision Date Title ts; Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) %P S ro& 9&,y 12-15ax el 1;?Uu/5 o% s -N DS .16 c%/ls r-yr i l m Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ✓J� Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ® � e Date Issued ^r No. O I _ _, Fee v THE COMMONWEALTH OF MASSACHUSETTS 4 Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLJ-F,,mASSACHUSETTS Yes 2pphcation for '.6pstem Construction 3permIt y Application for a Permit to Construct Repair(j),-Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./(o(o j5-(3r'n//r Z/=y" �� Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Installer's Name,Ad re s,and Tel.No. S-p Q�U-'J7S2 Designer's Name,Address,and Tel.No.s-U�_3G 2- 2 y2Z Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 5 ,55 gpd Plan'' Date Number of sheets Revision Date Title I I Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) jg r,4�// �[e,, a- � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date / Application Disapproved by Date for the following reasons t' tc°4j Permit No. O Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned b / at ((,G E__ 63 -4/ Z�� has been constructed in accordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No..9D t dated L' J-6 Installer /iJ,/ 44& / ��s Designer #bedrooms Approved design flow gpd The issuancd of this permit shal not 7b construed as a guarantee that the system wiki'fi'ancti d-4igned. Date - Inspector ------- i No. O - Fee THE COMMONWEALTH OF MASSACHUSETTS t PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS t Misposal 6pstent Construction 3permit Permission is hereby granted to Construct( Z-)- Repair( C)''_ Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date t'�' �ro ' � Approved by i Town of Barnstable ME' i.� Regulatory Services Thomas F. Geiler, Director BMWUABLZ Public Health Division �T 039. Thomas McKean, Director 200 Main Street,Hyannis MA 02601 Office: 5037362-4644 Fax: 503-790-6304 Installer & Designer Certification Form Date: Sewage Permlt , Assessor s IaplParcelZ Designer: rY Installer: J,_5 C/o/ ,f'J -;FSt9 rro Address: o 9 /�64dsi�'Ll41 9 S I Address: 1Ctn fir D 2, On " �. ' `' D S`C` issued a permit to install a (date) installer) septic system at (0(� e; E 6 - based on a design drawn by i _ /(address) dated AprI (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. OF MAS'P9� o DA (Inst ller's Signature) : 1140 SO I T00 (Designer's Signatur (Affix Designer's Stamp Here) PLEASE RETURN TO ARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNST ABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-164doc i Town of BkInstable Deportment of Regulatory Services � ,utxareer� Public health Division Bate L /� p A-a 1659. tee$ 200 Main Street,Hyannis MA 02601 �'rFtl MA't F � Date Scheduled `f1 I Time e� M r Fee Pd. 1 Soil Suitability Assessment fop Se�vr�ge �is�osal 1.Performed By: r� ��"�� Witnessed By: c.v W vl, i - LOCATION & GENERAL INFORMATION Location Address•.I(P(p,., C.BErj eZp-f- I Owner's Name. ��/ . ��1 Address Assessor's Map/Parcel: I ZZ/0 7 S 1 Engineer's Name A�y /VI NEW CONSIRU PION REPAIR , Telephone# �O QJ (�Z—Z-cl Z 2 & - Surface Stones b °. Land Use '� Iy� Slopes(�o) �'� Distances from: Open Water Body ft ' Possible Wet-Area 7 2-Mft Drinking Water Well ► ft i - Utainage Way f. ov it. Propsrty Linc I ft Other ft ,SKETCH:{Street name,dimensions of dot,exact locations of test holes&pert tests,locate.wetiands in proximity to holes) p2 �� 3g 37 _36 i. ��P/��CFGPRP�E•`` �R1VE . A2 d, • u S`% 4 N48'16'02"E' 224.51 cB lij} (/4 Parent material(geologic) l4[ `/ �`5 y Depth to Bedrock Depth to Groundwater. Standing Water in Hole:' Alk4 1 Weeping from Plt Face n Estimated Seasonal iliigh Groundwater Dtl`ERMINATION FOR SEASONAL HIGH WATER TALE. Method Used: In. Depth dbperved standing in obs.hole: In. Depth to loll mottlrs: it Depth toiweeping from side of obs.hole: in. Groundwater Adjustment ! A ,faetor�.._.r� Ad.Groundwater Level, ,o Index Well# . Reading Date: Index Well level dl PLRCOLATI;ON TEST' . v$tt �r; �' Observation Tithe at 9" Hole# i a 41 Time at 6" --.--= Depth of Pere ` b w (Q 0 S Start Pre-soak Time.