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HomeMy WebLinkAbout0038 SAND POINT - Health 38 Sand Point Osterville P A = 073 018 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 13 MAP�M sac PARCEL LOT TITLE 5 OFFICIAL INSPECTION.FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �pp CERTIFICATION Property Address:., `,O_ &'x Owner's Name: uu RE I ED Owner's Address: ,t.-LA Date of Inspection /04 O-02 AUG 2 5 2003 Name of Inspector: please print) J TOWN Or BARNSTABLE Company Name: �(Q HEALTH DEPT. Mailing Address: _ v6 � Telephone Number: -7 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 DEP. approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000): The system: YPasses Conditionally Passes Needs.Further Evaluation by the Local Approving Authority ai Inspector's Signature: /i Date: / CJ-3 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 & __" /0—,Y-,b P`' 4*&x6 d wDr . ****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 6/1.5/2000 page I "Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:' O`r0 Q9f/' Owner`• V Date of Inspection: . Inspection Summary: Check A,B,C,D:or E/ALWAYS complete all of Section D A. ystem Passes: .1 have not found any information which.indicates that any.-o.fthe 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 breakout 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): P 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 3 Page 3 of 1'l OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: -39 O .lLI Owner: Date of Inspection: /a 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.vtt less.Board of Health deter;nines imacco-dance with'310 CMR.15.303.(I)(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 l of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a priva.te:w.ater supply well. — The system has a septic tank and.SAS and the SAS is less than 100.feet but 50 feet or more frotn 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner Date of Inspection: 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 V 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 %2 day flow V 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. V 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 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.] v U (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 1.1 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI.ON`FORM CHECKLIST Property Address: C Owner:Lt/ Date of Inspection: 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? 2'Have large.volumes of water been introduced to the system recently or as part of this inspection? f/ 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? V/ 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 intecior 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)o�the site.has been dete.�nired based on: Yes no V Existing information. For example, a plan.at the Board of Health. L/ _ 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)] Page_6 of 11 OFFICIAL-INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTIONFORM PART C SYSTEM•INPORMATION Property Address: z3s�&A'6 �(A Owner: Date of Inspection: FLOW CONDITIONS f RESIDENTIAL Number of bedrooms.(.desi n): (e Number of bedrooms a DESIGN flow based on 310 CMR 15.203{for exam ]e: 110 d x#of bed rooms p by ) G__(9__a -Number of current residents: _ Does residence.'have.a garbage grinder(yes-or no): Is laundry on a separate sewage system( es oriro):� _[if yes separate inspection required] Laundry system inspected(y s or no). Seasonal use: (yes or no):A. Water meter readings, if av itable(last 2 years usage(gpd)):dZ—.Z_10er OZ-P�TI m�D Sump pump(yes or no): D ✓?