HomeMy WebLinkAbout0560 SEA VIEW AVENUE - Health 560 ;Sea Vieeti avenue ` \
Osterville
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COMMONWEALTH OF MASSACEIUSETTS.
EXECUTIVE OFFICE'-OF ENVIRO.NMENTAL'AFFA(RS
DEPARTMENT OF E.NVIRQNMENTAL PROTECTION.
I
TITLE_5 .
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL.SYSTEM..FORM
PART A
CERTIFICATION
Property Address. 560 Sea View Avenue
Osterville MA 02655
Owner's Name: James Phillips
Owner's Address:
Date`of Inspection. 'March 5,2012
Name of Inspector: (Please Print) Janes . Ford
Company Name: James M.:Ford=
Mailing Address: P.O.Box 49
Osterville,MA 026554049
Telephone Number: (508)862=940.0
CERTIFICATION STATEMENT r
I certify that I have personally inspected the sewage disposal system at this address and:.that the informatton reported-=i
below is true,accurate and complete as of the time.of the inspection:`.The inspection,was performed based on b y
training and experience in the proper function and maintenance of on site sewage disposal systems 3 I am a D)iP
approved system inspector pursuant to Section 15.340 of Title 5:(310 CMR15.000). Theaystem
Z;
✓' Passes`
71—
Conditionally Passes ?'
Needs Further Evaluation by the Local Approving Al thority
Fails
Inspector's Signature `Date March-14, 2012
The system inspector shall s b it a.copy of this inspection'report to the Approving Authority(Board of Health or
DEP)within30 days of comp eting this inspection. If the system is a shared system or has a'design flow of 10;000
gpd or greater,the inspector and the system owner:shall submit the report to the appropriate regional'office of the
DEP.' The original should be sent to the system owner and copies sent to the buyer,if applicable;and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection aitd under the conditions of use at that
time Tliis:inspectiori does not'addresshow the system will perform in the future under the-same or different
conditions of use.
Title 5 Inspection Fonn 6/15/N00 page 1
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Page 2 of 11 `
OFFICIAL-INSPECTIO 4 FORM-NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART.A
CERTIFICATION (continued)
Property Address:' 560 Sea View Avenue
Osteryille,MA
Owner: . James Phillips
Date of Inspection: March 5, 2012
II ts e cti on Sum
mary: Ch eck AB CD0 rE ALWAY
S co
mplete all ,
of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described'in 310'CvIR
15.303 or in 310 CMR 15.304 exist: Any failure criteria not evaluated are indicated below.
Comments;'
B. System Conditionally Passes
:
1
One or more system.components as described in the"Conditional Pass" section needto 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 lor break.out or high static water level in the distribution box-duo 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:
s .
The system required pumping morethan 4 times a year due to broken or obstructed'pipe(s)'.The system wilt:
pass inspection if(with approval of the Board of Health)'. .
broken pipe(s)are replaced
obstruction is removed
ND.explain:.:
-, 2
r
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Page 3 of 11
OFFICIAL.INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
,INSPECTION FORM
PART A
;CERTIFICATION (continued)
Property Address: 560 Sea View Avenue
Osterville MA
Owner: ,James Phillips
Date of.Inspection: March 5. 2012
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 MO CMR 15.303 (1)(b)that the
System is not functioning in:_a manner which will protect public health safe ty 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,i 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 1..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 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 matey 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.tbe 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:
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Page 4 of 11
OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM .
PART A
CERTIFICATION: (continued)
Property Address: 560 Sea View Avenue
Osterville.MA
Owner: Janes Phillifts
Date of Inspection:. March 5 2012
D. System Failure Criteria.applicable to all systems:'_
You must indicate either"yes"'or"no"to eachof the following for all inspections:
Yes No
✓. Backup of sewage into facility orsystem 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%z day flow
` Required pumping more than 4.times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped._.:
✓ Any portion of the SAS,cesspool or privy is below.high-ground water.elevation:
Any portion of cesspool or privy is within 100 feet of a surface Water supply or tributary to a'surface
water supply.
— " ✓ Any.portion of a cesspool'or privy is within"a Zone:I"of a public well..
_ ✓ Any portion of cesspool`orprivyis within-50 feet of a private water supply well.
Any portion of a cesspool,or privy.is less than l00 feet but greater than 50 feet from.a private water
supply well with no'acceptablewater quality.analysis: [Tills.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.]
No (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 Tails.,The system owner should contact the Board of
Health to determine what wilt be. to correct the failure:.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10;000
gp gpd;to 15,000
d
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 IL of apublic water supplywell
If you have answered"yes"to any question in Section E the system is considered a significant threat,or:answered
"yes in Section Ei 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 CIvIR
15.304. The system owner should contact the appropriate regional office of the be
4 .
Page 5 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE•DISPOSAL SYSTEM INSPECTION'FORM
PART B .
