HomeMy WebLinkAbout0045 SWIFT AVENUE - Health 15 SWIFT AVENUE, OSTERVILLE
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+TOWN OF BARNSTABLE
LOCATION , ` '� �//� ✓F�/lll= - - SEWAGE # s100 0 - -127
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,VILLAGE 5rA_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ,r 8-9,2 D^ IM3Z Jmze,4 Zl e 136-ne-5
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 4/^S00 (,/V/
NO.OF BEDROOMS y
BUILDER OR OWNER J04 1_3om wA.arD7—
PERMITDATE: —7—OG COMPLIANCE DATE: /6 —t7— Oa
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands_exist
within 300 feet of leaching,ffaacii ty) Feet
Furnished by
F. �..
,S'u/lFT f3VN
i� V `
I
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in compBwgmms ON uter:
Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for �Digogat 6p6tem Congtruction Permit
Application for a Permit to Construct( air( v)Tpgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.213- (r//FT 14Y1=M,qr Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
S— 3f
Installer's Name,Address,and Tel.No.5-a " y2 D-117 39, Designer's Name,Address and Tel.No..S D �Ard- 92 70
Type of Building:
Dwelling No.of Bedrooms `t' Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Altera ions( nswer when applicable) 06 /C rv:
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th's Bo of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reaso
Permit No. Date Issued
No. Fee
�a
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS• Yes
-2pprication for Mi�po$41 *p! tem Cong;truction Permit
Application for a Permit to Construct(4,., epatr(4,�rUpgrade( )Abandon( ) O Complete System El Individual Components
Location Address or Lot No.t-rS ' 1-4 V/=,t/u/= Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
bsT�=�'di�/� Jo/rH /3o��nh��tJr
3f4,WN
-Installer's Name,Address,and Tel.No.s 6 6 — L/2 D— ,A7 jg' Designer's Name,Address and Tel.No.S D$'NQ 92*740
JoscPti 0--4 L 4re05 :f- 1_101i5
Type of Building:
Dwelling No. of Bedrooms 4/ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers(, ) Cafeteria( )• ' ±
Other Fixtures
Design Flow gallons per day. Calculated daily flow .r'gallons.
Plan Date Number'of sheets•• Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
" hi,
yr `
`4 .Nature of Repairs or Alterations(/Answer,when applicable) h / Db 6.
#1 '
Date last inspected:
Agreement: 3 ''
-The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system; <
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until'a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed < :!4ns <. Date a
Application Approved by / .�!� A .� `° ' C ) Date
Application�Disapproved for the following reason 2
' r
Permit No. Date Issued
vtl
_ � ---.------------ --: —--------------------
THE COMMONWEALTH OF MASSACHUSETTS
D� BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(cam Repaired(e—)fiJpgraded( )
Abandoned( )by loe
at - has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No., K--'3 dated
Installer .145 r-tl4 4 ,06�0- Designer
The issuance of this permit hall n t unn be construed as a guarantee that the s ste t 'on as dpi•gn
Date SAC � �o Inspector r
�m. —_—-----
---------—------------------------
a r
No. Fee/X)
I-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migpont *p5tem Con.5truction Permit
Permission is hereby granted to Construct( G_)-Repair(L- "Upgrade( )Abandon( )
System located at 54wL,_1'" gyl/ /i/z./1..