-r'®�ir,CD Last date of occupancy: COMMERCIAL/INDUSTRIALj/k1' 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:. Was system pumped as pa of the inspection(yes or no): If yes, volume.pumped.: gallons--How was quantity pumped determined? Reason'for.pumping: . TY OF SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _:Privy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy'of the DEP:approval —Other'(describe): Apr imate age of all components,da itista led if known)and source of information: Weresewage odors-detected when arriving.at the site(yes or no): Page 7ofII OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: ►' � C� Owner n G2/GG Date of Inspection: 03 BUILDING.SEWER(locate on site plan)//-d— Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line:. Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: ✓(locate on site plan) Depth below grade 1G� l b`l �52 Material of construction:LL-eo`ncrete_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: X Sludge depth: i Distance from top of sludge to bottom of outlet tee or baffle: z� Scum thickness: Distance from top of scum to top of outlet tee or baffle: 3 if Distance from bottom of scum to bottom of outlet tee or baffl :_7 How were.dimensions determined: Comments (on pumping recommend tions, i let and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert,e idence of leaka e, etc.): �� GREASE TRAP{, locate 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 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: /Z) ,- TIGHT or HOLDING TAN]q (t2nk must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete__metal -fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast 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 distributi�tooutle equal,any evidence of solids carryover, any evidence of kage into or out f box,a ): , wr PUMP CHAMBE (locate on site plan) Pumps irf working order(yes or no): Alarms in working order(yes or no): . Comm entsf(note condition of pump chamber,`condition of pumps and appurtenances, etc.): 8 . Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owners L(/ GTL/1l✓� Date of Inspection: / 3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching.pits,number:_ leaching chambers,number: aching galleries,number: 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, ^� _ 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 or no): Comments(note condition of soil,.signs of hydraulic failure, level of ponding,'conditinn ofvegetatio::;etc,): PRIV�locate on site plan) Materials of construction: r Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A.+ I Owner- 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 or benchmarks.Locate all wells with in 100 feet.Locate where public water supply enters the building. d-�'.4d�-e-- 7D► 60 ► O 10 Page I 1 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner: Date of nspection: 3 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) :ZCAccessed.USGS database-explain: You must describe how you established the high ground water elevation: ✓`4i x 11 Permit Number: Da e. Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Lot No. Owner:_ �—M - Address: Contractor: D/� -��sT' Address: .y 'ed� STEP 1 Measure depth to water'table tonearest 1/10 ft. ................................................................................ .Date `5h7—ly3 month/day/year STEP 2 Using Water-Level Range Zone _ and_1ndex Well'Map locate site and determine: O. APPro.priate index well...... ............... �Ivi OWater-level range zone ...............................................:: STEP 3• Using monthly report "Current Water Resources Conditions" determine current depth to y water level•for index well .......:................... d> month/year 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 2B) determine water-level adjustment............................ l• 'STEP 5 e-st.imate depth to high water by subtracting the water- level adjustment (STEP 4) from'measured'de'pth to water level at site (STEP 1)•.:.................: / ...............:.......-............................................. Figure 13.--Reproducible computation Term. 45 yr�4� a 4 :I G t ( I f3 y. I 1 T = s ' i s VW i OF BARNSTABLE TOWN LOCATION v��l� O/�! T SEWAGE # 0�-6✓r`T VILLAG ASSESSOR'S MAP &LOT Ll , a 1 — INSTALLER'S NAME&PHONE NO. AprxyZelll �f57 >7/-3P3ef SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -Z�4 Ac -(size) NO.OF BEDROOMS BUILDER OR WNE 74 PERMTTDATE: ld` '� COMPLIANCE DATE: ! _ — IS Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 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) f Feet Furnished by 3g III G� O No.g ^ t fl Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MA ACHUSETTS 0(ppfication for Mkgool *pgtem Construction 3dermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ?'Individual Components Location Address or Lot No. 3 5_54 �ejw r l,,.:el, Owner's Name,Address and Tel.No. /` I'larIvV17 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Jt Lot Size sq.ft. Garbage Grinder Other Type of Building ' .j7CB No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow )ld gallons per day. Calculated daily flow gallons. Plan Date 7//6' q Number of sheets Revision Date " Title D ,E s1.` —; �S Size of Septic Tank ® X/ Type of S.A.S. s Description of Soil X Z 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 the system in operation until a Certifi- cate of Compliance has been issued by is Bo d o Health. Signed I Date Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued r 6 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in,cornputer: PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLE., MA JACHUSETTS Yes 0[pplication for �iopo'!M[ 6potem Construction Permit Application for a Permit to Construct( )Reydauf'n( )Upgiade_( )Abandon( ) El Complete System TI'Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 05) 07:0 0 6? Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. nm!;� 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building ,iRee No.of Persons Showers Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow 5750 gallons. Plan Date 7 Number of sheets Revision Date 4--4,, 7-70-Ap Title I. — Size of Septic Tank 1,5­0e � Type of S.A.S. zvI eW' I fe-A5 �,T. . I Description of Soil 6-4/ Nature of Repairs or Alterations(Answer when applicable" ee A, eeO, Mae 41 !�72 le t lape 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 issued by, is!Boar o Health Signed V19 - — , I Date Application Approved b Date 1 Application Disapproved foAthe following reasons Permit No. X!