@ r End Pre-soak Rate Min-Anch Site Suitability Assessment Site Passed_ Site Failed; Additional Testing Needed original:.Public k:;e'41th Division Observation Hole Data To Be Completed on Back--- ***If percolafiion test is to be conducted within 100' of wetland,you must first notify the week prior to beginning. Barnstable Conservation Division at least one (1) DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other. .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel d°1- �► t l� �j's N A t• DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel) tbv NIA J. 7/3 Cl DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel ICN DEEP OBSERVATION HOLE LOG_ Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Ora) Flood Insurance Rate Map: f Above 500 year flood boundary No— _ Yes Within 500 year boundary No Yes Within 100 year flood boundary No— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervipys material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per ous material? Certifications I certify that on (date)I have passed the soil evaluator examination approved by the Departme, of E iro mental Protection and that the above analysis was performed by me consistent with the required) t i to ,expert a exp'enence described in 3,10 CIvM 15.017. Signature r `� Date '—� Q\SEPTIC�PERCFORM.DOC >000" IN Commonwealth of Massachusetts Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 .Environmental Protection Teaticket, MA 02536 W1311am F.weld (508) 564-6813 Trudy Coxe t3aeratary,EOEA Dwld B.Struhs a' commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �j� PART A y e, CERTIFICATION !� Property Address: V,.A4 �C� eLEC' d Address of Owner: Date of Inspection: 3k1z\q%,o (If different) �. Name of Inspector: Company Name, Address and Telephone Number: CERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based.on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �/� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to :ne system owner and copies ser„ to the buffer, if applicable and the appro.ing authority. INSPECTION SUMMARY: Check(!�B, C, or D: AJ SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 8] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One WIMer Street a Boston,Massachusetts 02106 a FAX(617)SWI049 • Telephone(611)M-WW Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM1 PART.A y' CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken., settled or,uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are,replaced - obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRO\ktENT: _ Ine s%sien) nd> a !,euuc tank arw uii ibborp6on system and 6 KA",h 1, ivv fcci "G a So, '.'.'a E: S r j r v u::u'r t surface water supply. _ The s\s!P ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The s>sten, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS (continued): 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen: El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design floe, of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone tl of a public water supply wells The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: '�_bene e_r e� Owner: Date of Inspection: 3 t Z\oity Check if the following have been done: _L_,Bamping information was requested of the owner, occupant, and Board of Health. LNUne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. aNA built plans have been obtained and examined. Note if they are not available with N/A. _±�he facility or dwelling was inspected for signs of sewage back-up. Lime system does not receive non-sanitary or industrial waste flow l,-The site was inspected for signs of breakout. L-AfI system components, excluding the Soil Absorption System, have been located on the site. VThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _LThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _k5e facilit%' o•.'.^ 1A 111.in11rc if({iffPrPW frr)•n ovmp,) were vrovided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 4.')