HomeMy WebLinkAbout0027 FORTES WAY - Health '27 Fortes Way
Osterville
A = 142 062004
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: Commonwealth of Massachusetts -
• ns ection Form
Tale• Official p
5 Assessments
Subsurface Sewage Disposal System Form-Not for Voluntary Assessm
27 Fortes Wa , Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name MA 02655 _ 10/14/20-08
information is Ostervill State Zip Code Date of Inspection
required for cityrrown
every page.
mitted on this form.inspection forms may not be altered to any
Inspection results must be sub
way.
Important: A. General Information
When filling out
forms on the
computer,use 1, Inspector:
only the tab key
to move your Reid C. Ellis
cursor-do not Name of Inspector
use the return Ellis Brothers Const. Co.
key.
-- company Name
I I 23 Enter rise Road, P.O.Box 59,
Company Address MA 02675
Yarmouth Port State zip code
Cityrrown S121891
508-362-6237 t icense Number
Telephone Number
B. Certification 6`3
all inspected the sewage disposal system at this aeSecto hehnspection
I certify that I have personally P
information reported below is true, accurate and complete as operiencein the, f thefunction ction arWInaintenQ?ce of;_on site
was performed based on my training and exiroved system inspector pursueo Section 15 of
sewage disposal systems. I am a DEP app ;
Title;r CMR 16.000).The system:
Fails cz
Passes ❑ Conditionally Passes ❑ _
❑ Needs Further Evaluation by the Local Approving Authority
O
Date
Inspector's Signature Board
The system inspector shall submit a copy
of this inspection report to the Approving Authority
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
ro riate 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.
_•*• only describes conditions at the time of inspection and under
ten the mature under
of Us'
This report y
at that time.This inspection does not address how the system perform
the same or different conditions of use.
161A
Title 5 Offidsl Inspection Form:Subsurface Sewage Di sal System•Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'f 27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carob A.-Smith
Owner Owners Name
information is
required for Ostervill MA 02655
every page. Ciry/Town 10/14/20Q8
State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D
A) System Passes: '
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as des ribed 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 yea s 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 existin 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 ess than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break ut or high static water level in the`distribution box due
to broken or obstructed pipe(s)or due to la 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
ELLBROS INSPECTION 08.doc 27 fortes way.doc•03108 True 5 Official inspection Form:Subsurface Sewage Dis
posal sposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yy. 27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A Smith
Owner Owner's Name
information is
required for Ostervill MA 02655
10/14/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cunt.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 ti es a year.due to broken or obstructed pipe(s). The
system will pass inspection if(with approval the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Bojard Health:
❑ Conditions exist which require further evaluy the Board of Health in order to determine if
the system is failing to protect public health, or,the environment.
1. System will pass unless Board of Heatermines in accordance with 310 CMR
15.303(1)(b)that the system is not functiin a manner which will protect public health,
safety and the environment:'
❑ Cesspool or privy is within 50 feet of a s irface water
❑ Cesspool or privy is within 50 feet of a b rdering vegetated wetland or a salt marsh
2. System will fail unless the Board of Healt (and Public water Supplier, if any)
determines that the system is functioning in manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil sorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary t a surface water supply.
❑ The system has a septic tank and SAS nd 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.
ELLBROS INSPECTION 08.doc 27 fortes way.doc•03108 Title 5 Official.Inspection Form:Subsurface Sewage Disposal po System•Page 3 of 15
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is Ostervill
required for MA 02655 10/14/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
C) Further Evaluation is Required by the Boar of Health (cont.):
❑ The system has a septic tank and SAS an( the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of mmonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into.facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 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.
ELLBROS INSPECTION 08.doc27 fortes way.doo-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 2 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 5.303, therefore the system fails. The
system owner should contact the Bo d of Health to determine what will be
necessary to correct the failure�the
i
E) Large Systems: To be considered a large systeystem 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 c f a surface drinking water supply
❑ ❑ the system is within 200 feet c f 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 sys m has failed. The owner or operator of any large
system considered a significant threat
Y g t t eat under Sectiop E or failed under Section
D shalt upgrade the
system in accordance with 310 CMR 15.304. The s stem owner should contact the appropriate
regional office of the Department.
ELLBROS INSPECTION 08.doc 27 fortes way.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments sessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. Cdylrown 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?