�ngF�— _ Date Issued . r -_ - - . _i, ---—————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS I � Certificate of (Compliance THIS IS TO CE4TIFT,th t the On-si e Sewage Disposal System Constructed Repaired (lv_��Upgraded Abandoned( )by at 22 4ll;�?11.lpal,17/W, has been constructed in ac d Fgangg with the provisiols o(Title 5 and the for Disposal System Construction Permit NoYX'464r dated Installer -Designer The issuance of this permit shgll no be construed as a guarantee that the system will function as designed. Date Inspector -------------------------- ---------Fee 0�� Fee SO THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS liqool *pftem Construction Permit Permission is hereby granted to Cons Repair Upgrade Abandon System located at 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 thi t Date: Approved"r, TOWN OF BARNSTABLE V, LOCA, ION SEWAGE # VILLAGE ® 1 /'y%/1t® ASSESSOR'S MAP & LOT 61 11, INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 40011P r3zv LEACHING FACILITY: (type) -Z 41X S CS) (size) (24 f6 la � NO.OF BEDROOMS BUILDER OR WNE�� PERMIT DATE: A0��'Q�' 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) .t Feet <Furnished by =` � �� ���' �� �._ �'.. � �� �� . � ��I y w �_ ar:i .. O ��. '►� .S K..F:r l •'1. � l �� � e � � t + � R. C w\ No. - FEE 2 THE COMMONWEALTH OF MASSACHUSETTS J � Pt p'+_345M , MASSACHUSETTS &pp1tratiun for Disposal *Votem (gonstrurttun Permit Application is hereby made for a Permit to Construct( ) or Repair X) an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 9q(�•.. FCC wl .laM t�a�--t- o t5w t�,Ar Installer's Name,Address,and Tel.No. I"' _ 16 91 Designer's Name,Address and Tel.No. C01.�j1� �CN �Ow�--1 Co► k.. �N(ot6t�Qi�l►JZa ��r�C 3 Type of Building: Dwelling No. of Bedrooms tP Garbage Grinder( ) Other Type of Building No. per Persons Showers( ) Cafeteria Other Fixtures Design Flow tAo gallons per day. Calculated daily flow �+'�S• gallons. Plan Date �-' 5.� Number of sheets 1 Revision Date TP Title At--D SI=.IJJL+. Description of Soil 4 �� ® � 3`�-5�� L•5. r 5"-I IN S•�»• r `!N 32� G.S. �o 2 -t32 ' /►'1.5, ,5 Nature of Repairs or Alterations(Answer when applicable) 004�Dre—+ TD '-'rtTLg-_ 5 Date last inspected: f Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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 � Certificate of Compliance h ee issu d by�Bof Health. Signed Date L�J51g(rs Application Approved by Date ! I -& / Application Disapproved for the following reasons Permit No. �� ' `��� Date Issued FEE d r . THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS �yyfirativn for (gIInstrurtion ]Jerrnit is here m for a Permit to Construct or Repair an On-site Sewage Disposal System at: Applicationby ade ( ) p �) g p y Location Address or Lot No. -� Owner's Name,Address and Tel.No. 991+- 4CDO WIL.Z ? L���'r =S O Installer's Name,Address,and�Tell.No. rl I ,k— `�,,11 Designer's Name,Address and Tel.No. �2--� f�t1��Y'� ®Owl-1 �`,vk- E1L11to tatt. 5' S .Type of Building: Dwelling No. of-Bedrooms Garbage Grinder( ) Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ( gallons per day. Calculated daily flow �� gallons.. Plan Date k 5 - 9 to Number of sheets t �+Revision Date 11-(44`To Title ' Description of Soil p -3u �tl� G LI. 5, 4 � -A b t /© '2. �aP1.. Nature of Repairs or Alterations(Answer when applicable) :ro 7'trta 5 .. F Date last inspected: w. Agreement: s The undersigned agrees-to ensure the construction and maintenance of the aforedescribed 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 Certificate of Compliance Vee. issu d by his Board Health. F Signed l Date q Application Approved by 4, Date j Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS or&WO 6V I. IQN`��� , MASSACHUSETTS Gerttttrate of (foutyltttnre THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced( ) on .�-- b Px ., y ! .��..