��')Date of Insp : 3\%7Agb FLOW CONDITIONS RESIDENTIAL: Design flow: of c 10 allons Number of bedrooms: oD Number of current residents: Garbage grinder (yes or no):_Q0 Laundry connected to system (yes or no):L4.f-S Seasonal use (yes or no)I l� Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL• (1�� Type of establishment: Design.flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RtORDS and source of inform tion: A�� h0.S - Q�� System pumped as part of inspection: (yes or no) If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM +iSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: q`1 Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property A less: Ebe:ne2ec3 A ' Owner: Date of Insp coon p(w""- SEPTIC TANK: (locate on site plan) Depth below grade:�t Material of construction: L-<65ncrete metal _FRP—other(explain) Dimensions: Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1% Distance from top of scum to top of outlet tee or baffle: (o t Distance from bottom of scum to bottom of outlet tee or baffle: . ' Comments: (recommendation for pumping, condition of inlet and outlet tees or ffles, depth of liquid level in relation to outlet invert, structural integrity, evidence age, etc.) o Je- p,&cl GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Scum thickne». Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt <roi .. to bottom of ou!le! tee or baftle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/:5/95) 6 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I(Ac F—V!t�2er-,�6 Owner: Date of Inspection:_$;12AQ� TIGHT OR HOLDING TANK�� (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP--other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOkP�",(A (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if levei and distributwr. 0 eyudi, e%luence of so:id, carr)c.er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: D(�_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.;, (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \I PART C SYSTEM INFORMATION (continued) Property Address:' �i0e�ctiEzer�� Owner: 6 f vp'c\ (.. ' Date of Ins w 311L`gb . SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to.be present, explain: leaching pits, number: b�`�D leaching chambers, num r._v leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (nnoote condition of soil, signs of hydr lic fail , eveel of ponding, ndition of vegetation,etc.) CESSPOOLS: -Sa�Pr (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 ground.:a;c-. inflow (cesspool must be pumped as part of inspection) Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i 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.) (revised 8/15/95) 8 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A dress: Owner: Date of I ection: 31�21q(. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' bAc k Q oec� a_.0_i o AN DEPTH TO GROUNDWATER Depth to groundwater:_Iyfeet method of determination or approximation: S L.� kC�G('CS (revised 8/15/95) 9 No......................... a'a ....... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE LTH �\V .OF.... .... . VAppliratinn -for Utov r ial Worbi Tontrnrtinn Pprutit Application is hereby'made for a Permit to Construct r, or Repair ( ) an Individual Sewage Disposal System t __- ----------------- - -------.----_----- --•-. .--. --_-•---- Loc ' ''''Add``ress ,or Lot IVo. ... �d�.......................................... ........4= --... •--•--.....--•---.............................. W ne„ rd a -..• . . ..... ............................ .................... ...... ... ........._ ................. nstaller Address Type of Building Size Lot_./7 ---- feet U�+ Dwelling—No. of Bedrooms......... Expansion Attic ( Garbage Grinder ( ) aOther—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ------ -------------------- - W Design Flow...5_147-------------------------------gallons per pet-son per day. Total daily flow.__. ...........................gallons. WSeptic Tank—Liquid capacity/6:6fi_:gallons Length................ Width_____..._...._.. Diameter................ Depth---._____------ x Disposal Trench—No________________•._ idth........._..___ _ . Total Length__-_--__ ....__._ Total leaching area....................sq. ft. Seepage Pit No.__�42�-__ ..._.___.__. ............. ../. Total leaching area _; ------ ft. Z Other Distribution box ( Dosing tank ( ) U�� C�o (1— 47`77 — Percolation Test Results Performed by------ -------••---•----•-•----------------•------•---•--•---------------- Date------------------------------------.... ,a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...