CHECKLIST
Property Address: 560 Sea View Avenue
Osterville MA
Owner: James Phillips
Date of Inspection: March 5 2012, .'`
Check if the following have been done: Yon 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? (Ifthey:were not available.nofe 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 detennined based on:
Yes No
✓ — Existing information.` For example,.a plan at the Boardof 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)].
5
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 560 Sea New Avenue '
Osterville MA
Owner: James Phillips
Date of Inspection: March 5. 2012
FLOW CONDITIONS
RESIDENTIAL q
Number of bedrooms(design): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
Number of current residents: 0
Does residence have a.garbage`grinder(yes.or.no): N/a
Is laundry on a separate sewage system(yes or no): N/a [if yes separate inspection required]
Laundry system inspected(yes or no); no,
Seasonal use(yes or no): no
p.
Water meter readings,if available(last 2.years usage(gpd)): Unavailable
Sump Pump (yes or no): No
Last date of occupancy: Unknotivn.
COMMERCIAL/INDUSTRIAL r
Type of establishment:`
Design flow(based on 310 CMR 15.203): _gpd
Basis of design flow(seats/persons/sq/ft etc.):
Grease trap present(yes orno):
Industrial waste holding tank present(yes':r 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: Unavailable
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons 7 How was.quantity pumped,determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorptionsystem.
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 cop
y.of the DEP approval .
: Other(describe).., .
Approximate age of.all components,.date installed(if known)and source of information
Date of installation 12112103 per as'built card
Were sewage odors detected when arriving at the site(yes or.no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMJNFORMATION(continued)
Property Address: 566 Sea View Avenue
Osterville MA
Owner: _ James Phillips
Date of Inspection: . March 5 2012
BUILDING SEWER(locate on site plan)',
Depth below grade:
Materials of construction: cast iron. 40 PVC other(explain):
Distance from private water supply well or.suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.)::
SEPTIC TANK: J (locate on site plan)
- Depth below grade: 10"
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:. 1500 eat. H-20
Sludge depth., 2ff
Distance iron!top of sludge to bottom of outlet tee or baffle. 30"
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: 10'.'
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity;aiquid levels
as related to outlet invert,evidence of.leakage,.etc.). a
The tees were Present. The liquid level was even with thel outlet invert Theme did not appear to be anv sigans o lealra e
GREASE TRAP: None.(locate on site plan)
Depth below grade:
Material of construction: _concrete. _metal fiberglass _polyethylene `_other
(explain):
Dimensions:
Scum thickness:
Distance frorp top of scum to top of outlet tee or baffle: '
Distance from:bottom of scum to bottom of outlet fee or baffle:
Date.of last pumping. :
Comments(on pumpmg..recommendations,inlet and outlet tee.or baffle condition,structural integrity, liquid levels
as related to outlet'invert;.evidence of leakage,;etc,):.
7
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART G
SYSTEM INFORMATION (continued)
Property.Address: 560 Sea View Avenue
Osterville.MA
Owner: James Phillips
Date of Inspection: March 5. 2012
TIGHT or HOLDING TANK:, None (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:
g allons
Design Flow: ..gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no)
Date of last pumping:
Comments(condition of alarm and float switches,etc.)::
DISTRIBUTION BOX: ✓ (if present.must;be opened).(locate on'ite plan)
Depth of liquid level above outlet invert: Even
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: Nome-'`(locate on site plan)
Pumps in working order(yes or no): "
Alarms in working order(yes or no)
Comments(note condition of pump chamber,`condition of pumps and appurtenances;etc.):
8
s� Page 9 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY"ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 560.Sea View Avenue '
Osterville,MA
Owner: James Phillips
Date of Inspection: March 5. M12
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on.site plan,excavation not required) ;
If SAS not located explain why:
q
Type
leaching pits,number:
leaching chambers,number:
✓ leaching"galleries,.number ,6-leach chambers 12''r 53'per asbuilt
leaching trenches,number,length
leaching:fields;number,dimensions:
overflow cesspool,number:
Innovative/alternative system. - Type/name of technology:'
Comments(note condition of soil,signs of hydraulic.failure,level.of ponding,damp soil,condition of vegetation,etc.):. ,
The chambers.were dry and clean 7&ere did not appear to be any signs of failure A camera was used tor-the inspection
CESSPOOLS: None (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' condition of vegetation,.etc.).
PRIVY: None (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.):
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Page 10 of 11
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'OFFICIAL INSPECTION FORM-NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y. PART C:
SYSTEM INFORMATION`(continued)
Property Address: ,560 Sea View Avenue
Osterville MA
Owner: Janes Phillips
-Date of Inspection: March 5. 2012
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system:including ties to at least two permanent reference landmarks of
benchmarks. Locate all wells within.10o feet. Locate where public water supply enters the building.
00
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Page 11 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _.
