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HomeMy WebLinkAbout0404 OLD MILL ROAD - Health 404 OLD MILL Rlk,OSTERVILLE A = 143 021 003 „i,gym UPC 12134Ng,a-jjjL2N ' X48TIN01,MN -' I P � O ,� ��� �� � � i VS COMMONWEALTH OF KkSSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR.OTECTT RECEIVED JUN 14 2004 TOWN OF BARNSTABLE TITLES HEALTH DEPT, OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: D 'Alm MAR Owner's Name: PAR ca Owner's Address: LOT Date of Inspection: Name of Inspe (please rint) Company Nam — C Mailing Address: ' oe* Telephone Number: 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. I am a DE P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: --i/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ils Inspector's Signature: V Date: 4 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 11 1' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _, CERTIFICATION (continued) Property Address: 0 A Owner: Date ofInspection: Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. ystem 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: & 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 7' Page 3 of 1*1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (�� Owner: Date of Inspection: 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 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 ppm,provided that no other failure criteria are triggered. A,copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40V9 qcs h44, Owner: Date of nspection: S/ 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 'Xi 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. 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 Iarge 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 Page 5 of 1 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST Property Address: Q Owner: _ Date of nspection: 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 _LZWere.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) L_ 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 V _ 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 on SAS stem Absorption System Y ( ) the site has been determined based on: Yes no t/ _ Existing information. For example, a plan.at the Board of Health. _ Determined in the field(if any of the failure criteria relat4to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J 5 e Page 6 of I 1 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PANT C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):I Number of bedrooms(actual): y DESIGN flow based on 310.CM15.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):—4)() Is laundry on a separate sewage system (yes or.no):,dVif yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): .. Water meter readings, if ava Table(last 2 years usage (gpd)): Sump pump(yes or no): y Last date of occupancy: A&7,(/, ` COMMERCIALANDUSTRIAL� 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: A10 Wass stem. um ed as art of the ins ection e or no)- If Y P P P P (Y ) If yes, volume pumped: gallons--How was quan ity pumped determiried? Reason for pumping: TYPE F SYSTEM -?Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Priry, _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 copyof the DEP.approval _Other(describe): proximate age of all co .pone ts, dat insta (if known) source of information.- 0 Were sewage odors detected when arriving at the site(yes or no): 6 r 5 Page 7 of i I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: VOW Owner. v Date o Inspection: 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) I� 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) . Dimensions:/0 S k(o' k Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Z Scum.thickness: It y Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bo of outlet tqe or baffle:_ How were dimensions determined: Comments(on pumping recom_me dation , inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert evidence of leakage, etc.) GREASE TRAP;/ ocate 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: Owner: Date of iispection: TIGHT or HOLDING 7FAN✓(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): y Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): 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 e-iaakage into r ou of b x, c.): . r, / PUMP CHAMBER/" ,locate 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 f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ©v Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type I ching pits, number:_ leaching chambers, number: leaching galleries,number: leaching trenches;number, length: leaching fields,number, dimensions: overflow cesspool;number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation. etc A: cl kV (119 4z?