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HomeMy WebLinkAbout0080 OLD SALEM WAY - Health 80 OLD SALEM WAY, OSTERVILLE A=165-050 l i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° 80 Old Salem Way M Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osteryille Ma. 02655 4/7/11 every page. CityfFown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name 1 tZA 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 ` cl, U) 9" 417/11 "i Inkpector's Signature Date U_ The'-system inspector shall submit a copy of this inspection report to the Approving Authority(Board r._ of:Health or DEP) within 30 days of completing this inspection. If the system is a shared system or wv has.a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner • and-copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. Cityrrown 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 7 , Commonwealth of Massachusetts Title 5 Official Inspection Form _ e Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. City/Town 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken 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 t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments °M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. City/Town 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ;W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M ,.•''r 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ic Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. City1rown State Zip Code Date of Inspection D. System Information i Description: Number of current residents: NA 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 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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 Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form- Not for Voluntary Assessments c�M 80Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. CitylTown 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 F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is Osterville Ma. 02655 4/7/11 required for every page. City/Town 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 house vents. Septic Tank(locate on site plan): Depth below grade: 2 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: 1.500 Gallon Sludge depth: 4" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 every page. City/Town 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 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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: bate 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osteryille Ma. 02655 4/7/11 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 Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osteryllle Ma. 02655 4/7/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 40111 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: 2/2'x2'x49' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Stone was dry at time of inspection. 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 N, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4.1 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osteryille Ma. 02655 4/7/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters MaP.Size © a zoom Out n fi n U E L U E UIn - Q, ' ,. A" vi a1 MA 4. w �,• f £ x } Y .: 4�" 0 20 Fee t n Set Scale 1" = 20 b I Aerial Photos I MAP DISCLAIMER (^—rinht 90nF.91)10 Tnum nt Rnrncfmhlo RAA All rinhtc ra—mi, http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=165050&mappaiback=1650... 