�. ,�,Er,��r for at R (0Ail 4 N&V has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 3 dated Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on DATE r1 ✓ J Inspector THE COMMONWEALTH OF MASSACHUSETTS No. �j� , � bb TA � , MASSACHUSETTS FEE ` ,Ptsposal **item Construction ]Jernttt r Permission is hereby granted to �� '" to construct (fir) or repair( )an On-site Sewage System located at > f`- � 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. All construction must be completed within three years of the date below. DATE Approved by FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA - b.,:,, 'r. ;��t,;,,�?}r,:�s"T"u'r tx :w�,�,s. q^ ,.. ..,+ 'i'*>.'�,..•y.,,,..rv,�r'�,'�' ..u,...p.y✓".,w«r �a*r^,�:'x^r".,�''' F "y .'rs`'":,.-., . .,TOWN OF 'PARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: ` 11 nt`11 `a `C "l MAP NO. I- -> PARCEL NO. ' f t OWNER`NAME."4 F' { 1�-, 6"A5_. VILLAGE: J() ,rF 1, V l4 L INSTALLATION DATE: . ! BY: ADDRESS: CERT. NO. (= TANK INFORMATION LOCATION OF TANK: , fi'r 1;1 r)G7 CAPACITY -TYRE AGE. u ?,FUEL/CHEMICAL . T—,3 - TESTING CERTIFICATION E ] PASS C I FAIL DATE LEAK DETECTION C ] CHECK IF N/A TYRE/BRAND ZONE OF CONTRIBUTION C 7 YES C NO DATE TO BE REMOVED FJTRE-`-DEPT PERMIT ISSUED --C 7 1(ES' C ] NO=- DATE " CUNSERVAiION C 7 CHECK IF N/A DATE , BOARD OF HEALTH TAG NO. 47E ]C ]C 7 C ] DATE t I , PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION- ON THE BACK OF THIS CARD i SEPTIC PROFILE TEST HOLE LOGS �` } T.O.F. AT EL c. (NOT TO StlkE) � AC(XM COVER TO Ex e-A-%2rc iW. � r��,,>s✓k-. ACCESS ACHN �COVER NwAT ) to ENGINEER: r:�.. ��a � .� f 11ll UM .75' OF COVER OVER PRECAST / \ _ 1 :. OF FI . GRADE - � 2X SLOPE REQUIRED OVER SYSTEM j _..J - WITNESS: ;!>,r. , __ air s RUN PIPE LEVEL `-`- _ �•, J .__. ' � _ FOR FIRST 2' �� l DATE: � PROPOSED � = � � I rt� II GAUD N SEPTIC TAW (H. ) Tl ��z / . INVERT PERC. RATE - � � 6ir CLASS -- SOILS P ice- -;5 _ t .yt �X SLOPE) DEPTH OF FLOW ' COMPACTION.CRUSHED STONE O[2))ECHANICAL TEE SIZES: (i% SLOPE) (1X SLOPE) '- ?j - �I�' 1 'Is ov4�r��.E- s► Q �1 aJ Qr 2.l 3 INLET DEPTH- OUTL.ET DEPTH I Z Y Lam. LOCATION MAP z , I ASSESSORS MAP _ PARCEL FOUNDATION— �1 SEPTIC TANK - �= — D' BOX Z7 — LEACHING - -- 1 FACILITY , FLOOD ZONE 3i lv�r 5 1 1 S•to BUILDING ZONE:_ SETBACKS: FRONT - 3 SIDE - ► S_ _l Jl R ( REAR tS -. .•". ;i�{�r- �- $ ` -' �/ +� I I PLAN REFERENCE: -2 ? 15�°` - 4- _ NOTES.: �. - - ' i � 1. DATUM IS - — oR AS _ ) WATER --- - '� � .EPtIC E iGN: � �- � > 2. UUN1t;i1�A� 9� � � ,\" — r' P.I• ,! >{„� � � 1 _—. __ _ 8lu' Pt�.�E.R IS t--+� ��-L� W.��_ iS `bQ J f C`ES'GN 17'OW: _-- 9EDROOMS '__tv GvD� _ �c _ GPD 3. MINIMUM PIPE PITCH TO 8E '/8 PER FOOT. - -- 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHC-H � rra�, IaSE .a — GPO 0ESlGN FL OW 5. PIPE JOINTS TO BE MADE WATERTIGHT. 4 �. S .r TIC TANK: t,(.c� - ' r , ---_ _ L - _ ,ALLONS . CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ,• v LL ` t A SEPTIC TANK 6 ENVIRONMENTAL CODE TITLE V. USE GALLON SEP ` EACHING: i. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING. - C r 1 . _. --, r�- -�- 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. I t; ~�� \ - --- � 'LwJ Ei0 ,CM: _ (_ ) - _�_ GPO T >�_ I�???_._ I __ � _ 9. COMPONENTS NOT 10 BE BACKFILLED OR CONCEALED WITHOUT 42 ~ ' »J ---'""°� '" .�-'`"�-- / TOTAL. _=a S.F. a GPO INSPECTICN BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. Ir ' , . ?o.- � _. ,. r / r 1 � , _ . ..�E t . ,.�i r,a tt G+�r,�.^-s-•-!'(;Gt !•�11•S lZ�-1 / '. �.� ' '0. EXISTING C T I rt ` �'; G ,ESSPOOIi$,.TO BE PUMPED AND FILLED 'WITH CLEAN SAND OR REMOVED AS NECESSARY. `✓'6` ' 4-- d� i �c'/ I l. G L3►,.I.%��CY- '�37 I`�c..!= + r a•{ s.i"` r'"I !�•'�• k+G+h,}".