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HomeMy WebLinkAbout0089 STONE HORSE ROAD - Health PStonehorse Roa , Osterville s . X P t M •rl r r,� TOWN OF BARNSTABLE LOCATION r� SEWAGE# VILLAGE (/J sib,//s ASSESSOR'S MAP&PARCEL a INSTALLER'S NAME&PHONE NO. SY",07Y x.7c SEPTIC TANK CAPACITY /JZ9* .,;ol� LEACHING FACILITY:(type))?Jo C:,L C (size) /,7 NO.OF BEDROOMS OWNER ,s PERMIT DATE: /0— J r 9 COMPLIANCE DATE: Z 3 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) Feet FURNISHED BY ��� _� � ��ar a � _ �,��••� i ' ( p • �d �y' CO . . No. 9 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes plqq� apofication for Bisposal 6pstent (Construction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade(✓) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.�y 3�ohP f/a>se O er's Name,Address,and Tel.No. .,4P��/p �n�� d Puy l .�/c C�rt,•�, Assessor's Map/Parcel tea_pk4-1 ® 0 �� o✓S e �, Installer's Name,Address,and Tel.No.�®��O�pj `j�� Designer's Name,Name,Address,and Tel.No. a it v r Type of Building: �50�ya /1�Ili✓51rS //S �/� Oa(o`�' Dwelling No.of Bedrooms Lot S ize l y J9,a 4/, sq.ft. Garbage Grinder( ) Other Type of Building k1i No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 339 gpd Design flow provided 3yT gpd Plan Date //' a`/'O- Number of sheets o;L Revision Date Title Size of Septic Tank Type of S.A.S. 02-SOOs C! M�-✓s `/�S1o•� Description of Soil Se P 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 C de d t to lace the system in operation until a Certificate of Compliance has been issued by this Board QPTRalth. i .gn d Date Application Approved by e Date Application Disapproved by Date for the following reasons 3 Permit N . Date Issued Y Y.. -. 1..'-Llna 'S`.sa7w'ova*nn.,'vwrwr-::-..-.^w.+.r+-,.--w'°-'°-•..•ems:}:�v s.s is:-�+.-''i.�..;f:'.'ri...���,y.-..,-.. No. l r .: Fee; \ THE COMMONWEALT.,,H OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE,.MASSACHUSETTS Yes 0� ftprication'for Vsposai Opstem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade(✓) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.� j[P7-��/T��j��/o//� Owner's Na Jme,nAddress,and Tel.No. Assessor's Map/Parcel /ya- OkV /, Installer's Name,Address,and Tel.No.��/�Orpj�O/pS Designer's Name,Address,and Tel.No. Type of Building: ,l y�r� y-2 X �y �u'ar5/✓r�s ,�/ //s �/67 oat�' Dwelling No.of Bedrooms Lot Size 1 q j9 D?y sq.ft. Garbage Grinder( ) Other Type of Building / 5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 gpd Design flow provided yT gpd Plan Date /h a - 9 _ Number of sheets a Revision Date — -' Title }; Size of Septic Tank 15 0o p � Type of S.A.S. a-S00$ Description of Soil ' p ' .5'P t Nature of Repairs-orAlterations(Answer when applicable) a Date last inspected: Agreement: 1 t 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 d not to lace the system in operation until a Certificate of Compliance has been issued by this Board ealth. .gn d f D Date Application Approved by O U Date Application Disapproved by�T Date for the following reasons � r Permit N : Date Issued - - - -- --- ---- -- - _ - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) /Reppaiirred( ) Upgraded( ) Abandoned( )by .� .4� 1 /�// at Sy S�o�C 11pc15,t has been co r cted in acc d ce with the provisions of Title 5 and the for Disposal System Construction Permit NY ted 4 Installer Designer - #bedrooms 3 Approved design flow A gp.d The issuance of this pe" it shall not be construed as a guarantee that the system willfu cti`onl as s ed. Date T/J Inspector `Ar � � fr __--.----;--No.-- -----�--- --r-----�- -------------- -_-----•--_--�--------�-- - - ----------------'---- - Fee-=--- �THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-'BARNSTABLE,MASSACHUSETTS IISPOSal 6pstem Construction J)ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( ) System located at R ? Xl�f./ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Const on us be omple d within three years of the date of this permit. Date Approved by Town of Barnstable' Regulatory Services N ;. Thomas F.Geiler,Director �. gw%uucna i - p Public Health Division A a Thomas McKean,Director 200 Main Street,Hyannis,AJA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 3 °3 o I b Designer: tc,_X� " Installer:Address: . Address: M. 5 Vq 1Yk1 On /,9-7-u9 was issued a perreit to install a - (date)' - (installer) septic system at HO based on a design drawn by (address) dated (designer) V<I:eertify that the septic system referenced above was installed substanttall: accar i. e d which may include minor 2 :, din to design, y approved•changes such as Iat -relocation of the distabution box and/or septic tank, I cerW41hat the septic system referenced above was installcd anth'ma#or.chap" greater thug 10 lateral relocati6d of the SAS'or-any vertical ireioodlign-of any c?