4/12/2011 Commonwealth of Massachusetts W Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 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 trench 41' 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: 2001 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:Technica Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 80 Old Salem Way Property Address Thomas&Lisa Bigony Owner Owner's Name information is required for Osterville Ma. 02655 4/7/11 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 LOCATION 20 01-D S4�-M 1QAq SEWAGE # 2W0- 3-7 3 VILLAGE D5fO.A d L44 ASSESSOR'S MAPS�& LOT e INSTALLER'S NAME&PHONE NO. it» auer_ SEPTIC TANK CAPACITY / ®® LEACHING FACILITY: (type) PEt_r et (size) PL�1.1 k NO.OF BEDROOMS BUILDER OR OWNER CQAJS_r"e -r1 a� PERMITDATA COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist , within 300 feet of leaching facility) x Feet Furnished by ro a A e 3 0 { No _ ., Fee [ �c r THE COMMONWEALTH OF MASSACHUSETTS , in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migool *p!5tem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Al Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J 7� tlILLeip-, 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A:S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: U U 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 Env' onmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Board eal D� a Signed Date k/,0/ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ` rrt NO !fi �1 Fee /'�K N r THE COMMONWEALTH OF MASSACH gUSETTS in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01pplication for ;Dfgpool *pgtem ;e CongtructionL , ' "� rnttt Application for a Permit to Construct(t<R pair( )Upgrade( )Abandon( ) ,O Complete System ❑Individual Components Location Address or Lot-No. y'�/} Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 Tly Installer's Name,Address,and Tel.No. Designer's,Name,Address and Tel.No. 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 gallons per day. Oalulated daily flow gallops. —,---'-Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) U Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of-Compliance has been iss14 by this Board eaI . / Y Signed Date 01 A l Application Approved by _ Date �� Application Disapproved for the following reasons Permit No._ Date Issued -----------------------------------' ---- THE COMMONWEALTH,OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( _)byfi ��, at f'l?1' 1 ��; !l !� ,�i i' NA /''+- I I f'� 'has been constructed in accordance with'the provisions of Title 5 and the for Dlsp sal ysti7f Cons ction Permit No ated Installer Designer The issuance(�of this permit shall not be construed as a guarantee that the system will function as desi'gn/p d.fl O Date_ 4 1 /1) Tn Inspector !/l1 —————— ——————————————————————— No. Fee T� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS -Migogaf & gtem Congtrurtion Permit Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon( ) System located at i J�X.L ra 6✓ OL k,v r 16 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 must be completed within three years of the date of tl* t. Date: /��� Approved by I clown of Barnstable rfr O Department of I lcallh,Safely, and rnvironmen(nl Services V, * �1IM Public IleI1111 Division hole 5 �! 