2/ ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
I_J1 ❑ 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:
21/ ❑ 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)]
ELLBROS INSPECTION 08.doc 27 fortes way.doc•03J08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535 �-
Property Address
Sidny Smith Realty Trust-Carol A Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. Cltylrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): � Number of bedrooms(actual):
1_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 'S
Number of current residents: 0Ale,
Does residence have a garbage grinder? ❑ Yes 2 No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes LEI No
Laundry system inspected? El Yes B' No
Seasonal use?
/'5 7 El Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump?
❑ Yes PE�'N o
Last date of occupancy:
,r Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.)
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to.the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe):
ELLBROS INSPECTION 08.doc 27 fortes way.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information(cont.)
General Information
Pumping Records:
Source of information:.
l�r-t✓ecfP�•� /�tl
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:
LN 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):
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes W/No
ELLBROS INSPECTION 08.doc 27 tortes way.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 or 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron V40 PVC ❑other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:'
feet
;;�eri
I of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain)
If tank is metal, list age:
years
X/ Is age confirmed by a Certificate of Compliance?(attach a copy of certific ate) ❑ Yes ❑ No
----------------------------------------------------------------------------------------------
f , �
Dimensions: ' ,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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?
ELLBROS INSPECTION 08.doc 27 fortes way.doc-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
lug
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
S_idny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.) A-55ZA7
Comments(on pumping recommendations, inlet andleztitlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑f berglass' ❑ polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee r baffle
Distance from bottom of scum to bottom of oui et tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, in at and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidenc B of leakage, etc.):
Tight or Holding Tank(tank must be pumped at ti a of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiber ilass ❑ polyethylene ❑ other(explain):
ELLBROS INSPECTION 08.doc 27 fortes way.doc-03108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 27 Fortes Way, Ostervill, MA P.O.Box'535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is Ostervill
required for MA 02655 10/14/2008
every page. City/Town State Zip Code Date of Inspection
D. System
y m Information (cont.)
Tight or Holding Tank(cunt.)
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 switch s, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes /No
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
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.):
r� J
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
ELLBROS INSPECTION 08.doc 27 fortes way.doc•63= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is required for Ostervill MA 02655 10/14/2008
every page. Citylrown State Zip Code Date of Inspection
ei
D. System Information (cons.)
Comments(note condition of pump chamber, ndition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
❑ leaching pits number:
[� leaching chambers number:
❑ leaching galleries number:
. I
❑ 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.):
i
ELLBROS INSPECTION 08.doc 27 fortes way.doc-03/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 12 of 15
1
a Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is OsteNill
required for MA 02655 10/14/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
Cesspools (cesspool must be pumped as part o 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
Comments(note condition of soil, signs of hydrau is 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 hydraul c failure, level of ponding, condition of vegetation,
etc.):
ELLBROS INSPECTION 08.doc 27 fortes way.doc•MOB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 or 15
A/
Commonwealth of Massachusetts
• Title 5 lOfficial Inspection Form '
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Fortes Way,1Ostervill, MA P.O.Box 535
Property Address !
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is required for Ostervill MA 02655 10/14/2008
every page. City/Town State Zip Code. Date of Inspection
D. System Information (cunt.),,
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.
rA
0
VIP
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` y 14 • �7 b
All
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T .
ELLBROS INSPECTION OB.doo 27 fates wW.Cloj•03M Title 5 Of W Mspedion Fern[Subswface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
OEM
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•' 27 Fortes Way, Ostervill, MA P.O.Box 535
Property Address
Sidny Smith Realty Trust-Carol A. Smith
Owner Owner's Name
information is
required for Ostervill MA 02655 10/14/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope -�P-�—
❑ Surface water it/o�✓e.
❑ Check cellarli�
❑ Shallow wells 1-114
�t
Estimated depth to high ground water: • "?— �
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ 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 eleva ion:
il( .14 f
ELLBROS INSPECTION 08.doc 27 fortes .doc
�' 03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Zo f �pS''TOWN OF BARNSTABLE
LOCATION G'ye SEWAGE# �-
VILLAGE C S;�fT VVII ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. j
SEPTIC TANK CAPACITY Ce,'h
LEACHING FACILITY:(type) (size)
%NO.OF BEDROOMS,
OWNER
PERMIT DATE: -. COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetlarid and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
� N
r/ V4 ojr�op
�Y' P
tole'!
