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0485 PARKER ROAD - Health
48 .Parke2r1 ''Road' Osten-line F/R A � y y TOWN OF BARNSTABLEG. LOCATION / ���ke� �� SEWAGE # � VILLAGE aS�f'V�:I l� ASSES OR'S MAP &LOT INSTALLER'S NAME&PHONE NO. „/�' —8 I I i s *-Z. ��4 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 00 trSA a ��� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: I 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3 No. � Fee )Pisa, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS 2ppricatiou for Mtopooal bpztem Cong;truction Permit Application for a Permit to Construct( . )Repair(d)Upgrade( )Abandon( ) D Complete System O Individual Components Location Address or Lot No. .¢$$" Pave ker k..-f Owner's Name,Address and Tel.N_p. Ostervllle, iVA r`AH As5�a`(e9 �osT C/o /`nacy/Y, C/ecerr,Ti, Assessor's Map/Parcel //q j&,,,,f taw,,t /eve, Q HA ` . ns er's Name,Ad ss,and T .No. Designer's Namee,,Address and Tel.No. c �T '.Sl er s0ll,Va.t4 [w. i�[ G Pi w ,X14 C, Q noST. `7 ?&vrker *RX7 QS 1 es�.,�(e z{o `S oZ9 Os'fer✓IIle,HA (rbZ) 4AF-334� Type of Building: Dwelling No.of Bedrooms S' Lot Size 9f6 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S O gallons per day. Calculated daily flow gallons. Plan Date /O o:Z aao9 Number of sheets a Revision Date Title Sty PlaK !�ropose4 Swplfc Uo[arae�P aT 9SS Pa�kerX �a�rls7ado�Os�erva%/Q) /1.4S5, Size of Septic Tank /.5-00 aallmH Type of S.A.S. Description of Soil; ©a fl U1009. LOOLMoll �!` o g _ ca rt /B r 028 r ezo' �a v Co 9,0 S02" s Nature of Repairs or Alterations(Answer when applicable) c''J tea S r^j Date last inspected: �3 rya 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 EnvironmenX Code and not to place the system in operation u til Certifi- cate of Compliance has been' ed this Boaz He 1 f���/4'Z Signed Date /// Application Approved by - 4 Date Application Disapproved for the following reas s Permit No. Date Issued �r t No. r .�,. � Fee V • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS Ztpplication for Migpool *pgtem Congtruction permit Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. .¢gg P r ke r kC ,4 Owner's Name,Address and Tel.No. osl'erv;Ile, IVA -r,4M A53ncla�PS Trvs`f � T,-cac,/Y 641-y,?r, Assessor's Map/Parcel //g l000d la co4t fdve, v 16,s,le Ins ler's Name,Ad ress,and Tel.No. Designer's Name,Address and Tel.No. � ��r'� $u��rVain G=vi rat Ptiw j>awGeer kp C. Ter. , (tc Lf;'8-55aq Oder✓ llc. HA (Sod) 4AFs- 334-1 Type of Building: Dwelling No.of Bedrooms S Lot Size -9. 916 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 55 o gallons per day. Calculated daily flow gallons. Plan. Date /6 0 5-/�no 9 Number of sheets a. Revision Date Title $; 17iaw fr-oaos7cti 5-p-Ac �narae rr� 93 5' �o�k-rkm Ra�s7s`1u�10�Ds?tPrv;//o� f%4�S Size of Septic Tank r 1.5-0 ' QaIloii Type of S.A.S. le-"ck,,,4 �`. . Description of Soil, Dt�- r� 10 .-'Elp .09t, LOCKM 2"-I�!' 4 4aileCO Wc 6 ��••_ s q No 4r0yudGt1q Lre V s Nature of Repairs or Alterations(Answer when applicable) - Date last inspected: 3la w 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 Environmen 1 Code and not to place the system in operation until a Certifi- cate of Compliance has been i``slied b this Boar of Healthy D P Signed G�r�_ rr° I�� 'fI /l ., Date Application Approved by ft ~/ /° ��- _ N 'I/-L r�l�.