*Xia4 of the-septk�qwm)but in a ordazice with State&Local.IZegtilattons. Plan revision or certified as ht by designer t6 follow. (Installer's Signattirej �. sn 4 MSO -' M T 01 (D er s Signature} (AffixStamp Here) - PRASE RETITX2N Q FA I S ' 'li'ITBLIC:HI I;TH I3 IG C ®F COMP UNCE WILL- NMM, UE�.a 8� �- Q[S FQ BViI:.T`�At2��E YtEGEMD 7C�AIII.You. Q.HealtYa/SeAc/Designer Certificabon Form ;s Town of Barnstable �t►� Barnstable . Regulatory Services Department aMy 4639 ,m� Public Health Division RFD MAC 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 FAX: 508-790-6304 Thomas A.McKean,CHO March 15, 2013 RE: Issuance of Disposal System Construction Permits (a.k.a. septic permits) To Whom It May Concern: The policy of the Public Health Division in the Town of Barnstable is to issue the permits directly to the licensed septic installer. The permit issued at 89 Stone Horse Road, Osterville was installed for the owners, Paul and Janet McCartin. Since ely, Sharon Crocker Administrative Assistant Public Health Division Q:\WPFILES\89 Stone Horse Rd Ost 3-15-13 slc.doc ����m P �neF 3�'S6 � w �.� y(e,.�JH e> i i � 1 ev � �,r � C I COMMONWEALTH OF 1v1HSSA_HUSETTS I EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL, PRO T 'CTIOI\ ONF A:vTER STREZT, BOSTON, MA 02.108 617-292-5) i f r WILLIAM F.WELD y� Q TRL COXE cGovernor y��oSr9 .19S ecretan ARGEO PAUL CELLUCCI !BlF DAY STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR ` missioneT PART A \ \9 CERTIFICATION Property Address:gn-,6 S��e �Es� ®Ster V & ©ddress of Owner: i Date of Inspection.IV®v,aGIO9a`I (If different) Name of Inspector: Jl cd j:e.0 L,e t,v15 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: - Mailing.Address: P ® �l Telephone Number: 50q- CERTIFICATION STATEMENT I certify that I have personally in ected the sewzge disposal system at this address and that the information reported'below is true, accurate and complete as of the time inspection. The inspection wa.; performed based on my training and experience in the proper function and maintenance of on-site se age disposal system:. The system: Passes ' Conditionally Passes _ Needs Further E Kati By e Lo Approving Authority "'., �i Inspector's Signature, ) Date ' The System Inspector sh submit a copy of thi. in pection report to the Approving Authority within thirty (30) days of completing this i inspection. If the system is a shared system or 'as a design flow of 10,000 gpd or greater,-the inspector and the system owner shall submit j the report to the appropriate regional office of the Department of Environmental Protection:' The original should be sent to the system owner 1 and copies sent to the buyer, if applicable, and the approving authority. + + t INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM" 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, COMMENTS: j -- i B] SYSTEM CO DITIONALLY PASSES: One r more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon co �etion of the replacement or repair, as approved by the Board of Health, will pass. jIndicate es, no, 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, un;,�;s the owner er operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indic:a•ing that the tank was installed.within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cranked, structurally unsaund, shows substantial infiltration or exfiltration, or'tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank approved by the Board of Health. (rev- ad 04/25/97) Page 1 of 10 4 I ! DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep i . ej Printed on Recycled Paper ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C(ERTIFIICATION (continued) Property Address: 99 Sfor,@ �'}OfSe �• �IP[v� oulz Owner:Carl V,S Date of Inspection: �iqq7 BJ SYSTE CONDITIONALLY PASSES (continued) Sewage b!acku- or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) of due to a broken, settled or uneven distribution box. T'ie system will