367 A4a11,Street,I lynnois MA 02601 MASI UaleSchedilled OOO Time face 1 (1.12 t ,Soil Suitabililp Assessineni for Seivage Disposal � I'el formed lly: I ©��J ] �ri/f J 1 /( \VilncsScd fly: I vJ I StY6 CATION & GI NENW, INIFOftMATION Localloo Address f�� SA. j�� ���)%vncr's Name vv (//��Jc- ���� address Assessor's N-lap/Parcel: /Cs � Lnginecr's Nnmc NEW CONSTRUCTION _2�L REPAIR Telephone 11 Land ilse &Ae5Vj-7! /e¢J Slopes(%) j- Surface Stones /U�✓ , c I)islmlccs Iionn: Open Witter Ilody kfaa Il Possible Wel Arca 2`f-9© R Drinking\Vnicr\Veil >wU fl �r�r ' Drainage Wry �e7 Il I"011010.ine > 'W It Olher R SICI,'I'CI I: (Slrcet onme,dimcusioos oflot,cxncl li,cations of lest holes& tests,locale m1fraids in proximity I I n ly to holes) r c Parent owlerinl(geologic) SOS Depth to Iledrock 4\///-halt Depth to Gr000dsvalcr. Standing Wit lcr in I lolc:_ ' Weeping from I'll Face -t P-VL5- ESlimalcd Seasonal I ligh Oroondwntcr y � pC1'ElIMINATION I�OR.S4ASONAI, IIIGII.I'Vi�`I'I�R.'i'A13L1� Method llsell: Depth Observed sianding in oils.hole: in. Deplll to soil mollies: Deplll to weeping from side of oils.hole: Ill. Groonchvnler Adjustment It. li,dex \Veil// _ .. ItendlnR Dnle: _ _ Index Weil leVcl __ _ Ali).factor Adj.(iroundwnler Level Ct 1..A'I'ION 11(8,I, ,<. iiil colve i'Irlie Observation / I tole 11 fink nl 9" Depth of Pore 07 Time nl 6" . Slat l Pre-soak Time n ao 'I Inc(T-4) I:nd Pre-snak /gip AA I1111c Min./Inch 4 2 MIN' - Site Snilnbilily Asscssmcnl: Silo Passed_ _ Site Foiled: Additionlil Tcsliog Nccdcd(W/N) Al Originnl: Public IIcnith Division, Obscrvntloll Itole Daln To Ile Completed on Ilnclt j Copy: Applicmd DEEPOOSIOWATION, U:1,0C, bale 11 'Depill I'mill S Soil Colo, soil 01her Slit fince(ill.) (Sillichoc,stulics,lJollidercs. Ile 5-3 DKEPOIJ81,00"ATION mAJE 110G Hole 11 Drpill I'lool Soil I fol!mql vi Soll'I' till c Sol Color 011ict Sorlarcc(in.) (t IS DA) (KhlllsCll) Stolics,lJouldcles. 0-3 --C3 151 el!� *w Z�5 y DENN" OBSNAWATION 1101APj 1,001 Hole It DCpIil firoill soil I lol lzoll Soil TCA11te Soil Color Soil 0111cr Silt Iince(ill.) (USDA) (Mansell) Mottling (Sifocluic,sloocs,Hoolducs. DERWOUSEWVATION il LOG IWO/ Depth Imill Soil I lorimn soil TcAllic soil Color Soil Other Sorfine(ill.) (USDA) ( :111115CH) Muddling (S11110irc.Sloocs,liolliticic.s. Above 500 year flond boundnry No Y c.s C Millill 5o0 Yen boillithily No Yes Willifli 100 ycnr flood butliOnry No Y cs LWAluff Does al lead (i) lr feet or Imull."illy OC6111-1-ing pervious material cxis( in 1111 areas obscl-ved 1111oligholit tile R"e;' I)I-OlMsed for file soil absorptloji SYSIC1117 If no(, Aviiat is the del')III Orliallil-ally occurring pervious Ilmilul ial? I Celdry Him on 10 (dale) I have passed lite soil evalualim.ex. approval by (Ile /I— (d, '1111ilIntion Ippi Of I"I'vil-011111clif.11 Prolectioll and IlIT'll the -"13()vc analysis was perfol-lile(I by Ille consistent with lite I-efillired Iraitihig, expertise and Cx0cf-iclice(ICSCI-ibed in 310 CIVIR 15.017. 'Ile I a9. r s i.� ..Rua k s 0}EA 35 p 3 { 1 J -: TOWN OF BARNSTABLE :a LOCATION — SO ©LDI S4 SEWAGE # 21L'OD - 37 3 . I VILLAGE_ (>5"r52,1!]LLB ASSESSOR'S MAP & LOT 1 INSTALLER'S NAME&PHONE NO. _ Jt rv-� #Va 6--Y_ 41-0. OZ 9'0 SEPTIC TANK CAPACITY l5®� LEACHING FACILITY: (type (size) SEE f'LR NO. OF BEDROOMS BUILDER OR OWNER 0 ✓$Ta'Ae--rt 0 t J i /n PERMITDATE: ®L44� COMPLIANCE DATE: ` 0' 2-6D1 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 feef'of leaching facility) - Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 3.00 feet of leaching facility) Feet Furnished by-: 0 — 99 . ' 0 — c2 0- 6� 9 0- rZ Z rr� —.: TEST PIT #1 - ELEV.