SYSTEM INFORMATION (continued)
Property Address:. 560 Sea View Avenue
Osterville,MA
Owner: James Phillips
Date of Inspection: March 5, 2012 '
SITE EXAM
Slope
Surface.water
Check cellar
Shallow wells
Estimated depth to ground water. 14+/- 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:_ Topumr hic and water•contoitis maps`'
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:;
You must describe how you established.the high ground water elevation
Using Barnstable topographic and water coil/ours maps the snaps were showing approximately 14+/ to Qi ound water at this
site.
This report.has been prepared only for`tlie septic system and components described her el
Thi'sseptic systein has been:
inspected and passed as of the date of inspection:,This report is not a wdrr^aruy or guarantee that the system will
fzirzctiori properly i.rz the fixture. There have beemizo warranties or guarantees, either,expressed, writteiz.oi--implied,
relating to the septic systeni, the inspection,.this report and%r any components of the septicsystens which have riot
been located and inspected. .
11
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No. --------- Fee----- ---- --
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zipp[icat ion-*rWell Congtruction3permit
MTWN Jet
Application is hereby made f r a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
— Location — Address Assessors Map and Parcel
r_-?-k i r 1�_ -__--------- ----
Own r Address
I
�,_' �fit_ �_�-c w S�--e✓ c)Z� 3 �
------� !�_ —_- - - ------ ---------�---------- ------- ------______----------
Installer — riller Ali Address
Type of Building
Dwelling ----- -— — ------------
Other - Type of Building------------- - No. of Persons-- -------------------
Type of Well "I' R V C�
Purpose of Well- P -i ®K�------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well rotection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate f mpliance has been issued by the Board of Health.
d
Signed - 30 —-
Application Approved By — — - —
date
Application Disapproved for the following reasons: ------—- - —--- - ---—-----
date
Permit No. — —— -- Issued--------------- -- -----—
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compfiance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by----- ------------------------ ---------------------------------------------------------------------
Installer
at- -— -- ---—----- - -- -- -------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. -------------Dated----- --------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE—---- - -- Inspector---- — - - - -----------
w
No.------- - ---- Fee----- --------------
r,` BOARD OF HEALTH
'R TOWN OF BARNSTABLE
(pp[icat ion ArVeil Con5tructiodDermit
Application is hereby made f r a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
e'
Location = Address Assessors.Map and Parcel
Own r Address
1 -— Lam-- — - — - ------, L $"c w s+e v c3 Zb 3
---- ------ -------- v---------------------------
Installer / nller A 11 ��� Address
Type of Building
Dwelling ----- -- —----—
Other - Type of Building--------------- - No. of Persons-------------------------------
1
Type of Well
-----__-- Capacity------------------------=-------.
Purpose of Well --
r
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well rotection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of mpliance has been issued by the Board of Health.
<R 3L)
' Signed -- — -- — — —
Application Approved By r
f � � date
Application Disapproved for the following reasons:---------------------- - -- - ' —
i
j date
Permit No. -- — Issued------------- -------
{.. w date ---------
I,
BOARD OF HEALTH
tTOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
Installer —
I,
i
at —
{
€ - -— -----——-- ----
i
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. -----------------;-Dated-------------------
C
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ — — - -- Inspector— ---------------------- --------—----
BOARD OF HEALTH
TOWN OF BARNSTABLE
ell CongtructionAermit
o _� V Fee- - ---
.N -
AzlPermission is hereby granted 1 l/7
11
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to Con tr t ( ), W-I , or R i ( an I ividu Well at:
No. -�/y is -�� -�— YZL C,
-----------------------
street
as shown on the app/li ajti9n for a. 91 Co S�truction Permit
'E No.-- ( �-t' — Dated �J ----------- ------
v 7--
�� �J
——— - -- ---------------------- -
11521k, Board of,H/alth
DATE— � -� / ----
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TOWN OF BARNSTABLEc,
LOCATION SEWAGE # al)Q 3 S
VILLAGE LCIA I ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE.NO. (►J ,( l'1 � L_ .�c�l.lb''1
SEPTIC TANK CAPACITY. O0
LEACHING FACILITY: (type) _ (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: I OS COMPLIANCE DATE: I l
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) V Feet
Furnished by
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I ' ------------------- ------------------- ------------------ RESIDENCE
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I JAMES OZ IWL
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REED A.MORMSON
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I BASEMENT FLOOR
PLAN•DEMOLITION
CSe: SCIe
OBAMWWFLOORPUIN,DEM UTION
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Town of Btarnstable 1'Il /�, �5 0
Department of health,Safety,and Environmental Services /
�1"E Public IIealth Division Date 8- ll -03 ✓
367 Main S(rcct,Ilyannis MA 02601
• BARNRMBM
NAB&
rEunAl�+A )ale Scheduled 7 /Z D3 "Title AM Fee 1't1. 00. 00
Soil Suitability Assessment for Setvage Disposal
Perrormcd 11y: S JA1VgJ\ Witnessed B �
Y: _�,im Why
LIOCA i'ION & GL+NliIZt1[G INIi O1tMA I IUN
Location Address 5(Q0 Seavi�Lj" AVena2 Owner'sNantc Ph%Ilips
Os�eTv;lle , �1R.
