Loading...
HomeMy WebLinkAbout0045 THIRD AVENUE (OST.) - Health 3 Third .Avenue Osterville 140 002 a I c I i i ill I O o �ui��► ��.2o 12 00©0 � 1' Avr K AYE 77.9' 76.9 �A✓ f 75.4 t 2 19.57t N 7G 76.2' w ` + 76.6' S4.2 78.T 4 r' 24,f_ 75.8' pST1NG G pRpAYO GD g ` 77.4+ + 75.7' 75.7' 61 `, IN 75.8 . pROY, ` ..• DECK ' :ol pOSEA ' 76.0' G TIDN 76.2 74.0" ' r + 1\ ? 1 \ 74.2'+ 75.0'+ ` t h � \ N 73.8 73.8+ l 75.8'+ i� 73.8 76 GA�''GE \ + 75.T+ 73.9 74.5'+ � 73.9'+ i 1 142.41, If j L loft �iii►a P � �s rss o tit � Cc ss P a I S � TOWN OF BARNSTABLE LOCATION Li 5 GAM SEWAGE # d q VILLAGE ASSESSOR'S MAP & LOT /416 . ®w INSTALLER'S NAME&PHONE NO. s SEPTIC TANK CAPACITY____ ` LEACHING FACII.ITY: (type) /t n^�` (size) y o� y 3� y it NO.OF BEDROOMS BUILDER OR OWNER 2' PERMrrDATE: COMPLIANCE DATE: U Separation Distance Between the: �Q,y�, ,jpq � 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 --v... ._....... a I 1 A- aT o,,- a 3 431.0 a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 45 Third Avenue Osterville MA 02655 /�� , Owner's Name: John Wendell Owner's Address: 41 October Drive Franklin MA 02038-3471 Date of Inspection: August 10. 2006 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-0400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. ham a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: r„ r' 3 ✓ Passes » Conditionally Passes ' Ne Further Evaluation by the Local Approving Au hority _Fats �} Inspector's Signature: Date: August 14. 2006 The system inspector shall\incopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. F Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 I 9 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not detenmined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain:' - The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: 2 Page 3 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i 3 r Page 4 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to detennine what will be necessary 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 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ — Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back 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 infonnation. For example, a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 r Page 6 of I I r OFFICIAL INSPECTION FORM-NOT FOR VOLUNT ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 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 Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: House not occupied since new septic COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ' gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: None-new system Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? 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) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Instalied on 6114104-yer.as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 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: ✓ (locate on site plan) Depth below grade: 28" 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 ate_ Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Measuring stick Comments(on pumping reconunendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). The tank had P ofliquid on the bottom. The house has not been lived in since the new system was installed GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: _August 10 2006 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: gallons Design.Flow: gallons/day Alarm present(yes or no): Alarm level: Alanm in working order(yes or no): Date of last pumping: Comments (condition of alann and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was new. PUMP CHAMBER: None (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 z' Page 9 of 11 ✓ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: ✓ leaching trenches,number,length: 42'x 13'x 2'(per as built card) 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 leach field was new. 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): Continents (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. b o laYb3rc. ❑ 3 a 3y 35 31fly3 10 +� Page 11 of 1 I 4 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Third Avenue Osterville MA Owner: John Wendell Date of Inspection: August 10 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to detennine 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: Topographic and water contours 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 to o ra hic and water contours rna s the mays were showing a roximatel 20'+1-to round water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 TOWN OF BARNSTABLE 1 'LOCATION SEWAGE # VII.hAGE D S-re fv,ILL ASSESSOR'S MAP &LOT NO INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPACITY LEACHING FACILrN; (type) ^ALt— (size) NO,OF BEDROOMS BUILDER OR OWNER W �( PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 306 feet of lea ng facility)) Feet Furnished by T/tt t Dny�G�i� c aye 3f` ° 3 a 3y 35, .3, f l y3 �• " TOWN�� __OF BARNSTABLE LOCp►TION 5 j l nn Al SEWAGE # d 1` 1 WO I 10 0ev It VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. n'/kC�-U SEPTIC TANK CAPACITY LEACHING FACELITY: (type) ��,/1-1211 (size) NO.OF BEDROOMS BUILDER OR OWNER ;fv. PERMITDATE: �ti, LJ COMPLLANCE DATE` U `4�"`�'"'`' Separation Distance Between the: ��- �t., Maximum Adjusted GroundwaterTabI6 to the Bottom of Leaching Facility Feet I' 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 •lJf/ZJU 1 1 01 r a 34,�,� a 3 y1-o n 1 1-14 3 � � a, �� /JpAl No. THE COMMONWEALTH OF MASSACHUSETTS`P FEE Y+ BOARD OF HEALTH a r 1U�lJ ► t0F �LQ— t �= t C—_ ca \\\ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE _. I IT cz Rep f 7 Application for a Permit to Construct ( ) air ( ) Upgrade ( ) Abandon ( ) - mplete System ❑Individual Come jents � n tJtL� �✓V 1 --v c/Y ` `W�/� I CO Location Owner's Name M CLIP L�-n Q(1A- CO2 4 Ll!