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HomeMy WebLinkAbout0025 FIRST AVENUE - Health 25 irst Avenue Osterville P A =71116CO52. - e v m P : n a i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �^M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 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. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the I _ i computer, use 1. Inspector: I\yjl I only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)477-8877 S14454 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -z! 2/24/2011 Inspector's Signature Date --1 The system inspector shall submit 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 su6r-- it th�--n report to the appropriate regional office of the DEP. The original should be sent to the syst m 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. (J) /I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 s i Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments cwM 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. City/Town 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: The septic system is in proper working order at the present time. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 First Ave M Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):. C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or.the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. CitylTown 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: Y pp Y 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 1/2 day flow thins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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 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.] ❑ ® 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 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of.17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. CitylTown 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): 3 Number of bedrooms (actual): 3 i DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. City/Town 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA g ( Y g (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2/24/2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Forrm Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 10 �M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. City/Town 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for i req Osterville Ma. 02655 2/24/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2(' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.no evidence of Ieakage.System vented through the leaching. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 3" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °wM 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness V. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t ins 11 10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System m Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 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.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal'System Form- Not for Voluntary Assessments ^M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osteryllle Ma. 02655 2/24/2011 every page. Cityfrown 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 No 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.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Cisterville Ma. 02655 2/24/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Sandt soil.No signs of hydraulic failure.Leaching Chambers were dry at time of inspection.Stain line observed 13" below invert. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 First Ave M Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 every page. Cityfrown 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•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 H C, .��' '✓s...k '§'ram �� .�...ui"...�,�,µ...: P q x �€ �t5w2z� y3� ids„€�i u 7 fi „ �-"'gild A T „Fy;�iA i�'�.�a "• 3 � �i 3�",. 012, az ri-4iFy MIN ,. A ax {Id ,tgjy y'�jNy ".y � �# t �n rr nx s at r ; •Cr a p 'iFFax IN A- iy m C:.