�!rM:F AZ
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: Constructio m $t be completed within three years of the date of ' p •it�Date:_ Approved by
a
Town of Barnstable
�4f' y Regulatory Services
,. Thomas F.Geiler,Director
MAC Public Health Division
. ° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: ('Y Sewage Permit# 2, o - y Assessor's Map\Parcel 54-
Designer: L.16 49-45 Installer:
Address: (QZ- lit), Address:
f�'ll4 2bc7f
�19far�1��S' 2'�li/��
On was issued a permit to install a
(date) (installer)
septic system at 95- Swj rl- *V/9 based on a design drawn'by
(address)
S dated -J V^1G I
(designer)
L"Xi certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�N Of MASS,
(In taller's Signature) l l S 1 C ?w*
o • IVIMS •
i s i �lC i
ifs/sT
( esigner's S a ) (Affix Designer' p ere)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
03
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3
A
Commonwealth of Massachusetts _, R 1
Executive Office of Environmental Affairs S
.. _
Department ofx� ry � �'
ental Protection
Environm .�
Wllllam F.Weld
Governor
Trudy Coxe
Secretary,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: y 5 Sw e C 4xje Address of Owner: ,4U iI{-eN Li J14�5�
Date of Inspection: (If different)
Name of Inspector
Company Name,Addoa cnQd �e 'e um er.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signat { Date:
1
The System Inspector shall'submit a copy of this inspection report to the Approving Authority within thirty (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 sen;.0 me system owner and copies sent to the buyer, if applicable and the approving au:horit�.
INSPECTION SUMMARY:
Check A, B,C,or D:
A) SYSTTE 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 completion of the replacement or repair,
passes inspection.
Indicate yes, 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, cracked, structurally unsound,,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 as "
approved'by the Board of Health.
(revised 8/15/95)
One WlnterStreet • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
4,Printed on Recycled,Paper',
z �
I ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION (continued)
/
Property Address: Z 5-SW rt 4Ve OSi�—✓LA`
Owner: WALS
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or 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):
broken pipe(s) are 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 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ ThP system nas a sewic tanK ano soli absorptiun system anu is wlthii, 00 ice! t0 a su'a Y`dici SiipjJi) Oi tribuia )' t0 d
surface water supply.
The system ha! a septic tank and soil absorption system and is within 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 systen-, 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D] SYSTEM FAILS:
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 componentdue to an overloaded or-clogged SAS or cesspool
Discharge orponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
I
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) 3
Address: 5►.0 1 %!4V e 05► r
Property j'�
Owner: Wms-
Date of Inspection:
3•-/-1(o z
D] SYSTEM FAILS(continued):
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 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
Any portion of the Soil Absorption System, cesspool or privy is 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 large systems in addition to the criteria above:
The design flow of 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 a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a
public water supply well:
er
The owner or operator
any
S OOsuch
andsystem
6500. Please bring
consult the local and
regionfacility
offi e full
the Department with
forthe
further infortmation.treatment program
requirements of 314 CMR
3
(revised 8/15/95)
s a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
3
Property Address: L15Sviri A.1/•e_
Owner: W 95VA
Date of Inspection:
Check if the following have been done: i
Pumping information was requested of the owner, occupant, and 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.
c/ 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 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 existing information or
/approximated by nun-intrusive methods.
�' The faci;;;� o.;:.i ;�" ' 0CCJPan;=, i`d`" er, 4 ` o`"'e were provided with information on the proper maintenance of Sub
Surface Disposal System.
7
4
(revised 8/15/951
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: All ���
Owner: .,,��(
Date of Inspection: �
3- � FLOW CONDITIONS
RESIDENTIAL:r� '
Design flow: yNgallo s
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Laundry connected to syste dyes or noi
Seasonal use(yes or no):_7
Water meter readings, if available: �{
Last date of occupancy:y�WVNAr q%' ;
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupanq,:
GENERAL INFORMATION
PUMPING RECORDS and source of information: Now.
System pumped as pan of inspection: (yes or no)_
If yes, volume pLimPed' .allons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool,>
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE.AGE of all components, date installed (if known) and source-of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �� 5u-'f44;1 A-v-e— 05F1
Owner: W AL'Sk I
Date of Inspection:
SEPTIC TANK:,
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from.bottom of scum to bottom of outlet tee or baffle:
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:�I
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
C)ictance from bottom r%i crtim-'tn hottnrr of oiitlat tee or battle' .
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 8115/95) 6
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM.
PART C
SYSTEM INFORMATION (continued)
Property Address: L/S SW
Owner: L4141�5�11
Date of Inspection:
TIGHT OR HOLDING TANK:
4
(locate on site plan)
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:
(locate on site plan;
Depth of liquid level above outlet invert:
Comments
mote if ievei ano ciistriuut-ui, > ey�a:, e,�6cnce. of solid_ ca:r)o,,er, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION (continued)
Property Address: S� UIVC AVM
Owner: IvAll
Date of Inspection:3_) c/6
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:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet.invert: Dti
Depth of solids layer.