pass inspection if(with approval of the Board of Health). Describe observations: T , broken pipe(s) are replaced obstruction is removed i!, distribution box is levelled or replaced _ The system rejuired pumping more than four times a year due to broken"or obstructed pipe(s). The system will pass inspecti in if( ith approval of the Board of Health): ' broken pipe(s) are replaced r � '� • z obstruction is removed CJ UR HER 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 5J'feet of a surface water 1 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE i ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the .SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). I 3) OTHERS t, 4 (revised 04/25/97) Page 2 of 10 it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART'A I CERTIFICATION (continued) III Property Address: 91 �;to*P garS;e 05`Lorin l/P d6. 01V;6 Owner: Ca(I OaVj5 III Date of Inspection: 199-7 D] SYSTEM FAILS: You must indicate eir,er "Yes" or "No" as to each of the following: 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 e failure. �I i i o Backup of sew ge into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or p riding of effluent to th surface of the ground or surface waters due to an overloaded or,clogged SAS.or cesspool. r 4; s:... Static liquid I vel in the distribution ox 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 1/2'day flow. l` Required pu ping more than 4 tim s in the last year NOT due to clogged or obstructed pipe(s). ' INumber of mes pumped_. Any portio of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. I II i Any portio of a cesspool or privy is within 1.00 feet of a surface water supply or tributary:to a surface water supply.. Any porti n of a cesspool or pri is within a Zone I of a public well. 'j Any portion of a cesspool o, ari y is within 50 feet of a private water supply well. i — Any port on of a cesspool or pri y is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysi . If the well has been analyzed to be acceptable, attach copy of well water analysis for ° coliform�bacteria, volatile organ c compounds, ammonia nitrogen and nitrate nitrogen. E] LAIR E YSTEM FAILS: Yo m t dicate either 'Yes" or "No" as to each of the following: l e following c iteria apply to large syst ms in addition to the criteria above: h system se es a facility with a desigr flow of 10,000 gpd or greater (Large System) and the system is a significant threat to u lic health a d safety and the environ nent because one or more of the following conditions exist: Yes o j the stem is within 400 feet o a surface drinking water supply _ the ystem is within 200:feet c a tributary to a surface drinking water supply the ystem is located in a ni ro ,en sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a pu lic water supply well) The own or opera-- of an such system shall in the system and facility into full compliance with the groundwater treatment program Y Y g Y h P g P g requirem �ts of 314 C MR 5.00 and 6.00. Please consult the local regional office of the Department for.further information. s� (revised 04/25/97) Page 3 of 10 i i i � I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addre ss:� 54ovLe NlSc �, C;Arrt '16o Ma. 09655 i Owner: Caf baV ;S Date of Inspection: qv. KQ7 i Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ys Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least 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. 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. r The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. i All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different 'rom owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. t _ Existing information. Ex. Plan at B.O.H. ' Determined in the field (if any of the failure,criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] i I I i i i i i (revised 04/25/97) Page 4 of 10 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Hoc, Qa SYSTEM INFORMATION Property Address: qrq 'Slow `T "'�' 0�+,UI4 &.