____-_____-.._._.---. rrxq Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water__.___._________--_-.--. ------------ ------- --- O Descriptio of So'1____...... �`�.......................... Z r} } ,7 -------- --- - ----- -- - w 7r, ' ------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------------- V Nature 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 \I 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 board of health. Si Date :;�__Application Approved BY 'l. ��--------------------/-----•--•-•-- ' _r-----------------------------•-------------------------- --•--•-------- Date Application Disapproved for the following reasons____________________________ _ ...............................--••-- ----------------------------------------------------------------------------------------------- Date Permit No......................................................... Issued.-----�-��-'Ir------------7?...•------- Date No....... s .... F��. �.�................M�� THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Appliration -for D tipagal Warkii Tonstrurtion Vamil Application is hereby'made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: AO Locatiolvi"Address # or Lot No. :!'t.�...--•----r-�-----•---•----------------- --------•/4f.-..}'.r!!,P—e :---------•--•-'•---•----......................------. Y��r Owner yf �,d es W .. .C`,..rt.......... ..e t 1.-•n'n' !''"':. .. °`_ J?✓'"1..:'. e�'_..e I'�nstaller ��' Address Type of Building Size Lot.:!_.4� _ _..Sq. feet U Dwelling No. of Bedrooms____.__s ,.Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons_..__--.-______._._.____._. Showers ( ) — Cafeteria ( ) p' Other fixtures -"-...... -----•----------------_----------------- -----------------------------------------------------------d W Design Flow___!�:` -------------------------------- per person per day. Total daily flow____ _ ? !...........................gallons. Septic Tank—Liquid capacity/ gallons Length________________ Width---------------- Diameter---------------- Depth--------------- xDisposal Trench—No ------------------ Widtli................... Total Length.-------- ____.-fTotal leaching area--------------.-----sq. ft. Seepage Pit No... .-tf i' _. f _.._.._<'. l ebel, . Total leaching Z Other Distribution box O` Dosing tank /,7- 77 Percolation Test Results Performed by--_-------------- ------------------------------------------------------- Date•-.-.-------------------------------._.. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.._.-_---._..---__.____. (_ Test Pit No. 2________________minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water_-_._____--__.--___.--------------------------------------- D Description of Soil ( _-.�... !` =J ''� s i _._ _ �``` > . V == f f'� .._��- '�? e° s'1��- 21-�t` i dam.e W U Nature of Repairs or Alterations—Answer when applicable.____________________--------_------------------------------------------------------------------ ------------------------------------------------------------------------ i 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 board of health. Sie :��•.�: ,�----..c!i�":::.,_w-^-�- --- �----ram"------------ ...... -- --r> -- -'- ---- Dale Application Approved BY rG!lI11 `- ._.._.._.. -_ G)._- _7... Application Disapproved for the following reasons------------------- ---Y-------------------•------------------•------------------.-----.Dace------••••---- ---.-------•-------•----•---•---•----•-•---------------------------•------------------------------------•---------------------...----•----'-- -----------------•---------------------- ----------------- p Date PermitNo......................................................... Issued........ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. ... �`�-r O F... :.,. ..:., ................................. �rrtif iratr of Tomplinurr THIS IS TO CERTIFY,, That the Individual Sewage Disposal System constructed ( or Repaired ( ) byY: -< . ----- ---- ----- ----- f Installer t at. 