7 I
_ I _ Li
¢teaosoar�cnoxaaeeam�.w.�•awe msammewwmw�mm.r.°.a»�wo�msymm•ry°,°m�'j�. / ,� / /� /
TOWN OF BARNSTABLE r
L CAITUN 7 irT A;' SEWAGE #
VI:I,AGE I% Sl ��-' LZZ ASSESSOR'S MAP & LOT ) 'l1-OG)---OLy
INSTALLER'S NAME&PHONE NO.J �'7�•'G
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) i " 5aO I s,64 4—t (size) Xl 3
-NO.OF BEDROOMS
BUILDER OR OWNER 17E'n- n
PERMTTDATE: �_J 7"0-3 COMPLIANCE DATE: — 3'
Separation Distance Between the:
'Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I
y3
T ,
No. J� l Fee P
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprtcation for Mioaal *r5tem Construction Permit j
Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. VV A Owner's Name,Address and Tel.No.
-4 CVti�� os �° �c�anGi
Ft 40-5 12d Dsk-ftw Assessor's Map/Parcel 1 � 06 , GUY �
Installer's Name,Address,and Tel.No. ! �_ 3�.U Designer's Name,Address and Tel.No.
x�v��✓�r�� -1
��0. 6.x IaYS ,es�' / (1�G(��` 1
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures ff
Design Flow qLto gallons per day. Calculated daily flow l={T gallons.
Plan Date ao- O 3 Number of sheets ] Revision Date
Title
Size of Septic Tank /d4CJ,&( Type of S.A.S. r1YJ el f 0
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the En ' n ntal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu y th' r d of a . C_
Signed Date 3
Application Approved by Date l- 2'1-0 3
Application Disapproved for the foll(4;,ihg reasons
Permit No. '201) 3 -0 N y Date Issued t 2 7 0 3
No. Jr C)"1 I Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V�
PUBLIC HEALTH.DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS '
Yes
ZippYication for Mie;pool 6p!6tem Construction Permit
Application for a Permit to Construct( . )Repair( )-Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. V�1 f1 Owner's Name,Address and Tel.No. /
Fw14s Y f ctr, fi4(j6fiC, I d
Assessor's Map/Parcel ' U/ UG 009
���P ti C� 9 .5 /'� d 0314 c i l t
t
Installer''s Name,Address,and Tel.No. G Designer's Name,A
l f�G ddress and Tel.No.
�v y� Ora.,
� o• C�,x 1a�S Sk��(c lily D161fV 5qQ 6-It
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 f{4 0 gallons per day. Calculated daily flow T� gallons.'
Plan Date G 3 Number of sheets Revision Date
Title
Size of Septic Tank /,JOU 7 G ( Type of S.A.S. Sl J�f1
Description of Soil
--Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: i
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Titlee 5 of the Environ�Intal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued-by thi oard of ealt . _. -
Signed f Date
Application Approved by _ Date 12 (- 2?-0 3
Application Disapproved for the following reasons
y' Permit No. Z00 3 U t Date Issued to 7 C 3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(- )Repaired( )Upgraded( )
Abandoned( )by ?Mb•-G lz
at C.,le s Q2 has been construc ed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2-co -, O g Y dated / 2 7 v 3
Installer 2MX_0CC e_�ct_t:-en Designer '_\�,)lcL
The issuance of this permit shall not be construed as a guarantee that the system will functio a's de'sig d.
Date 11 71 o-� Inspector ` S
i
-oyy
-- Uo o--
No. 2 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
ligozal *pgtem Construction permit
Permission is hereby ranted to Construct( )Repair(i, Upgrade( )Abandon( )
System located at 6R 4q✓�eS (�A
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:Co strucf n must be completed within three years of the date of this pe it
Date:_ / Z 7 0 Approved by
i
TOWN OF BARNSTABLE
LOCATION ? 1-og -Oro SEWAGE #
VILLAGE f/ S/ �'�- �C ASSESSOR'S MAP & LOT j `' -D� -00 f
INSTALLER'S 1�;AME&PHONE NO.I /2 rd t.G.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) i -504'4A64, k—tct-> (size)
NO.OF BEDROOMS
! BUILDER OR OWNER
PERMTTDATE: `-,�7 COMPLIANCE DATE: t9 3'
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)• Feet
Furnished by
� � I
13- 1 !