�a`P�Ft�'M3NePi Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 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 high ground water: Bottom of LC 21' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f. i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °�M •'°� 25 First Ave Property Address Fred & Dianne Teceno Owner Owner's Name information is required for Osterville Ma. 02655 2/24/2011 " every page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE "cATioN a F.d 5 Ave SEWAGE # 73 `�'T,.CAGE VSr I/�e T� v F' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 194 12'� SEPTIC TANK CAPACITY . 15�00y r FACHING FACILITY:.(type) .27 SoOy C4a,"-4rrS (size) Z4•g.3?(2� X A " NO. OF BEDROOMS 3 E'r7ILDER OR OWNER /d 7ec c,7 y PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: =R �Maxii-um 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) ,r Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A 9.1 W ' Oct 3 _ S �:J 2 No. r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for ]k5pogar *pgtem Con!aruction 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 114 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. T�G 101-74p PEA/ c-,jXPA-- 4-1VI Type of Building: Dwelling No.of Bedrooms _ Lot Size t /,I;;- sq.ft. Garbage Grinder( ) Other Type of Building 1)jaeffC4NL No.of Persons Showers( ) Cafeteria( ) Other Fixtures jo"IDesign Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title FA Size of Septic Tank Ch Type of S.A.S. Description of Sofl ;,) A8 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 tle 5,of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued t * Board f Healt Signed Date 1 �— Application Approved by ef: Date C. Application Disapproved for the following reas s Permit No. Date Issued ' -� ...,,.� ./ �_ ` •t,.�_r.� '�'..x •r -fro{" _N-.w +rw.iri..te•y,¢•e,.i'ti..yr«-,- ...,_�.r-e. .-. .. .....- :-f,., , IN% No. .. --�. may. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS i Entered in computer: '. Yes PUBLIC HEALTH DIVISION' TOWN OF BARNSTABLE, MASSACHUSETTS 4 a ZIpprication for Mgogal bpgtem Congtructioh Permit Application for a Permit to Construct( )'Repair( )Upgrade( )Abandon(. ) ❑Complete System 0 Individual Components Location-Address or Lot No. Ow s Name,Address and Tel.No. Assessor's Map/ParceliL�✓/(.LLB Installer's Name,Address,and Tel.No. Desig is Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms K3: Lot Size 4/3;) sq.ft. Garbage Grinder( ) . Other, Type of Building 1"6-6 W4 ` No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow V gallons: 4 Plan Date Number of sheets Revision Date *' Title Size of Septic Tank _Type of S.A.S. Description of Soil 0 r 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 o tle 5 of the Environmental Code and nto place the system in operation until a Certifi' cate of Compliance has.been issue y t Board f Hea Signe /r /? 179 Date 1 1 / Application Approved by _ i-- t/ t� f v1� Date Application Disapproved for the following reas Permit No. Date}Is ued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that t e On- ize Sewage Disposal System Constructed ( )Repaired ( )Upgraded{ ) ! Abandoned( b �T� at � f' S o­e , has >eep constructed in ac ordance with the provisiort o Title 5�4nd t Q for Disposal System Construction Permit No ' )dated _i'1 10/0 f' Installer �` Designer ��'` The issuance of thi ermit shall not be construed as a guarantee that the systet wfi n,t as designed. Dateh`���`� Inspector R — n ----- -------No � Fee THE COMMONWEALTH OF MASSACHUSETTS r PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Migogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( J�Upgrade( )Abandon(. ) System located at ✓j w and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her.duty to comply with Title 5 and the following local provisions or special conditions. - . :. Provided: Construction must be completed within three years of the date of this permit. r Date:_ Approved by �• TOWN OF BARNSTABL.E LOCATION il a.5E ,'r g 1t �}v e SEWAGE # 2 3 0.Y — '173 VILLAGE 2176-V.,•11-e ASSESSOR'S MAP & LOT INSTALLER'S NAME&.PHONE NO. SEPTIC TANK CAPACITY.