-Z _&o CESSPOOLSiz4t4cesspool,must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: k Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIV1'� (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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Y 0,6V �0&- Owner*inspection: Date o 17 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. (.0q •3xa �i��Gn CrnYA � e oyLo2x-�.. �l rzF O to I SW q 00r) 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 0 -� �� Owner. Date o nspeetlon: SL 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: hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevatio n. S , • 11 s � _ fa Permit Number: Date. Completed by: - ,��� Ids t vim•:,t.,;ks,u ,m,,�...,• HIGH GROUND LE\�ELCOMPUTATION =ri% m cry Site Location: �� /'�'!` �(�� Lot No. ��Owner: � � Address: µor; z;'Contractor: (� dress g f ' w . .Notes: -/�,�-j/'�S �Y✓9�5 /y���.s x STEP 1 Measure depth to water-table ,. to nearest 1/10 ft. Date �D ................................ w : dmon2�d�ay/year STEP 2 Using Water-Level Range Zone :.. and Index.Well Map locate 3n site and determine: ri Appropate index well........:...................... B Water-level range zone ............................... ........... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level ror index: well ........................... . 7.� month/year, STEP q Using Table of Water-level Adjustments 'For index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level ?one (STEP 2B) determine water-level adjustment ................ ........................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) l from measured depth to water _ level at site (STEP 1) ......................................... �5 oz a ................................... Figure 13.--Reproducible computation farm. 15 t 1 , I 404 Old Mill Road Osterville, MA Second Floor BcM Stairs Bedroom BedStudy Bath room Hall Closet Closet Closet TOWN OF OF BARNSTABLE � D/0 LOCATIONW IVII � - SEWAGE # ! r' VILLAGE ®S� GyUCG"`� ASSESSOR'S MAP & LOT *` —0G�'J INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC C� � LEACHING FACILITY: fi��` L��1 size L3 3 (type) ) i NO.OF BEDROOMS BUILDER OR OWNE lot CO t t -PERMITD,ATE: -' COMPLIANCE DATE:: ®D , Separation Distance Between the: Maximum Adjusted Groundwater Tabie and Bottom of Leaching Facility t_Ta " Feet?. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 206 feet of leaching facility)' j' """ ._ - Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe chinf fa ' ) ,m i Feet Furnished by 1 f c , 1 57 3 A. O� - No. Feed I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Q�` PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLEi MASSACHUSETTS Yes �i01pplication for Miqogal gtem Congtruction Permit Applicationp for a Permit to Construct( air Upgrade XRe ( )U rade( )Abandon( ) ElComplete System El individual Components Location Address or Lot No. Lk[l OLIC> M71.Cr f'ZL" OS 3" O ner's Name,Addre s and Tel.No. w5e tz. Lj GusfG. hz0 Assessor's Map/Parcel ,1/3 P(a I 03 r P O .2, Installer's Name,Address,and Tel.No. esigneri's Name,Address and Tel.No. GG� �•:�� S Ai � P I ItrN + aS.5G CG ``P a s 1' I IV'►I' 1 6 w S F c_l Type of Budding:Ty Dwelling No.of Bedrooms 4 Lot Size 'I % sq.ft. Other Type of Building S F I-! No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 90 O gallons per day. Calculated daily flow`i57. - gallons. Plan Date G' -IS-9 5 Number of sheets / Revision Date Title Sewase, C,_+ 4Q01 Gr-V% e. �.s'f'G...., 2 O Size of Septic Tank i -o 0 Type of S.A.S. Description of Soil .4 e. c. a--++ e.. c, 1, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place t1jg syste operation until a Certifi- cate of Compliance has been is ue,jl his Board 4ealth. Signed r Date Application Approved by . Date Application Disapproved for theUfollofAng reasons Permit No. �`✓— �J c// A Date Issued No. ar i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes a PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 2 application for ;Dizpozal *pgtem Construction Permit Application for a Permit to Construct Re air ,'pp (� p ( )Upgrade( )Abandon( ) El System ❑Individual Components` i Location Address or Lot No. Lk(f M j L L/ZD QS7" Owner's Name;Address and Tel.No. E4.Se,v% e. 10; Gustav Zo �1 Assessor's Map/Parcel r P U C.27 0;Zj 0,03 (it. C- e-1 +e.v C� C_ Cj P- Installer's Name,Address,and(t Tel.No. )Atl1i/� 0 Designer's Name,Address and Tel.No. -� r L.. AG G CX �C_ . I e. 1' e,�� 'r '•f,.J e:l..