Address Nill RO•dl
Ntw Cun�y. 0- 0(08yp
Assessor's Map/I'arccl: I ICI ' �(OS Gtginccr's Namc PeAcr So\\N\Iq
NEW CONSTRUCTION V REPAIR .5v11wcte\• Cn.3in Qr e .n,
p_ 1 Telephone SU -`1Z$- 33y
Land Use .—CCSI[�A1 q, Slopcs(%) Surfacc Sloncs MIN
Distances from: Open Water Body + It Possible Wet Area
+ R Drinking Water Well �� } R
Way ��Drainage + r t
g Y `S R 1'mper(y Line 8S _ 1`1 other_ fl
SKETCH:(Street name,dinnensions of lot,exact loeatioos Dries(holes&perc tests,locate wetlmnds in proximity to holes)
A
' - T
t 4�, -8
} /Z.,J
NU
N ...
Parent material(geologic) 00 Lxls P I) Depth to Bedrock 500 t ±
Dcplh to Groundwater: Standing Water in Ilolc: AlQVE Wecping from Pit Tacc_V RE VED
Estimated Seasonal I li h Groundwater EL �g Z•S (�Ror1 l 0
< MAP)
A t1.�L`1'L+'It1VIYNA ION X�O! SI.ASOIVAL rx[CII 'VVA"I +Yt TAY3LI r SEP 1 6 2003
Method Used: NON- SEE" A►46� 70VrJN O
Depth Observed standing in obs hole: BARNSTABLE
in. Depth to soil mottles. HEALTH DEPT.
Depth to weeping front side of obs.hole: tt .- .
in. Groundwater Adjustment
•' Index Well N_ _ _ Rending Date: Index Well level n' I—..—__ Arlj.factor Adi.(-it ound%valer Lcvel
Plt,ItCOLATION'I' SST uRtc9 a Ltnic. Q(7
Observation
Ilolc N
'Time at 9"
Depth of pert 35"
Titne at G"
( V
Start Pre-soak"I'intc(rl
End Prc-soak
Rate Min./Inch G Zrrt�L�_
Site Suilabilily Assessment: Site 1'asscd ✓ Site Tailed:
Additional 1'csting Needed(YIN)
Original: Public licaltll Division Observation hole Data To Ile Cotnpletcd on 13ac1( .
Copy: Appre nt j
I)>��,1'OI��L+"+ILVA lON iOY.�'Y�UG
Depth from Soil Ilanzon Soil Icxlurc Soil Color Soil
Surface(in. Other
(USDA) (Munscll) Moulin
g (Structure,Blanca,Iloulducs.
PIRGSAND W _ u i tcn�. �oGravcl
�--�-- OU2ANICS 0 S
MED. .5AND
3 /6 3 —`
C CoAfSE SAMU Z'S
D >;P oUSE1tvA ION DOLL LOG �Ic It #
Midi from Soil Ilorizou Soil'Texture Soil Color Soil 01hcr
Surface(in.) (USDA) (Moll
Mottling (Slructurc,Stones,nouldcres.
—co mlSJ5snv-1,9 CUt_aYL1)
044T 90$ �A AT Orr t oL BOG xo��
Depth from Soil Ilonzon Soil Texture
Soil Color Soil Uthcr
Surface(in.)
(USDA) (Munscll) mottling (Structure,Stones,Iluuldcres.
�L i 1Eylo Gra�•I�
vcc�� :::::.AT ION [TOLL [`aG W.Dcplh from Soil If
vrizoll Soil 1'cxlurc Suil Color
Surface(in.) Soil Other
(USDA) (Munscll) Willing (Slruclurc,Sluncs,Uuuldcres.
Flood Insurance Rate Mail:
Above 500 year flood boundary No—\Z Yes
Within 500 year boundary No— Yes
Wilhiu 100 year flood boundary No ✓ yes
POW of Nattrr•lly Occurring Pe' iolrs M Itel i rl
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certifythat -A on PR►I. fyjr, _(date)I have gassed the soil evalua
tor examination approved by tllc
Department of Environmental Protection and that the above analysis was performed by file consistent with
the re uir al '
1 g,experti n x erience described in 310 CMR 15.017.