\ / 00ei. LEACHING FACILITY: (type)' a'660. C44.•jhPrs (size) NO.OF BEDROOMS 3 t BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottow: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 faVity) - _ Feet Furnished by A 3 Z } A • ' . .. w.e� • _,-.-..n+urF'^^^-...ram,-.r. -.. - .... ...r�.. ..-.�.-' . a 3� 31 31 MAY-04-2005 08 :56 AM DOWN CAPE ENGINEERING 508 362 9880 P. 02 �x Town of Barnstable Regulatory Services • Thomas F. Geiler, Director E N _ Public Health .Division Asa e Thomas McKean,Director ZOO Main Street,Hyannis, MA 02601 Office: 508-962-4644 Fax; 508-790-6304 Installer&.fts_lgner Certification Form Date: Sewage Permit# _ Assessor's Map\Parcel �-- Designer: v_,..a.� r. Installer: Address: Address: On {installer) was issued a permit to install a (date) septic system at 2 hT r �"�• -based on a design drawn by (address) !! dated i y t • O 3 (de� m V 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, W,,AV-%-.I ;..� ►��.,.e,,.,{. t.,�,�,�.a�[ I certify that the septic system referenced above was installed with for 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, C ��yqH OF (Installer's ignature) ARNE H OJAI.A CIVIL No. 3D re2 �Q7 �C18 T E Oy�� (Designers jgnature) (Af ix rw. I p Here) PLEASE ttZTUjW Td BAMSTAJILE PUBLIC jj&&FLU, DIVISION. CERTIFICATE QF CQMPLIANCE WILL NOT BE ISSUED UNTIL ®OTII_TIHIS F®&M AND AS-BtltLT CARD ARE II S&WED BY THE B&B—NJEABLE PUBLIC HEALTH DIVISION. TifMANK M Q: Nenith/8cptic1Degign®r Certification Form 3.2"4.doe COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION 00" F �F 9 2�Op TITLE 5 ���A <.�`��r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM PART A CERTIFICATION Property Address: r Owner's Name: Owner's Addres . 4 0 Co 6 Date of Inspection: //r) Name of Inspectftlease t)1nPS—+Company Name Mailing Address Telephone Number: !rpo 8- > qQ (� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.lam a DEP approved system inspector pursuant /to Section 15.340 of Title 5(310 CMR 15.000). The system: 1� Passes Conditionally Passes . ds F valuation by the Local Approving Authority ails Inspector's Signature: / Date: The system inspector shall submit 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A rt CERTIFICATION (continued) Property Address: �r � ��c�2'l �nCcf Owner: Date o spection: .� Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 7--sitha'v'e em Passes: not found any information which indicates-that any of tfie`failure"criteria described in 3 t 0 CIvIR 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 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: 2 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST h Property Address: C25 NZ7 � Owner: ha j Date of 149f ection: 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?(I.f 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? V _ Were all system components,excluding the SAS,located on site? y _ 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: Yes no — 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(3)(b)) 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: . Cam' � (� Owner: ` Date o spection: D FLOW CONDITIONS RESIDENTIAL Q Number of bedrooms(design): Number of bedrooms(actual): . oZ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):000 Number of current residents: Does residence have a garbage grinder(yes or no): /N,Pl— Is laundry on a separate sewage system(yes or no)-Mlif yes separate inspection required] Laundry system inspected(yes or no):,efZo— Seasonal use: (yes or no): 9 Water meter readings,if avMlable(last 2 years usage(gpd)): Sump pump(yes or no):/_� '•- Last date of occupancy: 1 � &U4 — � COMMERCIAL/INDUSTRIAL/f60— � . Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: i2�.� Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T7SOF 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) Tight tank _Attach a copy of the DEP approval Other(describe): A proximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no 6 r Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: cn) C gP gu'—e aa Owner: Date of pectiow. BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): ` Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade— Material of construction:_concrete_metal_fiberglass_polyethylene — other(explain)-If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) � , r Dimensions: k CP A( Sludge depth: /i1' Distance from top of sludge to bottom of outlet tee or baffle: 37 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels ^related to outlet invert,eviden a of leakage,etc.): --�J GREASE TRA ate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c7l' Owner• �f/ � Date of pection: TIGHT or HOLDING TANK✓�.4 '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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: t0 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ayz-64 Avpj Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of 1 age into or out of box,etc.): v C.0 .0 Qt.(+ 8 PUMP CHAMBEY4Iocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ` ,4-oac� S� Owner: Date o spection: 9D /CL— SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: aching galleries,number:� GCJI 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.) r CESSPOOU69 _(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRI (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.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:C225 Owner: Date of spection: 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. _ 1 (v sy iB ell 10 Page l l of l l ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ Owner: Date of pection: C) SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet' Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: 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: ll Page 3 of 11 ea OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .j wpl Owner: Date of pection:,fa ZLQ/W 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 un:.ss Board of Health determines i:accord' with 310 C1J 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. _ 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 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 ppni,provided.that no other failure criteria are triggered.A copy of the analysis.must be.attached to this form. 3. Other: 3 i r r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A4 Owner: Date of spection: a L� ailure Criteria a licable to all s D. System F pp stems:.Y 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 onclogged SAS or cesspool _ V Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z.day flow Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped i 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 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 No...............` ` Fimic 5M....... APPROVED THE COMMONWEALTH OF MASSACHUSETTS ` pbrnpble,Comry .'on Dwe e t BOARD OF HEALTH TOWN OF BARNSTABLE C/Stned Date Appliratiou for Diri wial Work.6 Towitrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair (p4 an Individual Sewage Disposal System at: � ` _ -•----......-r.---- ...-°-.....-=...-------------•---------.........................-------- >��--./^^U���� -Ad o anon t re — � . 4' t 8 ��� `/��r�_ ';r Lot N/o.� - // O.encr A 5 �iJ("`iit Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.................. Expansion Attic Showers —Garbage Grinder Cafeteria 114 Other—Type of Building ............................ No. of persons ( ( ) Q' Other fixtures --------------------------------- w Design Flow............. ...................gallons per person per day. Total daily flow........ - ....................gallons. rx Septic Tank—Liquid capacity// ..gallons Length---------___-. Width................ Diameter................ Depth................ Disposal Trench--No. ........../...... Width.....:Z._........ Total Length_. _:_!Total leaching area....................sq. ft. Seepage Pit No--------------_---- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GY ......----••-•-•--------------•---•--•-.. ---•--•-----... -•---•-----------.............._..........-------•------............------............