+w G w+" a Cam, 14 Type of Building: Dwelling No.of Bedrooms 4 Lot Size 4is 7sq.ft. -G_ b ear mkrt--t Other Type of Building S (= W- No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 `I® gallons per day. Calculated daily flow455• gallons. Plan Date -t .5 `f Number of sheets f Revision Date Title Sewc.ae. 0;sre,& I Lc- s+G... t O Size of Septic Tank I SO 0 Type of S.A.S. Description of Soil S e, e. a �•I' L �, e. cl Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place t syste operation until a Certifi- cate of Compliance has been i ue his Board ealth. Signed Date 0 / 1 R /9 9 Application Approved by Date Application Disapproved for th follo mg reasons y i Permit No. 7)2/ A Date Issued THE COMMONWEALTH OF MASSACHUSETTS l BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage D's osal Syste_m,Constru ted "X Re aired( )Upgraded( ) Abandoned( )by cx l at Ct5 ® has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 'dated Installer Designer 4 Al The issuance of t 's pgfmit sha not be construed as a guarantee that the yst-m will function as de 'gned� Date Inspector Z A € - r i No. �� Fee 0 d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION ->:BARNSTASLES MASSACHUSETTS MAPogar *p5tem Construction Permit Permission is hereby granted to Construct('u)Repair( ) pgrade( Abandon( ) System located at_� 4 Si & , f l d 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 mustbe completed within three years of the date of thi permit. Date: ,Z Approved by •TOVVN OF BARNSTABLE Q j LOCATION:OZ �V SEWAGE # VILLAGE_057V UGGl�l ' ASSESSOR'S . MAP& LOT � �� � I INSTALLER'S NAME&PHONE NO. �i7 I SEPTIC TANK CAPA LEACHING FACILITY: pe) r� .0" l�l&/ v zesi �J� L ) X NO.OF BEDROOMS . l BUILDER OR OWNE CQ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table and 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 Le hing Facility(If any wetlands exist within 300 fe Feet Furnished by -_:_- ....... .. - - PJ Q { � 3 Own 01 BarnStable P ft Department of lleallh,Safety,and Environmental Services qo oj� Public He nith Division Date ` 367 Main Street,I lyannis MA 02601 .v iRARMANUL _ nwsa iEo t►�� Date Scheduled Q'X'q cl8 Time Jo.eri Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By:l/T Y lE� ]/• M 1/ Witnessed By: LOCATION & GENERAL INFORMATION Location Address L45" :9 Oat 0 L,--7 V1 IL 12 L V Owner's Name — t e i l tk/ r A A. Address Assessor's Map/Parcel: �`�h�o 3 FAt9c a— 7-1'3 Engineer's Name G.� i NEW CONSTRUCTION REPAIR Telephone N "�� _7W— 0- 3`7 Land Use 14�19 hi w✓ Slopcs(%) b Surface Stones 'A' Distances from: Open Water Body VAI tl Possible Wei Area I R Drinking Water Well Drainage.Way r,' l R Property Line V/ ft Other R SKETCH:(Street name,dimensions of lot,exact locations of lest holes&pert tests,locate wetlands in proximity to holes) Parent material(geologic) bU[� �- , Depth to Bedrock 5t� Depth to Groundwater: Standing Water in{tole: t 'V Weeping from Pit Face v' Estimated Seasonal Iligh Groundwater r DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used:J(. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment n. Index Well H_ Reading Date:_ Index Well level Adj.factor A '.Groundwater Level_ PERCOLATION TEST Daft 4 me 10:CD FWT Observation I tole N I Time at 9" Depth of Pere Time at 6" Start Pre-soak.Time @ I �'�!/ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public I►ealth Division Observation Hole Data To Be Completed on Back-� Copy: Applicant DEEP OBSERVATION HOLE LOG Mole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. % �0" z , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. Consistency-%Gra ell 0i_9( 0 �`I�L 0-ye 39 `� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Ilorizon Soil'I'cxlurc Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Douldcres. % DEEP OBSERVATION HOLE LOG Hole# Depth Isom Soil Ilorizon soil'I`exUuc Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Douldcres. % I Flood Insurance Rate Man: Above 500 year flood boundary No_ /Yes Within 500 year boundary No � Yes Within 100 year flood boundary No,�Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? uu If not,what is the depth of naturally occurring pervious material? r R. Certification q certify that on :� 1� (date) I have passed the soil evaluator examination approved by the Department of Cnvir tmental Protection and that the above analysis was performed by me consistent with the required training,expe 'se and xperien&.AA cedescribed in 310 CMR 15.017. Signature Date Z �� • - J k. '� ^ 31 S ` �/ s� . o` L &4 Sz s TEST HOLE LOG DATE::- fE.B, 69v G SOIL EVALUATOR: ,44 AW,*SQ J, xss GTE WITNESS: . Cqm �a PERC RATE::— �q s� v o" o �G o �•� 0 3" 4 vV L A sc, y 7 /056 4Z'7 Lo c v s� .SA.v 0 1AN a /Zo y 2,SY 7.�,• y� � 120„ Z,sy7/3 ��,o DESIGN DATA SEC v�E.�S� .SioC DAILY FLOW: (y) DRMS,z 110 GPD GPD SEPTIC TANK:y GPD z 200%-Bg>7 GPD /=02 USE::/So o GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE:. 3) CAPACITY: SIDEWALL: 93�C Z X o,75/` /37. BOTTOM: -/-3 S'xo,7�v=3Z2,z TOTAL: - Ys9.9 010,21=11 ez� ,V,lN OF Rfq v RU, i A ` /gOrl.e SNP . NOTES: 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. r'.Y 15_l"'i 1 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION ``H OF BOX. ��FP9�, 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN o DANIEL E. y 6"OF FINISH GRADE. BRAMAN , 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A o . CIVIL -+ GARBAGE DISPOSAL V No.32686C S. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED O ON A 6"LAYER OF STONE. ,r 6 INSTALL GAS BAFFLE IN OUTLET TEL 2'LAYER OF Ut'PEASTONE OVER fss/OVAL ENG� 34'-1 14.WAMD STONE ALL ' AROUND •(fie TOP OF FOUND. EL. 5,49.o 10, 14' S3.00 S/.G7 S/.So °J� � �/900 S/, o o y5,o r SEPTIC SYSTEM PROFILE �fS•o To �.�iJ.zii?i`!gE�oTh! SITE SEWAGE.PLAN GENERAL NOTES o� 'c' �''���• y' FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR ,y/G G. .eD, OS7h,E�l//GGE TO ANY EXCAVATION OR CONSTRUCPION. G'v`T 3 .�• .mot'. yG8 • ��T• �� 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR M 00:TITLE V. 3. DINE ETERMINATION TO BE USED FOR PROPERTY L • 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. DATE: .eJE /.s/99�1 SCALE: ,95 S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY i REQUIRED INSPECTIONS WELLER & ASSOCIATES 1"S FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508)7754735 FAX: (508)775-0754 1 APPROVED BY: — — — — — — s �'-p- �'-sl' r-r n: y s_1� s-n�- �-s- s•-1t s-s' cim ^' LSiB o*. °sax e�eF1a I+ 824 ea : 9rv1tD• act /e IOU=wanR r1u 1,osr� el r———n r p1' m 11/t 3u a I^ qp 1 i I nn .� SUMS • n gg n Y d N DINING ROOM Os KITCI�J CRY� ;� LAUNDRY RM o b � _ n n FI c LIVING ROOM �g nvtx — v tlD illf _ 0 1 ti�0'6 � �� 14•"8� �� S-Y � + 13.2� >5 t 8ox i I1 3 III me WALL II _ OY 1 { 2/e � - -' o tea, ws 3fadtE n 3mI ; ht 2/s 2/e 1ws1 as 4 s starts i it - FOYHi r 1u Ld. — BEDROOM#2 wzI I pW' + I 3/0 .. .__ _ iE 1 r. 7'-� Ic 5-2' � 6•.1• Y-�• 6'-Y �T-2"� 1 S 1 S.9-, . IT-T TORMATION RE XJFM FFQM-bu-1- Y 611LDBT / - ELECTRIC DROP NOTE: BUILDER COPY ` L:ST%r'' i .�`.i rA i i; - RANGE WIRE DRYER - MASS CODE REQUIREMENT - WIRE 6R##lE�ftlC-? 1Ns nA11 IS 1NE E MLIOW PMWD rc a Av6alE1tlf t FZ4tWUC11p1 1 = DOUBLE SILL PLATE or ALL at AM carnal of ms Km UUMT W DrRms"mp CMSOff OF ArSMEl=6 A V AIM OF MO&ur. CCST�POE'R SIGij,;TLjRE - ANDERSON TILT-WASH � A XL0ol6�rm _ 04480 PHOTO ELECTRIC SMOKE DETECTOR 10 IWML IMUTM N ve atsaw of XL MUM DA, REVISED 8/8/99 3 AW-- A �cA- Avls E' ;77 l AmOWAs HOME BULM (717) 21 753-3700 CUSTOMER: DICOSTANZO REVISIONS CWD SERIES HERITAGE '98 GENERAL NOTES show LOAD: P.s.F. 3 aEVP.S 7 rz .�sww G MODEL CONCORD MOD 1. - INSTALL ALL BATH ACCESSORIES g. - i 2. - EXTEND KIT. FAUCET SUPPLY LINES W/COUPLINGS INSTALLED TO THE BOTTOM OF THE FLR JOIST 9. - 2 REV PREL J10 7-9-99 JPG DRAWING 1ST U FLOOR PLAN 3. - _ 4. - 10. - I 1 REV BC WS 6 0 99 BAN Syy�y NO. 5. - 12 - SULDER: C� JPG REFER 8740 SHEET NC 7 6. - 13. - G.B.I. DAiE 5/28/99 R Al 2 A 7. - 14. - TOTAL 1 Ci71 eru •he-_>.�• DR C o+•n tip+ y