Signature_ _ Date 1 Z�C3
TOWN OF BARNSTABLE
f
LOCATION SEWAGE #
VILLAGE - -AJJ�gS==S,;��--E��SSOR'S MAPS& LOT
INSTALLER'S NAME&PHONE NO' &� &iaC.t -�.Cy � ,►;<< '
SEPTIC TANK CAPACITY 00. '• k'1 ��'
LEACHING FACILr'Y: (type) ah•&� ' .�60p (size)
NO.OF BEDROOMS '
BUILDER-OR OWNER`
PERMTTDATE: COMPLIANCE DATE: l�
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'leact"g facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) V Feet
Furnished by
I� :4
0 0
a ('-772 ,
0
v �3
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(�aD'
�7 �` 'il(
�t
No. Fee #1��VV
`V
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: V
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Migwgal bpgtem Conotruction i3ermit
Application for a Permit to Construct( )Repair( )Upgrade(X)Abandon( ) %Complete System El Individual Components
Location Address or Lot No. SG O VC Owner's Name,Address and Tel.No.
os-reavii-Lt, InAss apmes G. PNIt_L-tPs
Assessor's Map/Parcel SGD sc19V/[.w AVE
M //y P65— C,S7EIZ✓ILLi /v)ASt
Installer'kNe,Address,and Tel.No. Designer's Name,Address and Tel.No.60fi-4 2 S-3 3 4 4
S 1J LLI t/AN-N(r/N6B1L 1 f1/G I!1/C-
;7l Cs-M&✓/LLE WASS
Type of Building:
Dwelling No.of Bedrooms ._°)S Lot Size I �2Z�►c sq-ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 5�® gallons per day. Calculated daily flow «_ •• w 6-3 gallons.
Plan Date Number of sheets Revision Date
Title SITE pc,4A/- Pro PosE®ADDytIoA,, a .G&P7--7G aP6-rl*D,
Size of Septic Tank 16-00 GVLLONS Type of S.A.S. 12°X :aLt/acd,�ra/�C/t/N/�fF3ER
5
Description of Soil 0 3�d A� G rtl Sit 13 ptw 1:r11'VE sto/✓D 1 o Y 2 3 � I g it
--[i— yFL isµ
BRN MED S,9/VP 10yfZ 18"= I-zo" BLIVE YEL. /M6D. 5141VD 2.3 Y G/G
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 be ' sue isBp, HePO" /f/7/D
Sign Date
Application Approved by Date
Application Disapproved for the following reas n
Am
Permit No. Date Issued
No. tl Fee
� V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: yes
PUBLIC HEALTH;DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Yicattort for 33iopozar 6potent ConMructian ertttit
Application for a'Permit to Construct( )Repair( )Upgrade(X)Abandon( ) ®Complete System ❑Individual omponents
Location Address or Lot No..SG O S 6/9 V/6 w AVC- Owner's Name,Address and Tel.No.
OSTE•2✓II—LE, IW14SS J/;A4 5 G. PHtt-.LIPS
Assessor's Map/Parcel 5G0 S,--o vi s w AVE.
057'E2✓ILLS /MA5-r
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.50 Lf 2 S
�—
tr 7 PA2Kl=R- RD
71 .311� osr�2✓���� ss
Type of Building:
Dwelling No.of Bedrooms Lot Size I iZ2 ac sift. Garbage Grinder`( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 560 gallons per day. Calculated daily flow ' 6 16 3 gallons.
Plan Date Number of sheets \ Revision Date
Title SITE P,_41!/- PfUPusEDADD%-tioA/ c} -G&F77c "PCrA./>A;-
Size of Septic Tank /50G GALLONS Type of S.A.S. I V X 10 - Lt/ac�+�ryt C�i�Mr3ER
63
Description of Soil O A. G rY1 SH B R1� FINE SsIND 10 Y R 5/Z
BRN MED S,91y,D 10fZ S/G� IS �- 12al' OLIVE yEc.. NJEQ S.gND 2.S), L�G
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 be ssuejd Jis B and o He 1
Sign ! / Date
w Application Approved by W �,A ,/ Date
Application Disapproved for the following reason
Permit 42 - ,
`J Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
` Certificate of Compliance
THIS.IS TO CERTffFY that th On-si a Sewa a Dis osal Svstem Constructed( _.) Repaired( 1 Uo raded 1
Abandoned( )by ���Z D
at 5Lo SENWRW Ave OSte/Z//!LL-E� AnXSS has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 455 dated 9 -'1 l0-03
Installer Designer S14LL t /-1 - IVO llk6o.
The issuance of t 's p rmit shall not be construed as a guarantee that the system wi fi• a d ig
Date 1111olA3 Inspector .� .
No. Fee .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE., MASSACHUSETTS
Mizpaoar 6potem Cou6tructiou Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(X)Abandon( )
System located at..5-60 SSA///C LA1 Ae/Es , 0S72E 2l-1/LLE� m,45 S
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: Cons t ctio ,must be completed within three years of the date of this pe
Date:_ 1� Approved by
t
QD
r a
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 y��ryD�NTjgB�
508-771-9399 508428-8926 FAX: 508428-9399 e9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S
PART A
A J! CERTIFICATION
Property Address:
Date of Inspection: /0 7 Inspector's N 'e:
er's Name and Address: -
i0 7
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System: .