�°i�C� Date /? [Y- Application Disapproved for the following reason✓ / r f L,. _ Permit No. Date Issued ' ----------------------- — ( /r,— fG.aS! 1 L c't� ' f ! THE COMMONWEALTH OF MASSACHUSETTS I BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by Q r,,,„ c a 5 at ' 11Mhas b e constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 41: ted I. Installer Designer alllyrrcr r;�,',,Fp�:,.,a �Hc, The issuance of this permit shall not be construed as a guarantee that the system,w' ill function as d�esff ned Date 11 r Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal 6pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( ,*,)'Upgrade( )Abandon( ) System located at yM5 A_,-ter 2 t{ OS�er r,'ji e- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to f comply with Title 5 and the following local provisions or special conditions. Provided:Construction in st be ompl ted within three years of the date of this pp_'ermi�.V 1 Date: l Approved by >�/ �1 AM. i fe's 1 ' �f TOWN OF BARNSTABLE LOCATION 7 �ArI�'�� 12D SEWAGE # 7 VILLAGE ASSES OR'S MAP & LOT 5 INSTALLER'S NAME&PHONE_ NO. 8 I I i S Z SEPTIC TANK CAPACITY fi5C A LEACHING FACILITY: (type) �0 6:p 4 beQ (size) NO.OF BEDROOMS! j 'BUILDER OR OWNER PERMITDATE: &—A �� 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9.1 P1 i P 3 Town of Barnstable OF IME T ,Regulatory Services Thomas F. Geiler, Director BARNWABLE, 9� MA . .0001 Public Health Division AIF0 Thomas McKean, Director '200 Main Street, Hyannis, MA 02601 Office.: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: Installer: aruC2 Address: C).—k�o\1 6 S9 Address: S ot\ ST On .,A10j/ 8',.2ooY cc �Apx,ol1',--ra . was issued a permit to install a . -st aooy-S`/4/ (date) (installer) septic system at LyBls 0�9 " 4-v t 0 e. based on a design drawn by (address) Sc>��Iu*6 gErg Rineec,•o dated DC-T, S, a004( ( &signer) 1. certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. cerl; Is f,Y (Th;% dce5 s2Ot Ceel, ' eo,")oIiCLWce Wg,f j Pj;.,W ,1a oe �1CcT/'�C�/`oGC�°`S �^! oe.sYA4er i-VI'L CTrO015e� I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Of NO.2973ti' � (Installer's Signature) CIVIL A-—10'� kAL (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP FAILED INSPECTION PARCEL �2 LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: 4 Date of Inspection: REC�IVE® . Name of Inspector, p int)Company Name:Mailing Address - � OZ Coye TTelephone Numb TOWHLTHDPT.,: 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 fimction 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 Needs Further Evaluation by the Local Approving Authority F i l s Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office ofthe 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 tinder 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 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 6A Date of Inspection ( .1,0-A29 ,,)6o S/ Inspection.Summary: Check A,B,C,D or E/ALWAYS complete 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 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 ap proval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain_ 2 Page 3 of 1'] OFFICIAL INSPECTION FORM -NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued) Property Address: Jr Owner _tWtk U �a1 h Ck GCJ 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 7 I 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 I 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: z Page 4 of I l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 7 Property Address: Ow►►e ; Date of Inspection: _ ,)CV y 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 'h day flow i� 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. c 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 inust be attached to this form.] (Yes/No)The system fails: I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a.large'system the system must serve a facility with a design flow of 10,000 gpd to.15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a.surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II.of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: A. Owner&� 0 Date of Inspect on: Check if the following have been done.You must indicate"yes"or"'no"as to each of the following: Yes o Pumping.information was provided by the owner, occupant,or Board of Health_ r/ Were.any of the system components pumped out in the previous two weeks? CXHas the system received normal flows in the previous two week period ? I/ 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 