'a'A-- --�-------- -------- r��_ ,�,�a:�� -�-- has been installed in accordane�e6 with the provisions of Ar 'cle I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--- __�....... 5 2.....,.. dated----. t_-__ 7_7.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION:A.-2 SATISFACTORY. Ic DATE li--....._._.. v�-- `` Inspector. ----•--'--'-----...--•----L.. ................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J6 �2_S— .......... , rF � .. .. of ............... F FEE...` 5--------- . � rrxk,� �l�tt�trttr�Y�tt rrntit Permission sF� eby granted , =r� I v...... - `................ to Construct( or Repair ( ) an Individual Sewage Disposal stem '' rr as shown on the application for Disposal Work<Construction erm't N ...... Dated---4r:o, .' 7� !f �I • - •------•-•-•------------ . DATE...�•............... ---------------------=----------------------------------- Board of Heal; FORM 1255 H0138S & WARREN- INC.. PUBLISHERS 4 0 Gay 1, /Coo 4.4 L PST' al F"CHARD A. RAXTt"p g No .e-1049 cEeTo��x� PLc7T �.Qtil y LOCA►Tlo" i'i�2�ll l GMZZTI.r-,q T"AT TPG t^OuQt)A'CIoQ SI C>WkJ A R i=cRG�JGE t-lEQEa►�l COAAPLI-(S WtTN THE LoT- 2� AWC>L , SET8,AC- G �C-QUttZENTS OF TNT 'TO w►J OP7 A�r+�.J S, '!'"i�4�.��:�) (� 0`.)r�2`�J��.Mice w El 61�T'ti DA T E. �'� f'1"� I C_c d J L--�"-a �- B,tS,XTCti2 <L, WYt_- INC-. RE615't'C�' D LAIWE> SUeVi�`(atZS THIS DLAE-! (S BUT SASE U A� US'lrEIZV% _t - o tIr�ASS� t.tv,' F5L USE: To U[-=Tc--Z iWE- LDT LtWe5 cr4!'� ��!✓''J'� t=�! OSTERVIL'LE LEGEND ti. PROPOSED CONTOUR J t ® PROPOSED SPOT GRADE 0 F` " >� EXISTING CONTOUR.UPOLE —— Q8 —— << + 96.52 EXISTING SPOT GRADE 2 o -'oy N PARCEL ID: 8± �CB -_--c�'pcc'of W— EXISTING WATER SERVICE 3 LOCUS O 4 N 122/074 �� A �O s TEST PIT 166 EBENEZER ROAD M �6 —---\-��j-� 11O 0 RO 28 — UTE U � off, I 4� 4 LOCUS MAP 43 _ , _ LOCUS INFORMATION EXIST. 1 ,000 GALLON `�' GLUS �`� #EX DWELLING -__ Pow ` 44 'UTILITY PLAN REF: LC37432-C SEPTIC TANK �� __-= DWELLING TITLE REF: CTF#140291 44 �� _=-_ __``� CB PARCEL ID: MAP 122 PAR. 75 TOF=46.58 4,5 IN ZONE II ZONING: "RC" GW DISTRICT "GP" _( ) �Q :_ FLOOD ZONE: "C" �, pF __ CQ-__ COMMUNITY PANEL: 250001-0015-C DATED:08/19/85 EXISTING LEACH PIT -- Dd _P NE�`j ___-_ �`O " (see note 10) �°q - - SEPTIC SYSTEM 5 RHO _ REPAIR PLAN - D. �� -,DAB ,w (TO SAVE - 16" �. LOCATED -AT: OAK TBM=46.00'(GISt) e 166 EBENfEZER ROAD COR. CONC. STOOP i OSTERVILLE MA. 2� PiNt S0 PREPARED FOR s sss4 53 , 6„ -- WALLACE J. & ADELAIDE F 30"�. ' sue s FORREST PIN , APRIL 15, 2011 PARCEL ID: PARCEL ID: �F. 122/079 OF Mgssgc 122/075 AREA=1 448t S.F. ti� oZ DAEf M yG �lb SAS. 9� v� " No. 1140 2 `9 GENERAL NOTES: 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 2 'TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.,Isl 2O'• 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY SR BOARD OF HEALTH AND THE DESIGN ENGINEER. THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING SANI TA?,,\ �0 2 OF THE STATE ENVIRONALL WORK AND MENTAL CODE,S SHALL NTITLE V.FORM TO THE REQUIREMENTS CONSTRUCTION. AND ANY APPLICABLE AND REGULATIONS, EXCEPT AS REQUESTED-BELOW: 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. LOCAL RULES '• — 310 CMR AND ( TIO BE SURE TO PROVIDE STABLE BASE FOR VEHICULAR,TRAFFIC. 0� 1) A 2.77 FT. VARIANCE FROM 310CMR 15.221(7) TO ALLOW LEACHING 11, 48 HOUR NOTICE FOR ENGINEER CERTIFICATION PARCEL ID: TO BE 5.77 FT (MAX) BELOW GRADE VS REO'D 3 FT. 11 THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY (H20/VENT PROVIDED) ` AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY D A R R E N M. MEYER, R.S. 1 22/092 13" NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING 3 TOEINSPECTION�AND APPROVAL ALL BY THE BOARD OFCHEALTH ANED D THE 14. ALL PIPING TO BE 4" SCH 40 0 1/8-/FT (UNLESS SPEC. OTHERWISE) �/ DESIGN ENGINEER. 