Passes
Conditionally Passes �.
Needs Further Ev tion.By a Local Aproving Authority
Fails
Inspector's Sig �/�. ��Z,: , , Date:-)
nature - t
..;.
The System Inspector shall submit a cop v of t his ins p 'ection r eport to.the Approving authority within thir-
ty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYS M PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion.of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined.(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,,structurally unsound,,shows substantial infiltration or
exfiltration,or tank failure is imminent.,The system-will pass,inspection if the existing sep-
_._. tic tank is replaced;with a conforming septic tank as approved by The Board of Health.=}
Sewage backkuppr breakout or high static water level observed-in the distribution_box.is due
to broken or-obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
-1 -
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART A
CERTIFICATION (continued)
."t
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four 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
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 the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNERTHAT PROTECT THE.PUBLIC-HEALTH AND SAFETY.AND THE
ENVIRONMENT:
The system has a septic,tank and soil'absorption,system and i`s within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.-
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool. _.
Liquid depth in cesspool is less than 6"below invert or available volume is'less than 1/2
day flow.,--
Required pumping-more than 4 times in the last year.NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
i-SUBSURF-ACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM ,.
PART A
CERTIFICATION (continued)
P i
Any portion of the Soil Absorption System,cesspool or privyjs below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well. `
Any portion of a cesspool or privy is within 50.Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well-with--no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
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 nitrogen sensitive area IriterimVellhead Protection Area.t
.(IWPA)or ma
pped apped Zone II of a public,water supply well. - ' t J _ "�
The owner or operator of any such system shall bring the system and facility into full compliance the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check the following have been done:
k, Pumping information was requested of the owner,occupant, and Board of Health.
V/None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
t/As-built plans have been obtained and examined. Note if they are not available with N/A.
,The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption System,have been located on site.
r/The septic tank manholes were"uncovered;opened, and the interior of the septic tank was in-
Y spected for condition of bales or tees,amaterial of construction;-'dimensions,depth of liquid,,
,,4epth of sludge,depth of scum. ,
4-,"The size and location of the Soil Absorption System on the site has been-determined based on
existing information or'approximated by non-intrusive methods:
-3- _
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
L.- a facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RFSIDENTL4,Le 2 / ,
Design Flow: allons Number of Bedrooms: 3 Number of Current Residents:(J
Garbage Grinder: ' Laundry Connected To System: Seasonal Use:
Water Meter Readi gs,if, ilable:
Last Date of Occupancy p"Vie t' !l�- c,Q /7�&X'da C]
COMMER LAi.%iND [ST iALe
Type,of Establishment:
Design Flow:_ , galloi day Grease Trap Present: (yes or no
Industrial Waste Holding Tank Present: - _ - --- _.____.__
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENE FORMATION
PUMPING RECORDS and source of inform tion: 1
System Pumped as part of inspection/00 If yes, olume umped:_ gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If s,attach previous ins ction recor if y
Cher lai ): 7`-
ROXIlNIATE AGE of all components,date installed(if known)and source of information:
Sewage odors det466ted when arriving the site:
r -
•SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
_ _:. -PART C _ - �.. •
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grader Material of Construction: k"concrete metal FRP_Other
(explain)
Dimisions: 6-'-Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 35
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees orb es,depth of liquid
leve 'n re 'on to u t invert, structural integnty„evide a of leakage,etc.) %
/ #
GREASE TRAP:
Depth Below Grade: Material of Construction:-
concrete-(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth ofaiquid
level-in relation fo outlet invert;structural integrity. leakage,etc.)g ty�evidence of
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBER,/
Pump is in"wo`rking order: ..
Comments:'(note condition of pump chamber;=condition.of.pumps,and'appurtgnarices;etc,)
5- •
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits, number: P-""'Leaching chambers, number: Leaching galleries,number:_
Leaching trenches, number, length:
Leaching fields,number,dimensions:
Overflow cesspool, number:
Comments: (note condition Qf soil, si of hydraulic failprF lev of pondin condition of g f lion,
etc.) a—
CESSPOOLS:-../-JU
Number and configuration: Depth-top of liquid to in_lef,invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
J ,
''-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r• _'` ' SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
I Include ties to atleast two permanent references, landmarks or benchmarks.,
j Locate all wells within 100 Feet.
I
to ea�,!t1
3, lj ,..
DEPTH TO GROUNDWATER: f
Depth to groundwater: 2-1 Feet
Method of Determination or APP roximation:
r ✓` (��
-7-
y=rEt
,y 53r;'^.( .y.�,r.y,,..k Y'�'•.;e�ik r'h�,�,,,;.5 9#»,a�ti
d.
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1-5
.,L000 f 5EWo,GE PERMIT QO-
VIL.L4GE
JW 7 LLER 5- U&ME ADDRESS--
-- - _ _° _ � , y
- BUILDER 5
DATE PERNAIT-15SUED
---DATE-. COMPLI &&ICE
6)
-to..............57`.4.... ..................