=53.5t DEPTH FR04 BOTTOM SOIL SOIL TEXTURE SOIL COLOR SOIL OTHER (STRUCTURE, BOOUU�SS, DESIGN FORMULA: WRFACE LA NO GARBAGE GRINDER ALLOWED NTH THIS DESIGN (INCHES) ELEV. HORIZON (USDA) (MUNSELL) MOTTLING CONSISTENCY, % GRAVEL 0'-3" 53.2 0 ORGANIC NONE !� �i r �� ` EXISTING TREELINI STEM REQUIRED PROVIDED SCUDDER BAY 3"-10" 52.7 A LOAMY SAND 10 YR 5/4 NONE TP-1 PERC TEST LOC ON DAILY FLOW: 10"-40" 50.2 B LOAMY SAND 10 YR 5/6 NONE 4 BEDROOMS O 110 GPD/BR 440 GPD �/ 40"-53" 49.1 Cl COARSE SAND 10 YR 6/6 NONE tOR GRAVEL do STONES EXISTING CONTC ;.9 SEPTIC TANK 53"-132" 42.5 C2 MEDIUM SAND 2.5 Y 2.7/3 NONE 440 GPD x 200% 880 GPD EXISTING SPOT EEVATt( N 1500 GAL �FlyA o: �T PERCOLATION TEST BY: PETER BRYANTON, T-5 ENVIRONMENTAL 76 PROPOSED CONTOUR LEACHING AREA FOR: ATLANTIC DESIGN ENGINEERS, LLC 2 - 49' TRENCHES Q 419 F WITNESSED BY: BARNSTABLE HEALTH DEPARTMENT �?� PROPOSED ELECTRIC TI _EPHONE 2' EFFECTIVE DEPTH ��.�' DATE: JUNE 8, 2000 ETC 0 S� PERCOLATION RATE: <2 MIN/INCH IN Cl AND C2 SOILS, NO GROUNDWATER ENCOUNTERED & CABLE TV SERVICLS 2' WIDTH p CD SIDEWALL: 2 x (49 x 2 + 2 x 2) x 2' 408 SF a. it 11P PERC TEST DEPTH: 50" G PROPOSED GAS SERVICE BOTTOM: 2 x (49 x 2) 196 SF LOCUS TEST PIT #2 - ELEV.=52f W PROPOSED WATER SERA :E LEACHING CAPACITY: DEPTH FROM BOTTOM OTHER STRUCTURE, SIDEWALL: 408 SF x 0.74 GAL/SF 301.9 GPD SURFp,M of LAYER SOIL SOIL TEXTURE SOIL COLOR SOIL STONES, BOULDERS, BOTTOM: 196 SF x 0.74 GAL/SF 145.0 GPD (INOIES) ELEV. HORIZON (USDA) (MUNSELL) MOTTLING CONSISTENCY, % GRAVEL SITE ZONING - R C ¢.It 0"-3* 51.7 0 ORGANIC NONE TOTAL: 440 GPD 446.9 GPD 3"-12" 51.0 A LOAMY SAND 10 YR 5/4 NONE PER TOWN OF BARNSTABLE 12"-48' 48.0 B LOAMY SAND 10 YR 5/6 NONE ZONING REGULATIONS 48"-66" 46.5 Cl COARSE SAND 10 YR 6/6 NONE 10% GRAVEL do STONES MINIMUM FRONT YARD - 20 FEET 66"-132" 41.0 C2 MEDIUM SAND 2.5 Y 2.7/3 NONE NO GW ENCOUNTERED MINIMUM SIDE YARD - 10 FEET EPTIC SETBACKS (MIN.) LOCUS MAP PERCOLATION TEST BY: PETER BRYANTON, T-5 ENVIRONMENTAL MINIMUM REAR YARD - 10 FEET NOTES (NOT TO SCALE) FOR: ATLANTIC DESIGN ENGINEERS, LLc ACHING TRENCHES WITNESSED BY: BARNSTABLE HEALTH DEPARTMENT DATE: JUNE 8, 2000 10' PROPERTY LINES 1. ALL DIMENSIONS ARE PERPENDICULAR TO THE PROPERTY LINES. PERCOLATION RATE: ASSUMED Q MIN/INCH, NO GROUNDWATER ENCOUNTERED 20' CELLAR WALL 2. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN COMPLIANCE WITH THE STATE SANITARY CODE TITLE V AND THE _T / l ; 10' WATER SERVICE BOARD OF HEALTH REQUIREMENTS. :PTIC TANKS 3. ANY CHANGE TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND DESIGN ENGINEER. 10' PROPERTY LINES 4. BEFORE BACKALLING THE SYSTEM, THE CONTRACTOR SHALL NOTIFY THE DESIGN ENGINEER AND BOARD 10' BUILDINGS OF HEALTH TO INSPECT. 10' WATER SERVICE 5. HEAVY EQUIPMENT SHALL NOT TRAVEL OVER DISPOSAL SYSTEM DURING OR AFTER CONSTRUCTION. 50 4" LOAM AM SEED 6. TIGHT JOINT (T.J.) PIPING SHALL CONSIST OF POLYVINYL CHLORIDE (PVC) PIPE, SCHEDULE 40. ALL PIPES TO BE LAID _i �� •`L 1 Xy ON FIRM BASE AND TO BE WATERTIGHT. ALL CONNECTIONS AND JOINTS SHALL BE MECHANICALLY SOUND AND TIGHT. �~ 4j OF CLEAN BACKFILL �'I Z /8�TOR1j- '" Atq At1A1 7. PROPERTY LINES ARE FROM "SUBDIVISION PLAN OF LAND IN BARNSTABLE'" BY MERCER ENGINEERING CORP, DATED ( W! PDOUBLE EA GRAVEL •,• ••••• •• ;'' MAY 3, 1965. PLAN REFERENCE: LAND COURT PLAN 313738, SHEET 1, DEED REFERENCE: CERTIFICATE NO. 34421. - °o ,'• 3 4' 8. THE DESIGN ENGINEER SHALL CERTIFY INSTALLATION. c, 52 kr c0, # 49 D To 1-1/2" DOUBLE `�' \ D e �• o WASHED 9. ENTIRE PARCEL SHOWN ON PLAN IS ZONED RC RESIDENTIAL PER TOWN OF BARNSTABLE ZONING MAP, LAST REVISED \` \ o` '.