u 9 — — y g � p b 5 P .. Was the site inspected for signs of break out? (� Were all system components, excluding the SAS, located on site? _7_ _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition. of the baffles or tees,material of construction, dimensions,depth of liquid,depth.of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example, a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) S . Page 6 of 11 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURI+ACE SEWAGE DISPOSAL; SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: OJ Pali Owner: wa OP," Date of Inspect on: oX� V FLOW CONDITIONS RESIDENTIAL Number of bedrooms(:design): . Number of bedrooms(actual): DESIGN flow based on 310 C1v1R 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence7iave.a garbage grinder(yes or no): Is laundry on a separate sewage system( es or no) .[if yes separate inspection required] Laundry system inspected(yes or no): :* Seasonal use: (yes or no):�v Water meter readings, if available(last 2 years usage(gpd)):a /Iv,©©0 03 Sump pwnp(yes or no�l.� Last date of occupancy:&�lt� COMMERCIAL/INDUSTRIAI,0, , Type of establishment: Design flow(based oil,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 Pun►ping Records Sourceof information: ? Was system pumped as part ofthatinspectiOl(ye or no): If yes, volume pumped: gallons--How was quantimpumped determined? Reason Tor,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) _Imiovative/Altentative 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 +s Other(describe): /'k. ADnroximate a e of all components,date installed(4f known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I 1 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: y� 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 liner Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANS locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): GREASE TRt��cate 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 I I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Vg� sU Date of Iiispection: TIGHT or HOLDING TANK: tank must be pumped at time of ins ecti n locate n site plan)( o o s P P P )( P ) 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 BOXY 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.): PUMP CHAMBER:&h-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.): O Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �✓�S Owner: �/Q evala � Date of Inspection: 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: leaching trenches,number, length: Laifchina 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, CESSPOOLS: (cesspool must be pumped es part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: -Y,-'— C 4-) • 011 Depth of scum layer: t Dimensions of cesspool: Materials of construction: 63&Ck� h - ljyjv- Indication of groundwater inflow(yes or no): C ments(note condition of soil, signs of hydraulic failure vel of ponding, co ition of ve etaationletc): �. Aca aj O)� PRI7// (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.): IDA- , kt� d /0 ior (310 j� JAL - .� Page 10 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Owner: A Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks orbenchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a'b 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C SYSTEM INFORMATION(continued) Property Address: Owner. ytL;i v Cluj /Ll 6 Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L )--feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: / - 1''or v 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION r ` ,�' Site Location: Lot No. y Owner: CC/fA��2°�fC� F Address: �1 / " �— Address: Contractor: Notes: STEP 1 Measure depth to water table 2�r � 1 to nearest 1/10 'Ft. ..................... .......................................... .Date .........,. "' month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determiner OAppropriate index well............................... . OWater-level range zone ...................................................... STEP 3 Using monthly report "Current Water Resources Conditions" / determine current depth to l 66G water level for index well ..........................