•••...... Description of Soil a:. . .e./ /��I Cu 7i_L.......... ':.. ._ /a iJ� x U ...--•--------•.....•---••-------•--•---•---•-------•------•---•-•-•----------•----•••--........•-••-----••••-------•••-•-••----•--••--•-----•••............••--•-..................................... w U Nature of Repairs or Alterations—Answer when applicable.--_- ....../606.�1� 0.... ...... C �---- '`�-------J•+J s--------------7-----/�° ----=-.�1 �..... '.....•---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian as even iss d by e board of health. Signed ..... .............................. ....... .. ............................................ ..... All Date Application Approved By .... ........... -----.--- %2 --. Live Application Disapproved for the following reasons: ............... .............................. ...........................................--....--................ .................................................. l:.. ...../.�.. . .....................................--.....--........ ................ . ........................................ Permit No. / .... ..`-` !` Z-------... Issued .........�1................................��.... Dace No. ✓-"� l ,V/ Fps... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /v/ 3 TOWN OF BARNSTABLE Ap.pliratinn for Diri.pnsul Work.5 Tonstrur#inn 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: C�5`z�e ovation-Addresa or Lot No. ., ----•-----.-_.......................................................................... -•--•-••-•--••-•-••-•----••-••----•-••-•--•-•-................................................... Owner Addre s 7 G�.•�.s?Z.tl /!�t`1 -7Lo�l�}ll� `9 GC a ......... Installer AddressY�I f IS d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............,3----------------------_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building __________________________ No. of persons._--____.------------------- Showers ( ) — Cafeteria ( ) Otherfixtures . ---------------------•-------•-------.---•---------•-••--------•----_-------- ---••----•-•-•---•---------•----------•-•-•----..._......__.: W Design Flow...........=5 -..................gallons per person per day. Total daily flow_.:__----� o....................gallons. WSeptic Tank—Liquid capacity%!?..gallons Length________________ Width---------------- Diameter..-.------------ Depth................ x Disposal Trench--No. ........../...... Width.....7.......... .Total Length-_��:757_Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. i Z Other Distribution box ( ) Dosing tank ( )f ~" Percolation Test Results Performed b .................................................. Date............... Test Pit No. 1................minutes per inch Depth of Test Pit------_............. Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ •---•---•--•-----•-•---•--•-•---•- --- --• •... . •...............•--........_... i D Description of Soil........................S. - 3 CG�?��1 SuG ,Soy L -- -Sit !/ .............. U W U Nature of Repairs or Alterations—Answer when 7applicable.____Z�?-5!�2.�-__.__�-__..._.lG��'�.._Cx. .5�-�/_.�.. ���_......... ......... ��S_%.:._.���� ?-.�....._��?-. �.�J�iC.:/1 �/GS .....W/ fir- • Agreement-. J The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance'has )eeen issu d by the board of health. Signed ......J.G-- . .......�'' .. ....... . Date Application Approved By ....---�---*...� �1r --... .... �' '� ...-... ... `l Dare Application Disapproved for the following reasons- ------------------------------------------------------- ................. ........ .....--........................... .... ................... ..................-.......................................................--------------------------------------------- d Permit . Issued --------- ��..-..../.... e _.... Dare f __...- —_.,_.___-- --__—_...-------..--- -._--_._____--._._._---_._..-- _._.1,--_-e.__, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C ertifi ate of V IIznlaIianre THIS IS TO CERTIFY, That tile-Individual Sewage Disposal System constructed ( ) or Repaired (�) by .... .... .. ....... ................... ..........;,-c�-r.:.