THE COMMONWEALTH OF MASSACHUSETTS
BARD F HEALTH
-r✓I'�...... .......OF...... . .
Appliratiun for Raposal Vorks Tottfitrurtiun Permit
Application is hereby made for a Permit to Construct (14'00or Repair ( ) an Individual Sewage Disposal
Syst at• _ --•----•••--•---•-_/�/�7
1............. :%5 -- � -- -------------------------/- ------ ............
. ocation- ddress D .......... .......�;z. ---_L.......... .. Me
W Own Address
da Installer Address y
Type of Building , Size Lot__ �. ?J.....Sq. feet
U Dwelling—No. of TBe�dooms.__.__.._ .......................Expansion Attic ( ) Garbage Grinder (!�
pa., Other—Type of Building ............................ No. of persons....................._------ Showers Cafeteria ( )
p' Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow................_...........................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter------.__----___ Depth_--_--_-..--.--.
x Disposal Trench—No..................... Width.................... Total Length-------_............ Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter................... Depth below Inlet..... _.__ Total leaching rea--__.--_____--____sq. ft.
dVF✓ l
z Other Distribution box ( ) Dosing tank ( ) — / L— 6 ,4 — &` 7S
aPercolation Test Results Performed by.......................................................................... Date------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--.--_-______-___._---.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------- --_-___-_---.
--------•----- -----------------------------
o r7 -
Description of Soil... 'G� V — ---•-............ �% ---- ---- --- -- ----- Tl��_ _
U ---------•----------------------------------------•---------------------------••--•-----------------------------,1'
W
UNature of Repairs or Alterations—Answer when applicable-----------------------------•--------•-.--___--__-•---.---.-----------__-.:-.-_---__--_-_--.-.
---------•--••-•---•---••------•--------•-•----•••--••••---------------••-••--•-•• -------------------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with,`
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system•'in
operation until a Certificate of Compliance has been issued he boar ealth.
Signe ... Ce o /® l/•-------------------------
i ate
Application Approved By---'••' % il�--- ..7,f"
Date
Application Disapproved for the following reasons:---------••----•----•--------------------------•-•-----•-----•---•-•------•----------------•---•-•--•••-•--•--
•-•--•-•---•-••••••-•-••.....----••••••-••••-•••••-••--••-•••---•••••••-••--•••••--•••••-••••••••---------•••••-••••--•--•------••-••-•••--••-•---•----•••••------•-----•-•-•---------•••...•----•••--•-
Date
PermitNo......................................................... Issued........................................................
Date
r
No......................... Fxs.. ..........................
THE COMMONWEALTH OF MASSACHUSET S
...... BOARD_... . ...._..............OF....................................... .............................................
. ppliration for Disposal Works Tlanstrurthin Vrrutit
Application is hereby made for a Permit to Construct (/, or Repair ( ) an Individual Sewage Disposal
System at: /
I` - - ----- ------ ----
Location-Address oLot No.
roe?
Owner- Address
W I f'.f( ,i.l f/'r�+�I �� �( •' fX 1'r "------ . ,
a r VInstaller Address
a
U Type of Building Size Lot__5�,R. l?'�:ra.____-Sq. feet Dwelling o. of Bedrooms.:______.__—._:-._._---_--__•.._________Expansion Attic ( ) Garbage Grinder (�°
Other—Type of Building �-___-• No. of persons-........................... Showers Cafeteria ( )
a' Other fixtures ......................................................-------•---•---------•------------•--------•--•••-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity....._...__gallons Length................ Width---------------- Diameter-------------_-- Depth-----__.---_.--.
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth bel inlet__ L Total leaching area.... sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) �'� t tO ^ 7`
Percolation Test Results Performed by.......................................................................... Date........................................
W
,_l Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................._. Depth to ground water...._.. .._.._.._...-..
0 •---•----•------------------------••---- -- -•t '� -
Description of Soil------=---�-'-'-11* ....=.....................................1- .. ----------------------------------- ---v 'C'L``
U -------------------------------------------------------------------•---•--•----------------------------•------ ---•-••-••-•......•--------•••-------•••-•-•-•-•----•---•-......-------•----.
W --
VNature of Repairs or Alterations—Answer when applicable._.._.:......................................................................................... r
---------------..................................................................................... --------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has-been issued by',the board-of
....................................-----------------------------------
-7!APPlication Approved BYA- 4 p -
--- ••-------••...............•••-•• - ------------------
_ Date
Application Disapproved for the following reasons-----------------•-----------•----------------------------------•----------------- ..............................
.......-•-------------------------------------------------------•--------------------•---•--•---------------•-•-••••-••-••--------•------•-•••----••----••--•--•-----. .................................
Date
Permit No. ......................... - --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
�.. - " ..................O F...... ..........GC�L-t".' ^
................................