• monthlyear STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) Z,,6 determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 43, y level at site (STEP 1) ............, •••••••••••••••••••••••••• ............................................ Figure 11--Reproducible computation form. 15 i 4 1 S y j. t � O i � } } 6 T • 7 3 ; i o 1 Town of Barnstable r# Department of Regulatory Services g : Public Health Division Date See Za, 1 sari 200 Main Street,Hyannis MA 02601 Date Scheduled L Time Fee PdAk lu Sil Suitability Assessment for Sewage Disposal r Performed By: e?E[Ee Jui-t-kVA.-t WitncssedBy. LOCATION&GENERAL INFORMATION Trim Fluoc-7 rus Location Address _ Owner's Name'c 10 4 ra-clv m•C l co.-ry Address UkJ1 tab 1 ty.mR Assessor's Map/Parr ep C a Engineer's Name I I S- NBW CONSTRUCTI N X RBPAQt x Telephone# b'�Pr q28' 33 4 Q Land Use f-ES t D E-M n P�r Slopes M V&r-%es Surface Stones N o +v * '��� ft Drinking Water Well a01it t: ft Distances from: Opdn Water Body A CO ft Possible Wet Area g Drainage Way )`a d_ tt .Property Line 'L O ft Other ft m a SKETCH;(Sbw' name,dimensions of 104 exact locations of test holes&perc tests,locate wetlands in proximity to holes) �arzKElZ -JD 1 4 17 �. aAas � o nn . Bedrock material t 'c 0 VT'��dk �TI.Pr l�w.l Depth to R Parent rlgn ) - (gC0 Depth to Groundwater Standing Water is Hole: ab a c Weeping from Pit Face ON t Estimated Seasonal{i(igh Groundwater ' Et,c v aTzOu, -t 3 awes DE' ERMINATION FOR SEASONAL HIGH WATER TABLE ml"" s C�acuwowA Method Used: T6w<w ecuu �+tt3r s In. Depth to soil motliea; Depth Observed standing in obs.hole: N�A. Depth to weeping from side of obs.hole: in. Omundvvaler AdJustment •.�—.- ft index Well# -_--_ Reading Date Index Well level ,....... Ad).faelor Adj.Groundwater Level,... PERCOLATION TEST Date q�2 Time 1 W.54 Observation Time at 4" -- Hole# Z Depth of Perc 3�0~ c7s; t.l—OkXS Time at 6"Start Pre-soak'fimerime(9"-G")N Had Pre-soak \l'.b!] is r> 2.r�ltnit.Q 2 tl.X0A Rate MinJlnch' L�` Site Suitability Asse$sn=c Site Passed SS -Site FaiAP led t> _ Additional Testing Needed(Y/N) N a Observation Hole Data To Be Completed on Back. Original: Public Hc�lth Division ***If percolation test is to be conducted within 100'of wetland,you must first notify We Barnstable Conservation Division at least one(1)week prior to beginning. Q.%SEVnLVERCFORM.DOC �..ovLl o t wrlT •. (7 kJ ?aD peed{ " DE Hol Depth from Soil Horizon Soil Texture Soil Color SoilZ� erSurface(in.) (USDA) (Munsell) Mottling Boulders. ravel) d k.loo v-Q tom- PAOr,v C-Lov A.VcSS-0 toc 4.�v(_ - VVW-A� 32" A 6ohrzst:�•aq It�Y 2 S/Z IZoes�g �e�aY�t. 32 -40'' Ca•.ass Salvo 10`((Z G/g 4 t<,FEw QDa5 4 0--IZA" /1 CoAR.s eS Q 7/ C.r-own-k l� � _ bewLCr DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Struc ure,Stones,Boulders. o- 2 b \1•l00 Paar►.y vs wPost=o ec ,�tc..�r� c�ac. /� Coo�¢sE $�►O 1b`(VZ S712 Fet�t� w.EwVwT 12 - ZPj B CoAest=3o.,vD . LooSc r PGI"7aa t0`{Q G/$ so!M C 6W^Vr c. 2t - 120° G CO Aass&wi> 1oYtZllq O S 5h 6LE i;Z, t►A Loo.SGr -IAFE\,U A-iE-2. SEeYEa :.S* DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structhre,Stones,Boulders. C n ' toe ravel DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structdre,Stones,Boulders. Flood Insurance Rate Man: ' Above 500 year flood boundary No— Yes x Within 500 year boundary No k Yea Within 100 year flood boundary No X Yes Death of Naturally Occurring Pervious Materlal Does at least four-feet of naturally occurring pervious material exist in all areas observed;throughout the area proposed for the soil absorption system? YC S If not.what is the depth of naturally occurring pervious malarial? Certification I certify that on AIAZI L 19� (date)I have passed the soil evaluator examination appfoved by the Department of Environmental Protection and that the above analysis was performed by rite consistent with the iequi red ing,expertise and a perience described in 310 CMR 15.017. Signature Date Co Ev i 30 Q.