� ,;_ i 1 .. t f� "'�-� (✓.1(.G-b•v s'-j i J't„-I 'i Gk.�-"'�` �(� -.?''n.. SITE AND SEWAGE PLAN OF I� IN THE TOWN OF: BOARD OF HEALTH APPROVED DATE 1tA PREPARED FOR: � i:�.VE `�E rlTfA SEA .- o O (ie:vt1, ,.�a¢ P- 0f p�,/EM��i SCALE: �,;> DATE: `' `ir I_ A2e-,i e V r! --2& r S•4 te:s.�. To io �r•.l kl�. down cape engineering, inc. Of CIVIL ENGINEERS ; .1 LAND SURVEYORS " pwt PHONE 508-362-4541 1 FAX 508-362-9880 z_ 93a JOB# ! main st. Yarmouth, ma 0,� ti �+ DATE SEPTIC PROFILE ST HOLE LOGS T.O.F.. . . AT EL Z'4 — -- - s (NOT To scuff - — ACCESS COVER T 0 e'/�r'ti 1 F \ w. . . ACCESS COVER (WATERTIGHT) TO ENGINEER: �, �A. Pe / . GRADE —_- }_ M1 , Ai11N14AU�1 . r �.- ► ©Tar-ca / ��� !_ rI } \ 'S' OF COVER OVER PRECASTWIIH 6' OF FAN Zvi.S 2% SLOPE REQUIRED OVER SYSTEM -- ------- - ' ------ � WITNESS: - -._ r r a .. -.<-• -ter -_z - RUN PIPE EVES --� DATE: ----- -- I I FOR FIRST 2' Lo PROPOSED GALLON SEP"'C E �Y[ a Jy,/T1 P ER(--'-. RATE 2 -A�PJTANK (H- _) ' IINERT - - . C LASs __ .ram._— SOILS P (L% SLOPE) - tt �, 6' CRUSHED STONE OR MECHANICAL J� t DEPTH OF FLOW a =-- COMPACTION. (15.221, (2]) TEE SRES: (,LX SLOPE) (�X SLOPE,, t ''/4 �/ 9t3e � � � � 1r1'•,-r � I� NLET DEPTH a I O I L �O�(�> fc-h�5 (J ht OUTLET DEPTH I 3' , ' -- -------- �"Gtv r•a {'`srZ-tom) e:x 1 T I t-!✓�.-I�-�f ���`� I �.2 = " �. LOCATION MAP �' = 2• ` ���t '�rG �rt hr rii..�s�'t F►.oyu '� O, IAiayc. I _ ,e., �-4 K � I s 1 II �. ASSESSORS MAP -- _� PARCEL _.__ FOUNDATION— �? -- SEPTIC SANK `�4 D' BOX _--- ------- FACILITY -_+- FACILITY � 6 ; ��, I FLOOD ZONE -- 44 say BUILDING ZONE: _ �'' t✓I-5 . { SETBACKS: FRONT - 3c, �— �'� `_' r - 1�►5S' iK t t.:!t i 5`( L1�4 SIDE — (S . G C J0 F. ,��" \ � ,r11 H i '�"►i►i�.J!'�F1� .%N rJ,..�'- `. ,`1 I REAR - t PLAN ,REFERENCE: — poor �l/j(I �. I 4 ` t i '► V9 o�r �r �1� 1. DATUM IS 5`-PTIC DESIGN: waAGE DlsPosER Is o �- ti MUNIL1f✓AL wATEK iS c __---- _ fJ T' t-w kLr�. t 3. MINIMUM PIPE PITCH TO BE 1 /8' PER F00T. �, 1 D SIGN FLOW BEDROOMS ( t t r GPD) _ :2�© GPD Z y USE A �E vP0 DESiGN FLOW 4. DESIGN LOADING FOR ALL UNITS TO BE AASHO-H _- 1. xf/ ! TF T r5. PIPE �0 NTS TO BE MACE WA� �R,IGN, . SEPTIC TANK: :=s GP^ ( ) = ILQQ GALLONS 6. CONSTRUCTION DETAILS TO 3E IN ACCORDANCE WITH MASS. USE A f- GALLON SEPTIC TANK �� s`�Ti�cvr ENVIRONMENTAL 'CODE TITLE V. --- 4- i. THIS PLAN !S FOR PROPOSED NORK ONLY AND NOT TO 3E SIDES: —_"sue._! .'i\� Z (_�1 la? GPO USED FOR LOT LINE STAKING. �I / "'e°c ( f✓-A."f 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4' P`/C J BOTTOM: ( ) _ L_ ;PD - 9. COMPONENTS NOT TO BE BACKFILLE D OR CONCEALED WITHOUT 7"DTAL: ]_� S.F. '2(k GPD INSPECTICN BY BOARD OF HEALTH .AND PERMISSION OBTAINED FROM 80ARD OF HEALTH. / L• s.4 1,� i D Ii� tL Z��,,,. ter'•-' /•.—.,._.. . ^,,,,,•- ; � � ��� I g� — , .mil= t.' ,,�I(;i����.C�- -!T�f `►•.�f 1 v 1 ��j:J 1L�( � �' ? ! 1 ` •, moo , �7a, �� r I." ",.- JL 10. EXISTING ("ESSPOIDUS)TO BE PUMPED AND FILLED WITH CLEAN SAND OR REMOVED AS NECESSARY. t~ 1 =t z GoQ?"r,,.`TQ %J, tt► F*r ;'I r , 1'4*..A--T„a �h- �P t� r �h� . >r�l s.-I T'�-t` ° {o ►.�s� ' F�vr� '`7��'j°t� S��- <_ *'�04nA4A$- 04KI ► ,�l Or , r� --� � SITE AND SEWAGE PLAN OF 1�1 THE TOWN OF: BOARD OF HEALTH -, L ►. )F1o,�. �'vTlc of e-x PREPARED FOR: t t^F F`''f 4a�r911 ��'Ch'( �V� " AaM f�c►t-a .APPROVED DATE s. f��►.A v�/(` " �i w 1�►,t�} Lt.drp',..1 hA-r+O 1�, Feet SCALE: _�?' ', DATE: 1I1-�1_ down cape engineering, in e. or CIVIL ENGINEERS A �RNE ', As r.l Ot,��,�s, LAND SURVEYORS " ,- ' ' a PHONE 508-362-4541h FAX 508-362-9880 939 main st. armoutht ma pJ iE DAT JOB# �.� }�, y