©d,6S5 i Owner: Date of Inspection: N®V. XG W7 { FLOW CONDITIONS j RESIDENTIAL: Design flow: e. edroom for S.A.S. 00 1 Number of bedrooms: Number of current reside tskVno 9Garbage grinder (yes or no):Laundry connected to syste ): w L Seasonal use (yes or no):�/� i Water meter readings, if avai -b (last two (2) year usage (gpd;,: { Sump Pump (yes or I Last date of occupancy COMMERCIAUINDUSTRIAL• ' Type of estab •shment: Design flow:Nreadin allons/day Grease trap yes or no)_ Industrial Wing Tank present: (yes or no)_ Non-sanitaryscharged to the Title 5 system: (yes or no)_ Water meter if available: { { i Last date of occupan I OTHER: (Describe) Last date of occupancy: { GENERAL INFORMATION i PUMPING RECORDS and\sourof information: System pumped as part ins e n (yes or no) If yes, volume pumped: J gallons 9 Reason for pumping: (i fill 117 { TYPE OF SYSTEM Septic tank/distribution box/soil bsorption system i Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, atta h previous inspection records, if any) I/A Technology etc. Copy of up to dat Contract? Other i ' APPROXIMATE AGE of all components, date insta\orn ) and source of information: I jSewage odors detected when arriving at the site: / i i 1 �\ (revised 04/25/97) Page 5 of 10 ) I 1 1 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (� SYSTEM INFORMATION (continued) Property Address:��{Q SAonP tfOfrw �• Oste'rv(lle A• © 65S Owner: CAA O,V iS Date of Inspection: Neu f lQgl BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter ` Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ L (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: - l/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee o affle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: -' Material of construction: concrete metal Fiber lass Pol t Ih e other ex lain — _ Y Y en _ ( P ) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba_ff e. Distance from bottom of scum to bottom of outI tee o baffle: Date of last pumping: Comments: (recommendation.for pumping, condition of inlet and outlet tees,or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ``* (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM II PART C i SYSTEM INFORMATION (continued) I �,(.. {�� f Property Addres gq S+oAe I I BLS a K(R, ®�NE C/t I(P Act, ©�-6 Owner: �� 4I S jDate of Inspection: TIGHT O HOLDING TANK: (Tank must,be pumped prior to, or at time, of in 4'ection) (locate on s e plan) I Depth below gr de: j Material of constr ction: —concrete _meta! —Fiberglass —Polyethylene ther(explain) I Dimensions: j Capacity: ga ns Design flow: gall ns/day j Alarm level: Alarm n working order _ Yes; _ No ; Date of previous pumping: Comments: ' (condition of inlet tee, condition of !arm and float switches, etc J. i DISTRIBUTION BOX: j (locate on site plan) Depth of liquid !evel above outlet invert: i Comments: (note if level and distribution is equal, evade ce of solids rryover, evidence of leakage into or out of box, etc.) i PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or/No) Comments: 1 (note condition of pump chamber, condition of pumps and appurtenances, et ) i i (revised 04/25/97) 'Page 7 of 10 J j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a�( 15-4cmo C[Orce Owner: ( i S Date of Inspection:Nov, ^ I I aye)) I SOIL ABSORPTION SYSTEM ($AS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) I i If not determined to be present, explain: I Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) j i i i I ' 1 CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: j Depth of solids layer: Depth of scum layer: I Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) i Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) j i i i PRIVY: _ (locate on site plan) it Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) I i (revised 04/25/97) Page a of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ���' �rsP �`� ®S�er v a S e X10. 01- 66*7 Owner: Cod JILIdI S Date of Inspection• �'� Nmu,�`(Or �qQ-1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) + AV I i i I ' i I I - i ` I i I I i I (revised 04/25/97) Page 9 of 10 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:QC1 ,I Owner. ��l Date of �nspiction�• yVt fggj Depth to Groundwater �eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) i Determine it from local conditions j Check with local Board of health Check FEMA Maps *Tb B 0 /V Check pumping records CCf� Check local excavators, installers i Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) I � I I ( oo ' I Page 10 of 10 (revised 04/25/97) a Town of Barnstable l Departimeut of Regulatory Services i Public Health Division �o i6J9 �6 20d Main Street,H ' Date rE4 tuc+ ,. Hyannis MA 02601 _ 4 t� Date Sch eduled � l �V � Time Fee_Pd, ° Ud Soil uitabili ` Ases ent or Se+ # , .f wage zsposal PerFormed'By: Witncssed.By: LOCATION & GENERAI, p LocaattiiOn Address RMATION owner's Name S% f, e e 5"�%.