-��.1_v�%7 --L=a ... ............ .................. . ..... ............... has been installed in accordance with the provisions of TITLE of The State vironmental Code as described i the application for Disposal Works Construction Permit No. .__.�°��0�. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................ /.J..-.. '. ...-........__..-...-- ----..... - ....-.. Inspector ................ ., .. .....:.............................------- --------._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !� TOWN OF BARNSTABLE No. ✓...� � FEE..�m..J Disposal Works Tnno#rudion f rrntit Permission is hereby granted ..U ��Gl....................... .....`JS%7Z�1C�".U�.J............................. to Construct ( ) or Repair (,) an Individual Sewage Disposal System atNo.... '- ids..........................................................LS rI /L L. ........................ Str,et "2 as shown on the application for Disposal Works Construction Perm}<t� �� ��_ Dated--_�D.....1..�_" _.�. 1 I......... .......... ........ Board of Health / DATE.__.....---G--/--._...../-•----------�----...__._a....-J----•------------••-----• FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS TOWN OF BARNSTABL,-; LOCATIONQ']L F,,rsy Au e%'Jap/ SEWAGE #�-,6-�/ VILLAGE "(��'��� ASSESSOR'S MAP & LOT ` INSTALLER'S NAME PHONE NO.BQr-10&�&SJ Sr PTIC TANK CAPACITY LEACHING PACILITY:(type)3 rXV�r� (size) NO. OF BEDROOMS PRIVATE WELL OR CUBL'IC WATER BUILDER qCOWNER (,(��i/ 7 -- ,:7: DATE PERMIT•ISSUED: 16 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes-0 No ` ems, Z�l �-� `O n ' . i t r Z� w� Gym➢r.i n v m pOo AwNmF 1 111JE11.i-11111111— IIII 11�1=IIII IIII =iI =IIII=IIII—!III II=IIII IIII III-1�111—III=1 °.D ���� IIIIIIIIIIi1� , ma II=IIII P III=11 - Fx � s IIII=.1 ': •. II—illi 0.2 11=IIII=1. 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A0N4S YR HOUT FIRST OBTAINING THE ` •O 02/09/04 urts Puxs DE f NxID-1 iocA°x' DISIINCTNE RESIDENTIAL&COMMERCIAL DESIGN EXPRESS Y.RITTEN PERMISSION ".bl. / Bu40 x0 OEPAPn[xf D/di x6RECTOR f0f NUN STREET YARuOUTHPORT•MA 026'/5 ANO CONSENT OF NOflTH51DE O6- 25 FIRST AVENUE IOR REVIEW AND ARR0.0YM REGARD xO ANY I000)362-2210 (SOB)36 ... 05TERVILLE MA. Poss eaE n[v[xats"a ARIA xu DES GN m IN If 18� ill, I'gill :E. I R I zi A a e. p. I TWJOA•TYQOA•traoo• 3 II I II I i I I I I I I I I I I •III I THlzw• TYIae•• l ' I , JI �m L------------ I x i I 1 I I I . �g N •a• TW2M• D z 12 x ` � Ln LJi (P y Va W •U •�� A z 8"LE• I/4°�I'-0° ea•rt uw Haan euuowc roam u.eT menr.cross ra oauxnn. out TO COPYRIGHT DATE REVISIONS nW um 0 OmU.WtlMt1 euo+ FIRST FLOOR PLAN y•4Ma�° aa .aH�°° NORTHSIDE mn..meue.ma N.naeun ar HORMSNE HEREBY E%PRESLY DESIGN oN-nrt Mmcbm m Imsme.m DESIGN RESERVES ITS COMMON LAN' sur[—. a wemmt.— COPYRIGHT.THESES PUNS ARE 9IRAO.0 eE®ox•euTY GI WPun SHEET N0. 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DISTINCTNE RESIDE.WK&COMMERCIAL DESIGN ERPRESS WRITTEN PERMISSION Zg FIRS 1'AVENUE ADMD'o D[PARTutNT'U1D�oA uISPECTm 767 MAIN STREEE•YARMOUTNPORT'MA 02076 CHECKED OSTERVILLE I UE FOR RMIN.0 APPROVAA REDWING ANY (epR)EOi-u,o. 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LOCAI BULGING COGEe UE T N GN(AnY ACROSS a CWNE NNE ro COPYRIGHT DATE REVISIONS Tme"ND"""'NSOR YNaABE[B 0`" �ND BUILDING SECTIONS q M RRRWS�iwozse¢v NORTHSIDE NORTHSIDE HEREBY E%PRESLY DESIGN ON-VIE.s ETON oN Cmrsm ON RESERVES ITS COMMON LAW 9J10—ON. E- aRTNsmE .- DESIGN COPYRIGHT.THESES PLANS ARE . A VNES NO RMON9IEUTY NIT UINI TY PROPOSED ADDITTIONS/ RENOVATIONS, FIAWE AN Ros[Es OR NANAO[x IN INRm NOT TO BE REPRODUCED SHEET N0, Luc TO ER OR wlmo"s�N rN[ ASSOCIATES CHANGED OR COPIED A ANY DRAWN DATE: THE OR.N.