�sy 3 6
,0-,� Y3
L- O C AT ION a27 SEWAGE PERMIT NO.
VILLAGE 01,
INSTALLER'S NAME & ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED ✓ply 8a
DATE COMPLIANCE ISSUED /ohs/82
�i.� ..it
3_5.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f
../-�/-- ------ ------OF.....�•1?�i�. - Z.....-----
Applira#iou for Uh4pnii al Workii Cnomitrurtion ranfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
C...... _ G -��� f� . . :...................... -•--•-----------........................_.
Location-Adcrress r •
. y /
........... cl 1.7lws�U�� = 1`.......�rC?r %d l.'�'G`�:/r ................
Owner Address
/ Installer Address
Type of Building Size Lot.......................;::::Sq.'feet
U Dwelling—No. of Bedrooms_._.........�-------------•-__-----Expansion Attic ( ) Garbage Grinder ( )
Other-T e of Building No. of persons........_:��------------ Showers — Cafeteria
dOther fixtures ----------------------------------•----- --------•----•---•-••-•-----------••---------•------------------------------------••-.------
Wx Design Flow............................................gallons per person per day. Total dai.l_....fl Towot...........al 3� .-_ ............ lons.
W� Septic Tank—Liquid ca acityldaf-)._ allons Length.-6 Width_ Diameter----�-----__. ptli_: ..........
leaching area,_�._6_.G__.s . ft.,Disposal Trench—No......../......... Width....... ........ Total Length.......
Seepage Pit No--------------------- Diameter................_... Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
------- Date
Percolation Test Results Performed by..../,�_lt-�d..`.1��� ----.-�
aTest Pit No. ly sue,.__._minutes per inch Depth of Test Pit----- ........ Depth to ground water-____/V
Test Pit No. 2........ .......minutes per inch Depth of Test Pit.................... Depth to ground watier........................
Pd ..........................................................--•-...............--•---._.............-.........................................................
0 Description of Soil.......... "�--------. t_✓.�... -------------------
r
U ---••-•---------•-•------------------------------•--•--•---------•-•-•--------------------------------------------------------------•--------__---------•---------------------------•-------------------
W -------------------------•------------•-------•--•----•--------------•-•---=•--------•.....-•----•-----••••-----••------•--•---•---------•-------------•---•----•-------------•-•-••-••---...----.-_....
UNature of Repairs or Alterations—Answer when applicable................................:.....................`.....__..........._..._._........._...__.
Agreement: I
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of THTL1E . 5 of the State Sanitary Code-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss by the b d of liealth.
Signed-•-..: . .-- "......-•-•--.... ..... 1"1`""'`"'7
Date.
Application Approved By.____- r4-----__ -----------------••------•-•----•-- ----�.1 ........
` Date
Application Disapproved for the following reasons----------------•------------=---------------•---------------------------------. -----------------•---------
.................................•-•--------------•--------...........----•------.....................--•--•-••----------------------------•----•-•------------•------•---. ---------------------------
Date
PermitNo.................................................=------- Issued.......................................................
Date
Ni6za.z.54...... Fxs ...7....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ........OF............. ......:......
Appliration for Dhipaii tl 01irks Tonstrurtiutt jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�
Location-Address or t No.
�..422...----------------------•----------------- 7�...A.2 ��4...............:............................
Owner Address
W --•• ` / -------f_._ -
---•.....................�...........---
Installer Address
dType of Building Size Lot___ .C�f. `�.....Sq. feet
V Dwelling—No. of Bedrooms.............. .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons..._\-Y................. Showers Cafeteria ( )
a' Other fixtures -------------------------------• .
W Design Flow............................................gallons per person per day. Total dail flow.................7.7�........_.._._..gallons.
(� Septic Tank—Liquid capacity./l �rgallons Length....
-E...... Width......
.....
Diameter................ Depth................
W Disposal Trench—No..................... Width_•...__._....__.._.. Total Length_......._._._ Total leaching area....................sq. ft.
x
Seepage Pit No........../......... Diameter........ ...... Depth below inlet.......... Total leaching area__,'71.6_..C.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Resultss J 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 Test Pit.................... Depth to ground water,....................
z
-------------------•-------.....................................................................
ODescription of Soil - Gy l �t t�-s /.........=.......................................................-............................ '
W •--•••-----•----------------------------•-----------•----------------------------------------•--------•-------••--•----------...-------•----••--••------------------------------..........------------•-
VNature of Repairs or.Alterations—Answer when applicable..................:.................................•__.__.._................................_..