15: THE DESIGN OF THIS SYSTEM DOES NOT ALLOW P.O. BOX 981 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FOR THE USE OF A GARBAGE GRINDER FROM THOSE SHOWN HEREON SHALL BEREPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING EAST SANDWICH M A. 02537 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 1 INSTALL 40 ml POLY LINER AS SHOWN, FROM ELEV. 67.50 — 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 63.50 TO PREVENT BREAKOUT. (5 O 8)3 6 2— 2 9 2 2 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 18. REMOVE UNSUITABLE SOILS 5 FT AROUND LEACHING AS SHOWN TO 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. .EL. 66.75 OR TOP OF "C" LAYER AND REPLACE WITH CLEAN MED..SAND. ,e y SHEET 1 OF 2 J 1318 NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:42.23 ' - FOR �A DISTANCE OF 15' AROUND .THE PERIMETER OF THE S.A.S. SEPTIC TANK "PROPOSED D-BOX PROPOSED S.A.S. `A. T.O.F. EL.=46.58 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER <71 OUTLET AND SET TO 6 OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. F.G. EL.=46.0-43.Ot F.G. EL.=45.Ot F.G. EL:46.Ot F.G..EL: 48.0(MAX.) �� OF MAss9Cy ' I o { VENT DE YR M. L = 30't 9" MIN COVER/ t L 10' - MAX INSTALL TWO INSPECTION PORTS MIN. �"No. 11`40 0 S=1% (MIN.) 36" MAX COVER 0 S=1% (MIN.) 0 S=1%((MIN.) I (MIN.) 4"SCH40 PVC .• 4"SCH40 PVC 4"SCH40 PVC wG/ EQ to" 14. a 10.75" TO : NITAROP� INVERT INV.= 42.49 48LE�LID INV.=42.24 PROPOSED INV.=41.97 GAS BAFFLE D-BOX 4 ROWS OF 5 UNITS AT 5'/UNIT = 25'/ROW :. = DS-5(H-20) INV.= 41.80. - Irly.-42.14 � SOIL ABSORPTION' SYSTEM • (PROFILE) , _ EXISTING 1,000 GALLON SEPTIC TANK EXISTING OUTLET RESTORE VEGETATIVE COVER BACKFILL WITH CLEAN PERC SAND TO TOP OF CHAMBERS• - 75"k NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL .BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=42.23 GRADE ON A MECHANICALL COMPACTED SIX INV., ELEV.= 41.80 ' INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 40.90 EXISTING SUITABLE 310 CMR 15.221(2) 2.88' MATERIAL 3) REPLACE EXISTING 1,000 GALLON SEPTIC,TANK 5' MIN. ABOVE BOTTOM OF �+ 60"WITH 1500 GALLON SEPTIC TANK IF FAILED, T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.88' = 11.52 DAMAGED, OR UNDERSIZED. (5.40 PROVIDED) USE 4 ROWS OF 5-ADS ARC 36HC 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL.=35.50 - (H20) UNITS NO:STONE PROFILE , GAS BAFFLE AS REQUIRED - SEPTIC SYSTEM PROFILE , TYPICAL SECTION.' 9 1 s" N.T.S. Krs . 10.75" n . e .S01 L ,LOG- .. P#: 13237 DESIGN CRITERIA DATE: APRIL 8, 2011 . �-34 „ SOIL EVALUATOR: DARREN M. .MEYER, R.S., CSE. #1614 SECTION END CAP NUMBER OF BEDROOMS: 2 BR DWELLING / 3 BR DESIGN WITNESS: DAVID STANTON, BARNSTABLE B.O.H. SOIL TEXTURAL CLASS: 'CLASS I T , T _ = Elev. I P 1 Depth_. Elev. I P-2 Depth - DESIGN PERCOLATION RATE: <2 MIN/IN ADS ARC 36HC CHAMBER H2O LOAD) _L_ ��V 2� ) �A 49.50 0 49.75 0'' ^ DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. _ _ A SANDY LOAM " r _ A SANDY s�2 ^_ MODEL ARC 36HC' 10YR 3 2 � - , GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 49.00 16.. 49.17 7" LENGTH 63" NOTE: -UNIT CONFIGURATION AND AVAILABILITY SUBJECT SEPTIC TANK: 330 gpd x 200% = 660 gpd USE EXIST. 1,000 GALLON SEPTIC TANK B LOAMY SAND B LOAMY SAND EFFECTIVE LENGTH 60" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 10YR 6/6 10YR 6/6 DIFFER SLIGHTLY FROM ACTUAL,PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. SIDE WALL HEIGHT 10.75" DISTRIBUTION BOX: 5 OUTLETS (MINIMUM)(H20 LOADING) , - OVERALL HEIGHT 16" 46.83 32" 47.00 33" OVERALL WIDTH_ 34.5" 4640 TRUEMAN BLI/D PRIMARY S.A.S. C C 10.7 CF a HILLIARD, OHIO 43026 USE 4 ROWS OF 5 - ADS ARC 36 UNITS-NO STONE COARSE SAND ; COARSE SAND CAPACITY $O.O GAL ADVANCED DRAINAGE SYSTEMS, INC. PERC 0-EL. 44.83 ( ) 2.5Y 7/3 2.5Y 7/3 ' BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF BIODUFUSER) i PROPOSED SEPTIC SYSTEM SITE PLAN (BIODIFFUSERS) 20 UNITS x 5.0 LF x 4.80 SF/LF = 480.00 SF 35.50 168" 35.75 168" 166 EBENEZER ROAD, OSTERVILLE, MA , TOTAL AREA = 480.00 SF PERC RATE <2. MIN/IN. ("C" HORIZON) PER SIEVE TEST Prepared for: Forrest DESIGN FLOW PROVIDED: 0.74GPD/SF(480.00SF) = 355.20 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering b : SCALE DRAWN 9 9 Y Surveying by: DARRENM.MEYER,R.S. dfeoDouBe1 5•urver NTS D.M.M., • 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX981 (508) 419-1086 DATE: CHECKED to conduct soil evaluations and.that the above analysis has been performed by me consistent with the EAST SANDWICH,MA02537 SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I.have'possed the Soil'Eval. Exam in October,,1999. 04/15/11 D.M.M. 2 OF 2 ' S0B�62-2922 i -