/ f ratr of Trintplia trr
TH S T CE' , IF
ivi `la See Disposal System constructed or Repaired ( )
----�-------- '9 I St a j^
at----------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•--•-------------------
has been installed in accordance with the provisions of 7tic o he State Sanitary od a describes in the
application for Disposal Works Construction.Permit No......................................... dated_-_.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
la✓C��s
DATE.........AC .".............................................................. Inspector.---- -^--a------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD- F HE H
.3 F~- 7,-,)Lz� '
No......................... F�. ..................
u ow, rruti
. � _�� � �
Permiss> is hereby granted.........................•--- ------------.........-------••------,-----�� 1
toat truct r e �i an ndivadua e a i > osal S st
P Y
Street
as shown on the application for Disposal Works Constructi ermi o atel , d•________________!__-______-------____-----
' l • �`�'I� -. •--•--••----- - --- ---------------------------------
DATE � J Board of
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LOCUS PLAN
� i se• ; / ; / ��'�� � Scale: 111= 20001
/ Q / Assessors Map 114
Parcel 65
Zoning:RF—I
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Setbacks:
Front 3..0 I i
Side 15
PPi w/F P Rear 15'
j i � ���1NG• /i ! / / Groundwater Overlay AP
4012•
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\ SEAVIEW AVENUE
EXISTING SITE PLAN
Scale: 1 30'
I
CD17.
/
1
i ` EXIST. LEACI••I PIT TO 131=- / In
I PUMPED 4 REMOULD
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Pam- :�`, // 1•22 A cL
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PROPOSED SITE PLAN
scale I"= 30' NOTES
DESIGN DATA
Single Family-5 Bedroom I. Water Supply For This Lot is Municipal Water.
Fldah 2.Location of Utilities Shown on This Plan Are A TEST HOLE -
No Garbage Grinder V °„d, Approx.Daily Flow I10 x 5 = 550 gpd t At Least 72 Hours Prior to Any Excavation For This P#10,556 Date: 09/12/03
a Project The Contractor Shall Mcke The Required Performed By: Sullivan Engineering
Septic Tank: 550 gpd x 200 /0=1100 gpd i ;FIINr i
o�m«Ia FIII. Notification to DIG SAFE-I-888-344- 233.
c
Use a 1500 Gallon Septic Tank. ^kboie Witnessed By: Sam White
LEACHING AREA lie-Ile 3.The Contractor is Required to Secure Appropriate 0" A LAYER-10YR 5/2 EL. 16.0 I
�.s�,we Permits From Town Agencies For Construction
550 gpd/0.74=744 s.f.Required Defined by This Plan. GRAYISH BROWN s�rye Gy.
SidewaII:2(12 +53 )2= 260 s.f. Within �e ',• '
4.Install Risers as Required to 12 of Finished FINE SAND-W/ORGANICS
L.achln9
Bottom Area 12x 53 = 636s.f. ch.mn.. a/a~-I vz•°Wm. Grade. W B LAYER-10YR 5/6 EE 15.8 �
896 s.f.Total Provided. � w.:h.d
5-All Structures Buried Four Feet 1,4')or More or 55 s�V!,
LEACHING CHAMBER DESIGN I Subject to Vehicular tobeH-20 Loading. YELLOWISH BROWN .�
MED. SAND-SOME FINES �.
All Pipes to be Schedule 40 PVC.Use 6 6.Septic S stem to be Installed in Accordance With
-500 Gallon Leaching Chambers in a y 18" C LAYER-2.5Y 6/6 EL 14.5
g I CROSS SECTION OF CHAMBER 310 CMR 15.00 Latest Revision And The Town of I � atx
12'x 53' Washed Stone Field as Shown. NOT TO SCALE Barnstable Board of Health RegLIations. OLIVE YELLOW BY y.�°f ,c
7All Piping tobe Sch.40 PVC. MED. SAND „ f A
35" PERC TEST 35"-<2 MIN/IN EL. 13.1 �)
Connect Existing House Sewer 120" NO GROUNDWATER ENCOUNTERED EL-6.0
F.G.15.5 to Proposed Septic Tank -
Vent F-G.15.2 APPROX.GROUNDWATER EL.2.5 SITE PLAN
ri PROPOSED ADDITION &
I3L13.13
5` I2.4 ; SEPTIC UPGRADE
1500 Gallon Top El. AT
Septic Tank 13.05 �cr> BOtEI. 10.4
I2.85 12.6 560 SEAVIEW AVENUE
OSTERVILLE , MASS.
Bedding as FOR
Per Title 5 Bottom T.H.EL6.0 A rox.
Groundwater El.2.5TO.B. JAMES G.PHILLIPS
Groundwater Map. SCALE: AS SHOWN DATE: AUGUST 26,2003
DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM
SULLIVAN
Not to Scale OSTEAVILLEE INC.
MASS.
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