-•----•----•••--•-----•--------------------•-•--•------••-••-----•------...._....._....-•-----------•••------•---•-•---•--.....----•-•-----•-----------------. ....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI.% 5 of the State Sanitary Code—The undersigned furtlaer agrees not to place the system in
operation until a Certificate of Compliance has been is by theb h th.
-------.Signed
�z
D t
Application Approved B �'5 1 l -----------------
Date
-Application Disapproved for the following reasons:----•••---------------••--------•••-•--•-------•-----••-------•••--•--•-•••--•-•••--••-•••-••••-•........._..._
..-------•----------------..............................................................................I--••••--••---••-•-••-•••-•---•--•------•-••--•-•---•-•-•-•--•-•-•-----•----•-•---••....._--•---
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtif iratr of Toutpliattrr
THIS TO CERTIFY, That the I'' ividual�ewage Disposal System constructed ( ) or Repaired ( )
by !
........... _ Installer
at. rj ... / /.. ----------------------•-- -----•---------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. 2._7.5Zr.................. dated-----------.....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A UARANTEE THAT THE
SYSTEM WILL/U CTION SATISFACTORY.
DATE.....-1® Y�Z/....-----•...................•-••-----..--.. Inspector......... ..... •-----......------...._..__........-----•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...O F.....................................................................................
N .-...�.1�:..._. FEE.-.��.�.�..............
�i���a��tl �r � tt,�trttrti.mrtt �er�tit
/� - �,Permission is hereby granted ��� .�_a. -Yl. :f...� ..
to Construct ( ) or Repair ( ) an Individual Se�rag Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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LEGEN
EXISTING SPOT ELEVATION . O,cQi �NQF , CERTIFIED PLOT PLAN
EXISTING- C0NTOU13
FINISHED SPOT ELEVATION r s! ,
FINISHED CONTOUR -- r. 0-- r kk
q RSA, ti N
APPROVED BOARD OF rtHEALTN '� N&1Q951#���`
DAT E AGENT; y ° ; 'a ` .SOLE ° DATE
DREDGE ENGINEERING CGt'1Al
p
-IE'.�1T - -- • I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED ,Ip� ; 8 Z 9 6UILDING SHOWN ON THIS PLAN
CIVIL LAND it CONFORMS TO THE ONING LAWS
E.NGIHEER UR OF BARNS TA E a9S.
712 MAIN STRE-& 2'
HYANNIS, MASS
OF ? bA E 0. LAND SURVEYOt�
No Y,- E/TN THE SEPTIC 7A4r,4< OR
�E14CN/NG P/T ARE, MORE TNA':A/ /211 BELO.&V
/O fT M/N JRA OE, A 24 O1A M E TER' O'OiyCR E TE CO liER
_ SJ/ALL eE BROUGN7' TO GRA Z>A=, N E�YTRA
CONCRCTE 4 PYC P/Pf �yEAYy G'�1 ST /RON ;CoV�R Sf�AtL QE USED
M/N. P/TGH /F/N 17R/VElt•'A y
coYEI9s /B oF,Q s=T
A :_a a- G ADE Cc' VER CL EA/V .5'A/V.O .
&ACle. ILL
' L/p[//D LEVEL
1'
4.. 4-CAST 2*LAYER
IRON PIPE p o
SEPTIC TA/YK D I sT, • 6 1 • ' • • • • e • • WASHED STn%YE
®D)e Y I n 1 • � D • D, D O ! •C • ..
I e EffECTf'VC • i
.. • • • • D�`PTH °' • • ' ' o • WAS/iED STaNE
At O • • • • • • •• � 0• o •
'' z � -_� • a. . • • • • � • • •. . •p •••, PRECA3 T SEEPAGE
7x . . /O v •. r • .• i . �.• • • o P/T DR eQU/V.