—D oFRofHm[e w FORM OR MANNER WHATSOEVER Mr. Mrs. FREDSRICK TECENO mA NIiE NE.I(IN[BEsc Gurus WTHOUT FIRST OBTAINING THE 1 B[lglF CNMNmICIN6 CONSINUCNON, 02/03/04 ms RLANs eE rAw+rN rouR Eacu DISTINCTIVE RESIDENTIAL k COMMERCIAL DESIGN EXPRESS WRITTEN PERMISSION CHECKED A,5 25 FIRST AVENUE eM nwc GVAa wmT A m/oN Ixm[N a Ar MA N S REE •YARMOMTHPORJ•MA OxeTs AND CONSENT OF NORTHSIDE ' Y°P REMEN AMD APPRWAE RCNARORIG ANY (soe)]e2-xzlG (sae)sex-aeox OSTERVILLE MA. oszaGoswERmm[aIN=C."u DESIGN. NX Z. a_ . � z c.3 � 0 LP M k cn 2 r z rb c o � � w - °e °C w TOP FNDN. AT EL. 35.2' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN ACCESS COVER (WATERTIGHT) TO / 6" OF FINISH GRADE ENGINEER: LISA LYONS, RS / 32.5' MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM SAM WHITE, RS 32.5 WITNESS: * RUN PIPE LEVEL 2" DOUBLE WASHED PEASONE> DATE: 9/24/03 31 f FOR FIRST 2 \ 3' MAX. PERC. RATE _ < 2 MIN/INCH PROPOSED 1500 T Rip 29 61• GALLON SEPTIC 29.36' 29.5 CLASS I SOILS P# 10576 w-Sr TANK (H- 10 ) GAS oa4o 2$,84' 90� m m 0 O a a F c� ,; : BAFFLE29.01' 0 28.67 Elpm0 o aam13 ( M2 SLOPE) �6" CRUSHED STONE OR MECHANICAL go 0 M � M m C� PP Q ELEV., LOCUS D COMPACTION. (15.221 (2]) $o$$ 2 0 0 r 0 CJ CD o 26.67' _ 32.7 DEPTH OF FLOW = 4' ( 1 % SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE FILL TEE SIZES: INLET DEPTH = 10" 17" OUTLET DEPTH 14" B LOCATION MAP NTS FOUNDATION 14' SEPTIC TANK 35' D' BOX 14' LEACHING LS ASSESSORS MAP 116 PARCEL 52 FACILITY 4.67' 21 f 40" 10YR 6/6 29 3' ZONING DISTRICT: RC *THE INSTALLER SHALL VERIFY THE YARD SETBACKS: LOCATIONS OF ALL UTILITIES AND ALL FRONT = 20' BUILDING SEWER OUTLETS .AND ELEVATIONS SIDE = 10' PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM C REAR = 10' NOTE: PLUMBING TO BE RE-ROUTED TO EXIT AT 22 0' LMS MINIMUM ELEVATION SHOWN (CONTACT ENGINEER FLOOD ZONE: C IF NOT FEASIBLE) NOTE: GROUNDWATER EXPECTED AT EL. 5'f (PER TOWN GROUNDWATER ELEV. MAP) 2.5Y 6/6 I 128" 22.0' PROP. VENT WITH CHARCOAL FILTER AND BUGSCREEN (FINAL PLACEMENT BY CONTRACTOR WITH HOMEOWNER NO GROUNDWATER ENCOUNTERED EXIST. CONSULTATION) NOTES: GARAGE (To-BE REMOVED) w SEPTIC• CAE`,lGhl: (?,APCA1:Z D!SPCSE^ 1S KO T AI I OW'Fr; 1. DATUM I�i APPROXIMATE IdGVD (SPOT EL. GIS MAP) DESIGN FLOW: `3 BEDROOMS ( 110 GPO) = 330 GPD EXISTING 30.4 � 2. MUNICIPAL WATER IS ?4 USE A 330° GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. A( j 1 SEPTIC TANK: 330 GPD ( 2 ) = 660 4. DESIGN LOADING FOR SEPTIC TANK TO BE AASHO H- 10 o BO� X HAM T - 7 G VEL t 30.3'"n USE A 15111Z GALLON SEPTIC TANK D & CHAMBERS 0 BE H 20 18" MAP DRI LEACHING. 5. PIPE JOINTS TO BE MADE WATERTIGHT. ,�j cp ��,®, � , 32. \ 2(25 4. 12.83) 2 (.74) = 11 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 1 1 0 2 1 y SIDES: -2-- ENVIRONMENTAL CODE TITLE V. HED 35 25 x 12.83 (.74) 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT + ,36.7 BOTTOt`1. 237 TO BE USED FOR ANY OTHER PURPOSE. 3 5 �0', GARAGE MPROP. 32.0 �, �, TOTAL: 472 S.F: 349 GPD 8. PIPE FOR kPTIC SYSTEM TO SCH. 40-4" PVC. + USE 2) H-20 500 GAL. LEACHING CHAMBERS (ACME OR 4? rH 312 �, --( 9. COMPONENI"S NOT TO BE BACKFILLED OR CONCEALED WITHOUT C.O. 36 Cps " APLE EQUAL WITH 4' STONE ALL AROUND INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 37.4 132.9 FROM BOARD OF HEALTH. LOT REA So 10. PUMP & REMOVE EXISTING SEPTIC SYSTEM 1 Q4. .p 7,432f SQ 31 4.9 °3 LEGEND EXIST. DWELL. n 1 BLOCK TF = 35.2' y ) + 31.7 29.9 - PATIO 35.0 100.0 PROPOSED SPOT ELEVATION TITLE 5 SITE PLAN .0 PROP, o, 30.1 OF 34.6 NEC.AS 40" MAPLE 100x0 EXISTING SPOT ELEVATION 2� FIRST AV E N U E CONC. BLOCK RET. WALL PROP. 500 GAL. 100 PROPOSED CONTOUR IN THE TOWN OF: 9 1 ' .6 SEPTIC TANK 100 EXISTING CONTOUR (OSTERVILLE) BARNSTABLE 104,a0 PLUMBING MUST BE-RE-ROUTED BENCH MARK - TOP OF - TO EXIT SHOWN. INSTALLER TO VERIFYSFEASIBILITY PRIOR TO CONC. BOUND. EL. = 31.0 C.O. PROP CLEAN OUT PREPARED FOP: M/M FREDERICK TECENO INSTALLATION OF ANY PORTION CP CESSPOOL OF SEPTIC SYSTEM 20 0 20 40 60 BOARD OF HEALTH NOTE: SEWERLINE TO BE SLEEVED FOR 10' EITHER SIDE APPROVED DATE MA SCALE: 1" = 20' DATE: DECEMBER 31 , 2003 OF CROSSING WITH WATERLINE Off 508-362-4541 fax $08 362-9880 o� ntins oyd down cape engineering, inc, mac_ ,�o ARNE H� � %903"0 b OJALA 9K9L'0N ° CIVIL ENGINEERS IVIL br LAND SURVEYORS .$ • 30792 a 112-S 0`1 3--249 _ _q1q mnih <zt. vnrmouth. mo. _02675 FPS E G\ TF - _ - __ - -- P.L.S. n