Depth of scum layer: �t
Dimensions of cesspool: bx$
Materials of construction: a
Indication of groundwater. No
inflow (cesspool must-be pumped as parrof inspection) -t OM `_:4_1
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
GI9UID
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised;8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address J JW 1�j /�� O�-e wOl`c
Owner: w h
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
b°�-
` bjl
DEPTH TO GROUNDWATER
No ma
Depth to groundwater. �O feet � o(G �7tTS Ale aver'a{ '�
method of determination or approximation:
hati�n wpm,—�1N1
(revised 8/15/95) 9
A- 1... Fs�.. -�-�......_
THE COMMONWEALTH OF'MASSACHUSETTS
BOARD OF HEALTH
1�? .............
Appliratiutt -fur Ulilivoiial World Tomitrurtiutt mu t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: P
.......�1
%----•---- -••-----_._ _..--•-••----•--•--•-•-••-•••-••--•---•-----•-•-••----_-•---
o tion_Address or Lot No.
Owner -•----__--••---------------•-•---•-------•--Address
Installe Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons_..______._________---___.__ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------•-•---_-_---___-------------------------------------------- --•--•---•-•-•-•---•--------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic "funk—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 area------------------sq. it.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
a Test Pit No. I................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.._._-__.___.._-._-.__..
f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__.__--.._-.___.__._....
V4 ................................................•-•--....••••-•---•••---------------•-••-••••--•-•••.........................................................
0 Description of Soil-------------_---........................ _____-------------•----------------------------------------------------------------------------------- ------------------
x
U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
x ---------------------------------------------- -------------------------------------------------------------------- -• y -
Natur of Re airs or lteratio s a—Answer when a livable______________ '' ! �' !�� _
U P P 5_� -------- --
'L�C; C/ .... .. ........ . ---_.-_--•--•-•----------
A reement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n I sued by the board of eal
Signe .... _ <_ r � ...7�5
Date
Application Approved By---- --------.__. _-_- -----•- -------------------- ,1 •--
Date
Application Disapproved for the following reasons------------------------------------------------•------------------------------____-----------------------------
--------------------------------------------------------------------------------------.........-........-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued---` i 7•.d..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
__ ..�... .............. OF..___-..............................................................................
A.Ppliration -for Uiiipoiial Workii (ion rurtioaa rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( )" an Individual Sewage Disposal
System at• r
vation-
....._.
r
Address / A-
or Lot No.
................/..--�f1 »��..t...�/vim•_�
c' Owner Address
Installerrr/ F Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.1 Other fixtures ------------------------------------------------------------ -----------_------- -------
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter------.--------- Depth................
r
x 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 "Pest Pit.................... Depth to ground water.-------.---.-.--..--...
CT, Test Pit No. 2-----_----------minutes per inch Depth of Test Pit.................... Depth to ground water.-._.__..__._-----------
Ix ------•------------ --------------------••---------------•..................__...----••--•----•----...........................................................
0 Description of Soil.............................................................................................................................-------------------------------------------
x
U
VW ------------------------------------- ---------------------- ----------------------------------- ----- - ------°---------• ---------------....
Nature,of Repairs or Alterations-- Answer when applicable.... '?_i-�2 � ' _. --_-` j-�_---------.-.._L-_�----r---.-----
�-- -' �� riY--c---- - - „ C/-----------------
Ag'reement:
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 furthel; agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed ' __.. r.1�, `U f ------
Date
ApplicationApproved By-- -----------------------------------------------------------------------------------------
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------•-.---- ............
-------------•---------•----•--.---•--------••---•---•--•----------------•--•---•--------_----••-------------_-----------------------------•------••----------------------------•---•--------------•----
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS (A;
BOARD OF HEALTH
9.
.............OF......... = ...................................