�Ic y, US�Q✓ville Address 9d 1NJ;Sfv�2J / Assessor's Map/Parcel: Engineer's Name �w✓�U m,- REPAIR S o NEW CONSTRUCTION L� r ., - Telephone# so land Use slopes(go) l t Distances from: Open Water Body ++ Surface Stones f. i Possible Wet Area_�ft Drinking Water Well �_ft Drainage Way ft. Property Line ---_Ft Other ft SKF-JTCx: (Street name,dimensions of lot,exact locations of test holes&.pere tests lo cate wetlands fI proxirmty to holes), Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping 11•om.Pit Face Estimated Seasonal High Groundwater DETERNENATION FOR SEASONAL HI WATER TABLE' Method Used: Depth Observed standing in obs.hole: ` Depth to weeping from side of obs.hole: tn, Depth to soil mottles: Index Well#__ ReadingDate: tn, ©rdundwnlerAdJtistment ln' In Well level ft. --� ,AdJ,factor _ Adj.drnundwatcr 1 cvel y Observation PERCOLATION TEST' Hole# I bate Time Time at 9 Depth of Pere Time at V Start Pre-soak Time @ 2 _ Time(9" 6°t End Pre-soak ''� +. t Rate Min./Inch u-t,1 Site Suitability Assessment: Site Passed , i, Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division t y Observation Hole Data To Be Completed on Back----------- ***If percolation test Is to# be conducted withiu 100' of wetland, you must first n Barnstable Conservation Division at least one (1) week prior to beginnin ot>fy the. Q:\SEPTIC FRCFORM.DOC g DEEP.OBSERVATION HOLE LOG Hole#Depth from Soil Horizon Soil Texture Surface(in.) (USDA) Soil Color Soil Other (Munsell) Mottling (Structure,Stones;Boulders. UDf on isten.cy,% ,ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon ,. Soil Texture Soil Color Soil Surface(in.) (USDA) (Munsell) Moulin Other g (Structure,Stone;:,Boulders. onsistenc %Gravel) DEEP OBSERVATION HOLE,LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) Munsell d. ( Mot Mottling (Structure,Stones,Boulders. Co i to c % Gravel)+' _77 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, I • f R 1 Flood Insurance Rate'Map: f Above 500 year flood boundary No— s Within 500 year boundary Ni es Within 100 year flood boundary No Yes . DeT)th of Naturally Occurrin,r Pervious Material Does at least four feet of naturally occurring pervi u ial exist in all areas obserJed throughout the area proposed for the soil absorption system? , If not, what is the depth f naturally occurring perv' us material'? y Certification I certify that on �" 1 (date)I have passed the soil evaluator examin t n approved b the P PP Y Department of,Environ 1 Protection and that the above analysis was perfo m d by me consistent with . the required tra' ' g,ex r ' e nd�Xli nce described in 310 CMR 15,017, Signat Date d y Q:\S.EPTIC\PERCPORM.DOC t { `TOWN OF ARNSTABL for 17- SEWAGE # VILLAGE. � ASSESSOR'S MAP & LOT 'D INSTALLER'S NAME&PHONE NO. y SEPTIC TANK CAPACITY _ LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER Lee& � PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility LK Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 2 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by 'Waal- �its�c � ���y� �7 � I� q + Oif b la AT ION SEWAGE PERMIT NO. VILLAGE INST A /LLLER'S, NAME A ADDRESS o4/Y� dew i 5 -T B U I L D-E R OR OWNER (22 DATE PERMIT ISSUED _ _ DATE COMPLIANCE ISSUED =2 1 06 � 0O lyr Fps.... 5_:....o.. THE COMMONWEALTH OF MASSACHUSETTS B®A ROOF HEALTH C.L..I I...................OF................ Appliration for Dispaiial Works Towitrurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: F ....... ...�.�..�-----•..��n.P.__/. . se------. ..... .........0:5.1-p�...1&..............--------.--......-•----.....---- tion-Address or Lot No. • ► ........... - .................................... --........------•-••------•------•--_-•--- ---•••--........--...-•---•••••.............-•-- W C T� Owner GCS/s Address Installer Address UType of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms......1.................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building No. of persons............................ Showers A� YP g ---------------------------• P ( ) — Cafeteria ( ) 4" Other fixtures -----------------------•------••-•-•---------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 0 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................... ----- ------------------ •................ Date........................................ W Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_______-__-----._. ri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................ a -•--------•------------------••-----------•---------••••----------........----------•--•-•-•-••••-••.....................................•--------•-•--••••-- 0 Description of Soil......................................................................................................................................................................... x W U Nature of Repairs or Alterations—Answer when applicable.__../. �_F`h. __--:-.._._...14"—_ Q- _ .� -----------� ��z. ------------- ........... �(-- = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'LU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' e y the board_,9f health. Signed%011-V � ' - -. !! Date Application Approved BY....................i -'- ---------•--------------------•-•----•-----------------..........-- --------.-----� 't--------=•-•------ Date Application Disapproved for the following reasons-----------------------•----------•---•-----------------------•-------------.................................... ----•---Date--•--•-------- Permit No..�j� .. -----�------------------- Issued----... Cc h --- �........... T�5..... Date No. ....0.9n,�.... THE COMMONWEALTH OF MASSACHUSETTS BOA ROE HEALTH ....................OF............. Appliration for Disposal Works Toustrurtion rnmit Application is hereby made for a Permit to Construct or Repair (4,orR`n Individual Sewage Disposal System at: .............. llic5.ao........Rd..... ........ ................................................................ J#m,4tiort-Address or Lot No. ...........vhvi....K------------------------------------ ................................................................................................. Owner Address ......... ......... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-----kI..................................Expansion Attic Garbage Grinder a PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria (..._.). PL4 Other fixtures ............................... Design Flow....................................:.......gallons per person per day. Total daily flow............................................gallons. IY4 Septic Tank—Liquid.capacity..-__...:..gallons Length................ Width................ Diameter---------------- Depth._..._-.._._._.. :V4 Disposal Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.__.___...__..._.... Depth below inlet.__........_._._._._ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................ ............... Date........................................ 7--------------------- .. Test Pit No. I................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.........__.._......_... 04 .............................................. .............................................................................................................. 0 Description of Soil........................................................................................................................................................................ U ....................................................................................................................................................................................................... W ....................................................................................................................... .............................................................X ..... ty U Nature of Repairs or Alterations—Answer when applicable...,, *4:01-----=-------- -------44"la........ F------- . ..............'C" P.* 4'4�.I..... .........................................I....................................V.... ........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been jpu y the board of health. Signed- --------I V?A...... X-----_--_--- Date ApplicationApproved By.......................... ........................................................................ ..............;k2t. i I/ Date Application Disapproved for the following reasons:................................................................................................................. .....................................................................................................................................................I......._......................................... Date Permit No.. ..................... Issued----- -4-ol....... 4p�......OF Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ..............OF.....f 3.otr- st-,oLle........................... 9rdifiratr of Toutpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (C.,)e by....... ......... .WLS................................................................................................................................. nstalle......r......... . ..... . ... at �5%, LZIS .......................................... has been installed in accordance with the provisions of TITL, 5 of The State .Sanitary Code as described in the application for Disposal Works Construction Permit No.......................................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS A AS UED GUARANTEE THAT THE UED AS A C, SYSTEM WILL FUN ION 5ATIVACTORY. DATE.................. ... ....... ................ ........... Inspector.............. --------�_ " THE COMMONWEALTH OF MASSACH ETTS BOARD OF HEALTH "In...................OF.......... .Ql '.p1..$.A.Ah............................. No.. - Disposal 0 s %D11ptrudw- It Permission is hereby granted----_--.. ... ... ... .... ........ ................................................................... to Construct or-.Repair an Individual Sewage Di po al System atNo..... ................ -- - -------- ......................................................................... /. ;L .Pj_ as shown on the application for Disposal Works Construction Permit No..?Ir ...2,-Dated........................................ ...... .... -�7 Board Health DATE........•n.................................................................... FORM 1255 A. M. SULKIN, INC., BOSTON nce Existing Reside Foyer _ i Dining Living Room i a Room �( • y L------fir Existing s all. S C Garage G Master Bedroom Mudroom New Kitchen Laundry Existing I Office Bath 'F I Existing I'. - - I • _ .. - ..': .ti bulkhead door - to be� .c I removedTV 3068 I I O Master - ——————_——— - - - - I - Cl01- - I Bath ---'o _ Bed room S Dn. Bedroom I_ .First Flloor.Plan. for Smoke Detectors sc all I. Bathroom a� s Addition "I. ieth d • I . I ' (2) x6es " } E �SG�wCQ CA`�Nroy L_-- -------------------- -- �-t V7 wfi Second.Flloor Plan ' for.Smoke Detectors Pro osed -Renovations and Addition Rob ert' A. Faeltea Architectural Deli n - o �_ 8 P - . o to'89 Stone Horse Rd. y Box, 591 Rochester, MA. 02770 (508) .291 =7103 Q Z Osterville, MA: NOTE: WATER SERVICE IS AD H O R.S.E . LOCATED IN FRONT. OF HOUSE. STONE R / 48.44' 51 .56 \. N 84°42 20 E APPROXIMATE GAS LINE 38.8ft I �• LOT LOT LOT 58 0 0 Feet LOT 55 56 �, 56B DAViD LOCUS MAP B. y ' MASON m PLAN REF: LCP 183661 No.toss 1991123 EXISTING \ //��//�//�//�/////////, i 9 y CERT REF 147810 ///•/•//•//////•//•/•// c— I ASSESSOR'S MAP 142-084 BULKHEAD TO BE REMOVED 9.8ft SETBACKS 30'10'-10' BENCHMARK: SURVEYOR'S SPIKE FLOOD ZONE. "C" . cn ELEVATION: 100.00' PANEL NUMBER. 250001 0016 D DATUM: ASSIGNED O DATED. 07/02/1992 W O Un LOTS 56 & 56B m I PROPOSED DECK ���� p PLOT PLAN OF LAND COMBINED AREA ADDITION i w m LOCATED AT.• a o24.8 SQ. Fr. 89 STONE HORS' RD. 0.3 ACRES 15.3ft� ®6.,&AaA 10.6If �,i ® �,�Or�''S') `�® 23�9ft �� ® OSTER VILL, MA 19, 07 ` o J. SEE GENERAL NOTE #8 \ I \`�,� 115.3ft VENT 1� g �c \ 51.Oft 'I--v,�, ® PREPARED FOR.- I -,\ 0 I 5 .STRIP—OUT °®��lvo ` ��� JANRT & PA UL McCARTIN I~ `` ►► ' NO VEMBER 24, 2009 if 0 ` a y5.Oft —— — — — 96 20.5ft REV.' X=95.0' \ REV- EXISTING LEACH PITS W� �67.88' REV PER SURVEY S�82`20 OD �\ 31 .64 `- 9 N 84'57'50 E '94 6 YANKEE LAND SURVEY " GRAPHIC SCALE CO., INC zo 40 INDUSTRY ROAD LOT N/F POWERS MARSTONS MILLS, MAX 02648 1 inch 20 ft. 54 TEL• 508-428-0055 FA 508-420-5553 = , SHEET I OF 1 JOB OF 54580 SH S`IE W`, A IS E. SYSTEM. PROFILE VI EW N =Te s T.O.F. EL. 100.56' NV FIN GRADE = 98.5't cD RISERS FIN GRADE 99'f 3 3if D 20" 20" 1/8" TO 1/2" DOUBLE WASHED STONE ®'3", THICK OR GEOTEXTILE FABRIC I INV EL. DIA. MIN DIA. CD RISER i i i / i i, i i i i FIN GRADE = 99't INV EL. 10" MIN. f 14" MIN. INV EL. I 8•5' I INSPECTION 95.35' 95.1' oar ONE L. 95.00' EL. 95.0' BELOW FLOW LINE IN EL. MIN. 6" INV EL. LIQUID LEVEL 48" 94.62' SUMP 94.42' EL. 94.1 O 7.' O. O STONE ° 15' GAS