>` ' - 2.c. �,N. ' o0 0 STONE APRIL 28, 1998. SITE DOES NOT LIE IN A GROUNDWATER PROTECTION ZONE. N 4" PERFORATEL 'VC 2.0' I ►1 Tp 2 SCHEDULE 40 10. PROPERTY IS LOCATED IN FLOOD ZONE C, PER FIRM MAP 250001 0016 D, DATED JULY 2, 1992, \. 6.0, WNIA m BOTTOM OC 7RE� LE T1 SEPARATION 11. DISTRIBUTION BOX SHALL BE WATER TESTED FOR LEVELNESS. / ti DISTANCE - 65. FOR ENTIRE 'n;TH FROM / MAINTAIN 6.0 _ET GROUNDWATER 12. DISTRIBUTION BOX SHALL HAVE AN INLET TEE EXTENDING TO ONE INCH ABOVE THE OUTLET INVERT ELEVATION. I J BETVIEEN TREK;4S - # j I PROPOSED MAP 165, LOT 49 13. CONTRACTOR SHALL OVEREXCAVATE LEACHING AREA AND FIVE FEET ALL AROUND DOWN TO TOP OF COARSE �t DRIVEWAY N / F TYPIC/ :' LEACHING TRENCH SAND LAYER (APPROX. ELEV=49.1) AND REPLACE WITH CLEAN, COARSE, 2 MIN/INCH SAND. N .W MARY P. GERMANI c. FOSS- SECTION (NOT TO SCALE) 14. EXISTING CONDITIONS AND TOPOGRAPHY FROM TOWN OF BARNSTABLE GEOGRAPHICAL INFORMATION SYSTEM. MAP 165, OT 43 15. EXISTING LOTS SERVED WITH TOWN WATER SERVICE. RICHARD N. WAYLIK I 54 # 80 Z 16. BENCHMARK ELEVATION ESTABLISHED FROM TOWN OF BARNSTABLE GIS SITE MAP 166. o - _ OPOSED \ 4- HOUSE 3 G 64.0' FF EL =55.0 34.0' 15.9' ROPOSED THREE MANHOLE COVERS 4- PERFORATED PVC. �/SCH 40 ` 1500 GAfLON 12'X25' DECK SEE DETAIL 'A' G MINIMUM OF ONE COVER TO WITHIN 8" of FINISHED GRADE R A ' ND 5/8" NTH MIN. J_ SEPTIC ANK 42. BRING OTHER COVERS TO WITHIN 12' OF FINISH GRADE � w 21.0' BUILDING SETBACK F.c.-s4.o 3/4 - 1-1/2" DOUBLE o I LINE (TYP) F.c.-szo FINSHED GRADE rVASHH� CRUSHED s17JNE 1 .� 10. - J z HWN. 2X SLOPE- - F.G.-52.0 2. OF 1/8"-1/2- DOUBLE MAP 165, LOT 99 z o tJ TOP OF PEASTONE ASHED PEA GRAVEL F.c.-53.0 N / F LLI o ° ° - N 2I- e' SUMP _ - WI LLI A M K E LL Y -j o - - - 0 �,; INV OUT ELEVATION- so.o 4' PVC CAP 2 - - - INV. IN 1�TICC GALLON \_INV.99 � /INV END Q - -1 ~ H' O , 50'4I 50.24 �� �--MV. OUT NV. IN • •• T 49.25 D-BOX ��_ 19.1 NV. IN 49.82 49.50 e; •.r< 'e;�•. •. 20 2 49' LEACHING TRENCHES �•: �, 4979 r � OMIT OF 5' OVEREXCAVATION I -- - _-� ( RESERVE AREA DASHED) I-10't-�° Q l - . . • e . . B0170M OF TRENCH BOTTOM of 10 t ELEV 47.25 49' TRENCH LEVEL STABLE 8" STONE BASE � - 8't BOTTOM OF TRENCH LEVEL FOR ENTIRE LENGTH V 47.25 p MAP 165 LOT 50- - - - l 20,698 SF 6.0' - 3" MN. 0,�r7 �(•, � .. � 20' MN. DISTRIBUTION BOX SHALL HAVE A MINIMUM SUMP OF SIX INCHES NTd 64.6 n As MEASURED BELOW THE OUTLET INVERT ELEVATION. DAVID SEMAN - y 28.9 A r2 NOTES N84•49•30nW a I TYPICAL SEPTIC SYSTEM PROFILE 1. SEPTIC TANK SHAL BE EMBOSSED WITH 2SM # 31NTH ASTM 108.1't tO• MIN. 24" (NOT TO SCALE) 2 ALL SEPTIC SYSTEM COMPONENTS SHALL BE metDESIGNED TO WITHSTAND H-10 LOAD#W& MAP 165, LOT 51 OF A66, , 1 SEPTIC TANKS SHALL BE PROVIDED VATH AT N / L DETAIL A CONTRACTOR TO INSTALL CORROSION LEAST THREE 20" DIAMETER MANHOLES WITH Dy y RESISTANT GAS BAFFLES BY TUF-lW, OR EQUIVALENT READILY REMOVABLE qW ERMEABLE COVERS OF ALGIRDAS & REGINA DAPKUS Yc APPROVED BY THE ENaNI>1t, ON OUTLET TEE DIRtABLE MATERIAL FILE: 2002SEp2 Designed by : SCALE � � a PREPARED FOR PROPOSED SEPTIC DESIGN PLAN Sheet Drawn by : SCALE 1 " = 30' RM PROPERTIES FOR 1 1 tlan [ kDESIGN ENGINEERS, LLC. Checked by : 0 5 10 15 30 192 SANDY VALLEY ROAD 80 OLD SALEM WAY JOB NUMBER MARSTONS MILLS, MA 02648 OSTERVILLE, MA 02655 P.O. Box 1051, Sandwich, MA 02563 (508) 888 - 9282 Approved by LICE Date N0. DATE REVISION JUNE 19 2000 2002. 0 ..ram.. .. ..i ...,w. r. .r.. ,. ..-. ': .. .. ...n