lNVBRT CLEYA�"/oNS nir �PA c/ EL=
INVERT AT OU/LD/N6 t OQ o FT 4
_ ET
lNtET .SEPT/�C .T*4NK .,- 99�8 .FT . - -
r �o FT ai,a/►� C(sE AauL.AT�ov�
OtJTLET SEPTIC TAN/t' ;
/NLET`DJSTR/8!/T/O.N'BOXF7 .:£ '"SECT/CN OF z 2 GROUNDi! �'ATER'�TAe6LE 1
/NLET LEACHING o/T '31:6 FT. SEWAGE PISAPOSAI. SV.STEA9 •TAeULAT/D/V
LEA�Hl./VG-PIT �
CA .E �s~ s'. /=D� D/MlNS/ON
S L. A
DES/G/V CRITER/.4 - a/•�r.�Ns♦o/v 8�--F'�'•`
NUMQER Of BEDROOMS 3 f �
wslam Al
GARQAGED/SPO.SAL(/NIT MONIT .SOIL . LOG
TOTAL E.?T/M►ATED FLO#V 3 3 o G.�c.%DAy SOIL TEST S SOIL 7 ST p
e0/L TEST
Z O Z.
. NUMBER QF 4rACNIN4 P/TS_L_ �"E[Ei�! �DO.`T �ELPY, OATI; OF S0/L TEST ,
SJDE LEACHING PER P/T ` Sot FT. O _Z z RESU.':;TS. WilrNESsED dY ll.R� �s���
: 0TTo/w LE�ICN/NG PER P/T 7�S4. FT PERCO.:'AT/OAV RATE#/ G s-5 M//V°//NCN
70TAL LEACH/NG AREA Z.to to SQ FT. i GD A- PEA-coo:.A'rva/i/RATE 2.
RESER1iE GEACNlN6 ARE/ �' SQ. FT. L
�SN.OF At, Pti N AU pi�O r v/v1 ��0 7 a` �v IZ 7 5 VIA y
4kLBR
4 y o No-10951 O Q� ELOREDGE ENGINEERING CO,/NC.
4
�e/gTE��Q' 90 �G/5TE� ��'`' LLG V. •9 WZ MA/N ST- , AeYANNis. "Ass,
O ,c
SU S FSS�ONA%- ® NO GROUND I�YAM ENCOU/VTERED CL/E"T:N/c,rvGR5 DATE
� I (� GROU/VO WATER AT BLED
J�l . - g•2.
OWN � - �t 1
'Vest Barnstable P ih =rs, Inc. _ �3 ���`" r SHEET NO _,.
K Q k W U-I/ CALCULATED BY DATE
1170 RT. 6A West Barnstable, MA 02668-1124 J
^f �, 2 3
p - G CHECKED BY DATE
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ASSESSORS MAP: TEST HOLE LOGS
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q, PARCEL: OGZ
R' SOIL EVALUATOR: 'i ,
FLOOD ZONE:_� ��G/G'`9�3L-�.
�� hI� Lt lG NOTES:
v REFERENCE: -�
WITNESS :__. t-�. �? d ! 1 DATE: �i�l V _
PERCOLATION RAT Z 1v1 I
1) The installation shall comply with Title V and Town of Barnstable Board of
TH- I TH-2 Health Regulations.
oi= DAM 2) The installer shall verify the location of utilities, sewer inverts and septic
components prior to installation.
--- x +is 3) All septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.
v °�o � 6 /D 4) Existing leach pit(s)to be pumped and backfilled per Title V abandonment
► jprocedures.
LOCATION MAP(dTA) \, 4,\�2/ 1�2 t 5) This plan is not to be utilized for property line determination nor any other
purpose other than the proposed system installation.
\\ �� 6) All septic components must meet Title V specifications.
) Parking shall not be constructed over H10 septic components.
8) The property is bounded by property corners and property lines as depicted.
�3 2, 9) The property owner shall review design considerations to approve of total number
` M '' of bedrooms to be considered for design.
011
/ .Y .........- _�._....-. ..._.. .. .... .. ...........- _ - _ ...- ..._...-- -......_ --..... .
SEPTIC SYSTEM DESIGN
FLOW ESTIMATE
fl BEDROOMS AT GAL/DAY/BE ROOM -,�D GAL/DAY
ti
lid SEPTIC -TANK .10e
'� GAL/DAY x 2 DAYS - GAL
USE /MOGALLON SEPTIC TANK
S01L A6SORPT ON SYSTEM
0
l� a^i tl
S 1 DE AREA: Zu 3Z IBS' X Z X C7,—1 I
; .
BOTTOM AREA: 2 1 X b �1 7,
I ?�aa SEPTIC - SYSTEM SECTION J, , ,
C� 619 0 F l
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