BAFFLE 6 o.Q °o a ° • ° °e EL. 92.1 T DISTRIBUTION BOX ° PROPOSED 1500 GALLON TANK 3/4" — 1 1/2" --- — °48"° PRECAST REINFORCED CONCRETE DISTRIBUTION BOX DOUBLE WASHED STONE f TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A DISTRIBUTION BOX SHALL HAVE WATERTIGHT COVER ' MINIMUM OF 6" ABOVE THE FLOW LINE OF THE SEPTIC TANK AND BE ON MINIMUM WALL THICKNESS = 2" 25 THE CENTERLINE OF THE SEPTIC TANK LOCATED DIRECTLEY UNDER THE MINIMUM INSIDE DIMENSION 12" PROPOSED CHAMBER TRENCH. - CLEAN—OUT MANHOLE. OUTLET INVERTS SHALL BE EQUAL TO EACH OTHER AND AT THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR MORE THAN 3" 2" MINIMUM BELOW INLET INVERT. ABOVE THE INVERT ELEVATION OF.THE OUTLET PIPE. THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX SHALL ALL HAVE SEPTIC TANKSHALL HAVE A MIN IMUM COVER OF 9" EQUAL INVERTS AS DETERMINED BY FLOODING THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION LINE INVERT AFTER ALL LINES HAVE TWO 20" MANHOLES WITH READILY REMOVABLE IMPERMEABLE COVERS BEEN SEALED IN PLACE _ BOTTOM OF SOIL PIT = EL. 84.48 OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS PORTS. INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE AND PERFORM 5' STRIPOUT DOWN TO C HORIZON NO GROUND WATER OR MIDDLE ACCESS PORT SHALL BE 8" DIA. MINIMUM. NONDEFORMABLE MATERIAL PERMANENTLY FASTENED TO THE LINE OR (APPROX. ELEV. 93.82'). SOIL CONDITIONS— REDOXIMORPHIC FEATURES OBSERVED THE OUTLET TEE SHALL BE EQUIPPED WITH GAS BAFFLE. RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE OF EQUAL ELEVATION. SHALL BE INSPECTED PRIOR TO SOIL REPLACEMENT SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL, DISTRIBUTION BOX SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL, PER TITLE V REGULATIONS IF NECESSARY. STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON WHICH STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON WHICH 6" OF CRUSHED STONE HAS BEEN PLACED TO ENSURE STABILITY AND 6" OF CRUSHED STONE HAS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT SETTLING. TO PREVENT SETTLING 4" PVC ^} SEPTIC TANK CAPATICY: VENT REQUIRED - 330 GALLONS AT 200% DESIGN DATA: PROVIDED — 1500 GALLONS THREE BEDROOM = 3 X 110 = 330 . GPD REQUIRED FLOW FIN GRADE = 99't j NO GARBAGE DISPOSAL ALLOWED 12.83' . USE: CHAMBER TRENCH 251 X 12.83'W X 2' EFF/DEPTH 34 ° "° • °° • °6 24" ° °a • °� GENERAL NOTES: (25' + 25' + 12.83 + 12.83) X 2.0 151 S.F. _ _ ° ° • ° 1 . ALL THE WORKMANSHIP AND MATERIALS SHALL CONFORM TO DEP 25' X 12.83 320 S.F. 48" ° 58" ° 48" TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS 471 X 0.74 348 GPD TOTAL DESIGN FLOW FOR THE SUBSURFACE DISPOSAL OF SEWAGE. NUMBER of TRENCHES = ONE 2. ACCESS PORTS OVER TANK TEES SHALL BE ACCESSIBLE WITHIN 6 NUMBER OF UNITS = TWO OF FINISHED GRADE PROPOSED LEACH TRENCH END VIEW 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF INSTALL TWO 500 GALLON UNITS WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' WITH FOUR FEET OF DOUBLE WASHED STONE OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN AT SIDES AND ENDS 10' OF DRIVES OR PARKING, UNLESS NOTED. T.P. #1 PERC <2 M/INCH T.P. #1 PERC <2 M/INCH 4. THE EXCAVATOR/CONTRACTOR-SHALL CALL "DIG SAFE" AND VERIFY THE LOCATION OF SITE UTILITIES PRIOR TO ANY EXCAVATION, AND SHALL BE RESPONSIBLE FOR EL. 96.48' 0.. EL. 96.48' 0„ ALL MATTERS RELATING TO ELECTRIC AND/OR GAS EASEMENTS. 10 YR 3/2 10 YR 3/2 5. SEWER PIPES SHALL BE SCHEDULE 40 PVC. (4" DIA. UNLESS OTHERWISE NOTED) "A" "LS" 101, "A" "LS" 10" 6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE "LS" •10 YR 6/8 „ „ "LS" 10 YR 6/8 SOIL DATA: MORTARED IN PLACE AND SECURED TO UNAUTHORIZED ACCESS. B 32" (EL..93.82') B 32" (EL. 93.82') 7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FT. PER FOOT. TEST DATE: 11 —10-2009 "C" "MS" 2.5 YR 7/3 "C" "MS" 2.5 YR 7/3 SOIL EVALUATOR: DAVID B. MASON G� 8. EXISTING SYSTEM COMPONENTS — IF ANY — SHALL BE ABANDONED PER APPROVAL DATE: 10 TITLE 5 REQUIREMENTS. L. 84.48' 144" EL. 84.48' 144' /1994 9. THE EXCAVATOR/CONTRACTOR SHALL BE RESPONSIBLE TO CONTACT YANKEE HEALTH AGENT: DAVID STANTON SURVEY 24 HOURS PRIOR TO ANY REQUIRED INSPECTIONS. P# 12767 10. ALL COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR NO G\WATER OR NO G\WATER OR COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. REDOXIMORPHIC FEATURES REDOXIMORPHIC FEATURES SHEET 2 OF 2 JOB NUMBER 54580