Carr#ifirate of Tompliaurr �,-
THITS IS TO C �RTIFY That the IndividtiallSewage Disposal ystem�const ucted ( ) or Repaired
r
y.......- ..�. Y
.... - � - - --.
�Install¢r
- ------ . .._.. ...--•-
has been installed in accordance with the provisions of Artisl'e.)XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. -_________------- dated. . -
7-
THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... -------7 r............................. Inspector------- .....................
..
THE COMMONWEALTH OF MASSACHUSETTS
,7 BOARD OF,, HEALTH
J, / ........ ...........�OF........... .A `...G.cs... �'.�-------------------- r�J
1V o........................ FEE
Permission is hereby granted-- o ------------------------7---------------------------------------
to Construct' ( )/,or Repair-z( )n Individual Sewage DisposdSy^stem /�
at No._�.. - �U!t�a ai_��-LIB.*1 a �� �.f''� ->__!7' =. ....<: .
L .„
Street � S
as shown on the application for Disposal Works Construction 1?eiriit N'o.:y' .., _/__ Dated.._ _'_../.__Y�.7 S—
. ..............
-•---/� •--^--•-•---------•-----•�-------.._..............................................................
Boa rd of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
_---yLOCATION_: _ - _-- ___-- - 5EW&6-4E- PERMIT_-M.P.-
-
-- -DNTE -PERNA17- .1.55UED _:iO=
_ _p.ATE__COMPLI &MCE_.I-SSUED
a
t
5
i
1500 GALLON SEPTIC TANK DISTRIBUTION BOX 500 GAL DRY WELLS - R40 CROSS SECTION Focus PLAN
NOT TO SCALE NOT TO SCALE NOT TO SCALE �; -I O NOT TO SCALE NOT TO SCALE
BM 100.0 MIN049gg 98.0
IX
COVHR TO HE WTTHN 6"OF GRADE MAX.36"COVER 2" 1/8"- 1/2" WASHED S ONE
I
1"9CN.10 P.V.C. 3"NONIA1I71K .^ 18CII.10 P.V.0
�f \ }
" =
ol-
3" +311 94.8 �V 93.9 / 0 0 9, `
17-
94.3 00000 � 00000 2 1k, � 000 ;
I 4.0' 94.1 91.s :` 0 0 0 O 0 O O O w
l
MIN
2. 34' 2.5 2.8' 4.811 2.8'- i
39' 10.5'
10.5' 3/4"-1 1/2"DOUBLE WASHED STONE MAIN STREET
BOTTOM OBS 86.5
SITE SPECIFIC NOTES
FLOOR PLAN DESIGN CALCULATIONS GENERAL NOTES
i LOOR i LAB ` ALL PIPING TO BE SCHEDULE 40 P.V.C.
CESSPOOLS TO BE REMOVED FIRST C t EXISTING BEDROOMS 4 0 110 G.P.D. ALL LOCATIONS OF UTILITIES SHOWN ARE AS
INSTALLER TO NOTIFY DESIGNER 24 HOURS MY p - FLOOR aao G.P.D. MARKED BY DIG-SAFE AND ARE TO BE
65 34 VERIFIED TI INSTALLER PRIOR TO
PRIOR TO BEGINNING OF JOB TO DE of BELOW
4 CONSTRUCTION
DEPTH BELOW INV. 2' THERE ARE NO KNOWN WETLANDS WITHIN
COORDINATE INSPECTIONS WIDTH 10.5' 150' OF THE PROPOSED LEACHING FACILITY
FAM LY ROOM LENGTH 39' UNLESS SHOWN.
•4+8 f ACRES SIDEWALL AREA 198 THERE ARE NO KNOWN POTABLE WELLS WITHI
BOTTOM AREA 409.5 100' OF THE PROPOSED LEACHING FACILITY.