%SBPnCT8RCP0RM.D0C y N, . .. .. - .. . „ ._ ..� '", Notes . . . ` _ '- a.,) The property line .information was obtalined from-- II` �# . Land Court Plan #2664-72. and the topo raphic ' _. . . _ .. _______.:-..:,_ _,:__.____ _.: _- _ ______ in for-m.otianawas�ob.talned_fr_om" the.�Town.:o ,: _ . . . , �.., _ ,.. M .r -. _ -_ _ _ Barnsfotile"GlS. _ _ . Ai� b hC ' 2).:The datum used is NOW '29 oyrxed mean - V , .sea level datum. 1aVrt)C` 2CtiGu �p the Intent of this "lan is for the- � "�� k V ) p perm ng ltti e _..' 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" _. - ,. _ -- _...._ - - - ._ . :_. F —ZON . _ - - RF 1 8t RP (gyp OD' _, ,. - _,.,.,.,_ .. r �. ., - ---t"----. t - - - . .'._, _ . ., .._: : . . . w; - - - 7 _ 3 _.-- _, . .. �.•�'gam.__..--. ....___-_. __." .. r-_� - - - -- - - - - ._,.-g• `,I - f ,�. _ _ _,.._ .,� - _ dth :-min)�1252 _ �o t - 3_ _. _ _ - .. ---- - - -- �8 • - - aSetbacs 0 f Front :a' - _ ._ .. T_ _. - -- -- - . - . - - _- .__ _-�. - 0� . —Side-1 6 y1_. Q _, ___..,__ __._- �._ --..n .K.�. _ - - _ �:�; .. ,..T.�- _ ::Rear.-..,f 5 Q- - -- - - - -_ r. . _ . - - - w _ :.: . �_. _. - Y- _ .. _.. _ : . ,., w - _ - . - - _ =' - - - . ^ ,_ ..�,. qurfer Protection::District f.� _ .. - - Ln . . _ - a AP � A As Shown on Plan' n'E titled - -- - -c.:- _ --:4 _ _.._- _. - -- - - - _...__w. -- _ -_ ::.- -85 .Parker Resod ,.. _. _ - o ;_._: __. _ .. . . .� - RevisezJ--Crownd�►%a#er:Protect�on� - ._ a _x___in ,.. _ _.".:: - -0veela ,.Districts A ri - -... Dw I 1:9" -_.:_ - _ ells. _ _ _._._ 93 : .. , _ _ _ _ _, _ o. ... .t . . \_ �aoo <c, :. i P , _ . � . _._ : _ _ FL_ D.Z O _ " ONE amm - - - _--. ,,�.-. ..- . - - rty.P - _ Zone C ,-. �e. Con`acriyn an21:;No _ .., r ro 00 - , �, - , - - 23000T--SOOT 6 t. _ .__> _._ �;: July 2 _t992 D _ _ - A .- - - . , k R `L _. ,� - a .. - 0 - : , : . - - aoo: t=: a.00 a o - - --_ -- - -_ _ _ � . = _:. - ,� o. . , ... _._ _ .. ... ._... -. .-..... L ....._.. .. - _... ._ ... .... - _ ,c _. . - � . , I f- � __ , ,� ._ :,�_..,...- err- -__,,., _--- ___ _. �_ _ 4:� - _ - ,. w - - - - _ . . _ . �, _ _ - : . -. ,M _ . -� w - - t\ _ a. \ _ - _ - - _ 0 •d' c u :.-' - - 4 3 - - - - - sh S _ - : �. rt K Am _ - . .. . - - _ - t a tY� oZS -� -m - Pl. r _ _. 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Sulhan,.�n ineeri - Inc. .. ,p ;- ; w O OSED SEP C .UPGRADE ,.. _. _ _. ...:. r, s r .e :,7e C .Q, Cie r_ Tr..; + , _ soc at s usa _ .,.- _ .._._,., �,,. y' r - .-,.,. ,.....,-....:..,. ...,, a .........-.nw.i,_�:,..,:,.-_-•'__ _:.,.,..-..,..:..�:_.,.Y:: :>L ». wP ..,BOX_..B ,:: .., , - n,-+.-+ems..... .a :;'" - . , ,. _ Wood a_. ...,,. --:-�----- .. ,. _- f .. r-tit_ _026� .-<- - - _ _. _ _ �.. -_. _ „ . - _.4 ' rlc r , _ry 8,5 a e .Rood,- .. _ ,_ .,. _ ,_.., _ , T ,:,.. _ _ _ .,.: 508 42t7 JJ44:508 4 , .._... .. a. ... . . ,:" „�. ). 28,Jf15 tox ,.-_.. y_ _...). x os. t ,_, ec..BARN T -w Pr.,o `2 0 S A 1 1. 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The property line information was obtolined from Land Court Plan #2664-72. and the topographic Information was obtained from the Town of Barnstable GIS. 2) The datum used is NGVD '29, o fixed mean ,t,C• sea level datum. apD� 3.) The intent of this plan is for the permitting of the septic upgrade only, and is only valid with an original stamp and signature. ZONE: RF-1 & RPOD Area (min.) 87,120 SF Frontage (min) 20' Width (min) 125' Setbacks: a s Fron t 30' or Side 15' Rear 15' OVERLAY DISTRICT: AP - Aquifer Protection District As Shown on Plan Entitled U "Revised Groundwater Protection 485 Parker Road Overlay Districts" - April, 1993 m Existing Dwelling p0 law, e � FLOOD ZONE: '0aua ox zone C sa ucTa Community Panel No. a #250001 0016 D rm00' July 2, 1992 Mm a o 0 0 '�' o 0.00, _ Mm. 45.50' J (L 1� C Q �LJ • •~ . Rnv.e A'cee �J' OF b� a d N PATER �, : .