TOTAL SQUARE FEET 607.5 SF T5EFOHEPO SETEAVEISNIHIIN0OTRODLCHIING
CAPACITY SIDEWALL 00.74 146.5 G.P.D. FACILITY
BATN BEDROOM LIVING ROOM CAPACITY BOTTOM 0 0.74 303.1 G.P.D. THIS PROPERTY DOES NOT FALL WITHIN A
BEDROOM CAPACITY TOTAL 449.6 G.P.D. FLOOD ZONE AS SHOWN ON FIRM MAP
HIS DESI(GN DOES NOT REQUIRE VARIANCES T
THIS SYSTEM NOT DESIGNED TO SUP LEME3NTTAL R GULATTIIONS.R BARNSTABLE
ACCOMODATE A GARBAGE ALL CONSTRUCTION SHALL BE IN ACCORDANCE
DISPOSAL WITH TITLE 5 AND BARNSTABLE SUPPLEMENTAL
REGULATIONS.
BENCHMARK SET BEDROOM GAIN BEDROOM IN-LINE ELEVATIONS PROPOSED AS-BUILT SURVEY INFORMATION
LeFt corner driveway INV. 0 HOUSE EXISTING PROPERTY LINE DATA FROM
E1.=100.0 (Assumed)
INV INTO TANK 95.05 Yankee Survey Consultants 3/1/96
INV OUT OF TANK 94.8
BASEMENT INV INTO D-BOX 94.3 PLAN TO BE USED FOR INSTALLATION
OAK INV OUT OF D-BOX 94.1 OF SEPTIC SYSTEM ONLY
R�P REE INV INTO CHAMBER 93.9
<� P` SHE q� BOTTOM OF CHAMBER 91.9 NOT FOR DETERMINING PROPERTY LINES
CSO S. I BGTTum OF OBS HOLE r6.5 BFNC!f fvi h t:K -
pIR pl� ARD TVRooM WATER TABLE NONE ENCOUNTERED CORNER OF DRIVE 100.0 (ASSUMED)
���� BAiH � 'iNFe�61ED
` DATE: OBSERVED BY: WITNESSED BY:
S.OEL TOGS May 31, 2006 LISA C. LYONS UNWITNESSED
+ SOIL EVALUATOR BOARD OF HEALTH
�+ DECK ELEV. OBS. HOLE #1DEPTH iELEV. DEPTIH
OUTDOOR OBS. HOLE #1
CP KITCHEN 99.0 0" �97.2 FILL 0
FILL
W97.83- --- - -14" 95.9--
f�0 A LOAMY SAND A LOAMY SAND.O OYR 4/2
1 OYR 3/2
_ ____ "
97.34 B LOAMY SAND 20 95.5 B LOAMY SAND
10YR 4/6 10YR 5/6
�}A C�
95.75 39" 93.9 4L
#45 C2 MEDIUM SAND C2 MEDIUM SAND 49"
POOL 2.5Y6/6 94" 2.5Y5/6 61"
GAS
L' E 106"
O v 5 26" 86.5 120
O �� NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED
C L E A PERC RATE< A/INCH PERC RATE<2 MIN/INCH
/+ OUT log
+
+ OAK
/ TH 'P :..' H 1 TREE
oil
❑AREE
OT I
CIO �����tH OF� I4. -
SAS - 4 DRY WELLS LISA t. ••'GJ�% 4� bLP FLAN SHOWING:
10.5' X 39' c � � N- FOR:PROPOSED SEPTIE_ ;SYSTEM REPAIR DINyBARNSTABLE
BNs
00
�.8 StOl�e On 5%desj. L Lit.
: *AC
JOHN AND EETH BOMMHARDT DESIGNED & CHECKED BY:• „`3 LOCATION: LI A LYON2.5 stone on ends UP �9 � ' 45 SWIFT AVENUE OSTERVILLEvISIO S: O : DATE:
(` jf �� LOT P34DA'R.JUNE 16 2006
S.�ALE 1 , 20 �?f�l$�► N .S.
I CERTIFY THAT THIS'PLAN CONFORMS TO LISA C. L Y O N S, I \ , .�, (508) 790-9270
TITLE 5 AND BARNSTABLE B.O.H. REGULATIONS ��4���"J-16$8
(EXCLUDING WAIVERS'SPECIFIED) HYANNIS, MASSACHUSETTS