• a .� SULUbA9 ,�p' { 8A. ' © LOCATION MAP: R�6 Scale: I" = 2000' ASSESSORS REF.: Mop 115, Parcel 021 Ln Prepared For: 2004 Title: Prepared 8y. p Date: Oct. 5, SITE PLAN Sullivan Engineering Inc. rt PROPOSED SEPTIC UPGRADE Po Box 659 TAM Associates Trust, CIO Tracy M. Cleary, Tr. AT Osterville, MA 02655 119 Woodlown Avenue Scale: 1' = 40' J 485 Porker Road Wellesley, MA o BARNSTABLE� (OSTERKLE) MASS. (508)428-3344 (sullPE 00l.co fax Project # 24026 PSuI1PE�o1.corn sr r' r F r ' PERC TEST, 10,826 Finish Grade PERI"UR,ED By SULLIVAN ENa WITWSSED BY, DAVE STANTON NOTES ran } LJt J' II fir t� n ,i ri tj�� } 111+ I +,f tini,ZF ,i',+ iJl +ll tilts' SEP 20,20104 1, Water Supply For This Lot Is Municipal Water. 3/y.P'IQX lilt.`_ Ilter 2. Location of Utilities Shown on This Plan Are Approx. Min Compacted Fill Fabric TEST HOLE - 1 At Least 72 Hours Prior to Any Excavation For This PERFORNEO BY SULLIVAN ENaanng - Project the Contractor Shall Make the Required lao Notification to Dig Safe (1-888-344-7233) Mj 1/8• - 1/2• 3. The Contractor Is Required to Secure Appropriate Pea Stone ZED ORGANIC vaaor LOAN -PART 14.E Permits From Town Agencies For Construction A LAYER IDYR 6/6 Defined by This Plan. 'r..r COARSE SAND 4, Install Risers to Within 12' of Flnnlshed Grade. COARSE SAND Y 5. All Structures Burled Four Feet or More or Subject 3� rEW ROO SSSOlW GRAVEL imp to Vehicular Traffic to be H-20 Loading, C LAYER 0 6. Septic System to be Installed In Accordance With AR E MAIN LEACHING " COSE SAND 310 CMR 15.00 Latest Revision and the Town of >� _ Barnstable Board of Hentth Regulations, 2e CHAMBER 3/4' - 1 1/2' 7• All Piping to be Sch, 40 PVC. H-20 Double Washed .c c„'� ,,z., `•3, -�j x`+-�.; Stone No GRWNOVATER ENCOUNTERED 8. Wherever Sewer Lines Must Cross Water Supply Limes, Both Pipes Shall Be Constructed. of Class 150 TEST HALE - 2 Pressure Pipe And Shall Be Pressure Tested To PERFORMED BY SULLIVAN ENa Assure Watertightness. 4'-10' SrP 30. 201014 0 LAYER 12'-10• WOODY law-PART AN Y CROSS SECTION OF CHAMBER 12 W COARSE SAND-SINGLER 6 NOT TO SCALE rEW`! LM VEL 17.9 COARSE SAND A - PERC TEST 17.2 r.23 GALLONS IN',as NOl RESAT(eNRI/GNCN NO GROUNDWATER ENCOUNTERED �PEFENR — OULUVAN_ .2973 CML Design Data Single Family - 5 Bedroom NA G� Daily Flow = 110 x 5 = 550 GPD F.F E 692' F, , 0.2' Septic Tank, 550 GPD x 200% F.G. EL. 2 _ ® 1,100 GPD See Note 4 ctyp.) Use 1500 Gallon H-20 Septic Tank w/ 2 compartments Ri n ri z:1 7. Leaching Area Too El. 18.69' <Mln.) 550 GPD / 0.74 = 743.2 SF 1500 Gallon SF Required Septic Tank O > '� Sidewall = 233,3 SF Flow Bottom Area = 583.8 SF i © Equ zers -, = 817,1 SF Total Provided As Required ~ 1 1�\0 ` Leaching Chamber r Y; Bedding, 'T's. 4. ot, t. 9' DeSiQn r iX .._ti..,. 'U's, lo' & Baffels If Encountered Remove a a All Pipes to be Schedule 40, ^' as Per Title 5 RALLepUnsultable Sails Within 5' of N H 0.2 Use 5-500 Gal, Leaching Chambers 20 The Outer Perimeter, of The No Water in a Washed Stone Field as Shown. ^' System DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM El,r Q 3.0 G NOT TO SCALE Peroundwater aps Title: Prepared B Prepared For: (ASITE PLAN p Y Sullivan Engineering, Inc. Date: Oct 5, 2004 PROPOSED SEPTIC UPGRADE PO Box 659 TAM Associostes Trust, C/O Trocy Cleary, Tr. <D AT 119 Woodlown Avenue Scale: As Noted 485 PARKER ROAD Osterville, MA 02655 �) Wellesley, MA O (508)428-3344 BARNSTABLE, (aSTRwur)MASS. PS�PEa7oLcorm fax Project #: 24026 N i i O `T L S N - - < i J/V`' CA i rr r i O I I F f \ - - 1 i ( � I fl I i I � I --... ----_----------- ---!- 1 V7 1 1 I I- I1I1 1 Lit \� C5 i 17 LA-11, 11 Rl . 0 � 70 S VL '-' Dl Ikl Q rn � - 'Ti O FJ �c O - t { I ,