�3 ZS rn Map/Parcel# Address Lot# r�^^ rl Tplephone#,,,, Installer's Name 1 Y gn Designer's Name Address Idrj2�� Telephone# Telephone# Type of Building: Lot Size Q,-�F 6-C r85Sq-fMt Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons C� Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow cJE gpd Design flow providedS�Zgpd Plan: Date 3`�J�-(?�- Number of sheets Revision Date Title ' me aria, 4 ;2=0 - Description of Soil(s)U,4ekIXJ�f l v`JZ 41,6 6Qi 32=-A-aN mod. Soil Evaluator Form No. Name of Soil Evaluator •Sci.at c Date of Evaluation 3-3Q-C4 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. y Signed ate 10 Inspections .Q 1114k, 00VFORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 r!'j.•.s^..c yr;. x._HeA ..'Trc-. �...Y r�_��tT+v+ r:y�p"li::t'r +ar'+.:7 - »�i.-.�. •at-,•._ ,xtw�,Yti .._. ' �.. ..s - �Jr�,.. ti,. �_ a.. .. .I ,No. / HE COMMONWEALTH OF MASSACHUSE TS t '�y, FEE f' x° ! � I'BOARD OF HEALTH� .11111�614jri 0- APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT , »- Application for a Permit'to Construct ( )✓Repair ( ) Upgrade'( ) Abandon ( ) - EKomplete System ❑Individual Components ,r Location Owner's NameH ,•,. Map k4o 'r �. Map/Parcel#'"-0� Address t Lot# Telephone# Cr, � 3 E4_0 j x Installer's Name Designer's Name Address \ Addre Telephone# Telephone# Type of Building: , Lot Size Q �C eSSq-"f�e�t Dwelling—N�of Bedrooms Garbage Grinder ( ) ' Other—Type of Building No.of persons 01 Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required)• gpd Calculated design flow �JC gpd Design flow provided D?.igpd Plan: Date �"-3L 0 4- Number of sheets Revision Date Title' Qd. 4 `' /// Description of Soil(s)0�-Vy 2= l am' F Soil Evaluator Form No. Name of Soil Evaluator 71:5•-SO_ttti Date of Evaluation 3-36- DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of l TITLE 5.and further-'agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. _ Signed ate g » Inspections v �� f i FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. V � !n THE COMMONWEALTH OF MASSMGHUSETTS FEE f: XXXiii"' 11 BOARD OF HEALTH CERTIFICATE OF COAIPLIANCE Description of Work: ❑ Individual Component(s) 9complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded(Abandoned( ) r by: Q 5 has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer Designer: eMAaAWAjjcto Dat� t The issuance of this certificate shall not be construe as a guarantee that the system will function as. esigned. n FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. O / THE COMMONWEALTH OF MASSACHUSETTS FEE �'�� BOARD OF HEALTH �. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair (JooOf Upgrade ( ) Abandon ( ) an individual sewage disposal system at y 1 X— se as described ` imthe application for Disposal System Construction Permit No. dated ti Provided: ConsVuction all b comp eted within three years of the date of-this pe rt. nditio must be met. Date / Board of Health FORM 2 - DSCP D P APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN'm PUBLISHERS- BOSTON Sep 15 04 10: 33a 5084779072 p. 1 - 'Town of Barnstable Regulatory Services Thomas F:Geiler,'Director • Public Healtb Division 'Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 509-790-6304 Installer & Designer Certification Form -' Date:. 41 5 log Sewage Permit# d q— /L1 6 Assessor's.Map\Pareel �0 (x�I A LSD ' Designer: `�4ti�� A �;�e�.,tc+_5 �l.t�_: Installer: 4 AMC> Address: Address:. a On was issued a permit to install a (Mate) (iQ ller) septic system-at `� fit.: l�Lil L based on a-design drawn by (address) . 4COCA l00LVJJ 4k.j I 't�:Jd ��tgvdated (designer) , ✓ I certify that the septic system,-referenced above was installed substantially according to the design; which.may, include-mirror 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. flan revision or certified as-built by designer to follow. nstaller's Si naturej OF DAVID jH Aq '�ov CHARLES SANICK: • -, f 28086 — (Designer s Signature) (A g p Here) t LAND`. PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED-UNTIL BOTH THIS FORM AND-AS-BUILT-CARD ARE., RECENE&BY THE BARNSTABLE PUBLIC HEALTH'HIVISIQ& TtWK Y®U. i !1•blues,lih/<,•ntirAl.•cionrr!`rrtilinot;nn Timm 2_�I_Ild lry RL J E { Town of Barnstable P# I o , (, Cgs Department of Health,Safety,and Environmental Services Public Health Division Date lu 367 Main Street,Hyannis MA 02601 � BARN3rABtE, � hh �ArfDMAI"`� Date Scheduled �3C�`�� Time/ ;Q0 Fee Pd. U �� Soil Suitability Assessment for Sewage Disposal Performed By: 1)t3 Witnessed By: LOCATION& GENERAL INFORMATION Location Address JIL,) Owner's NameX ,\ I' .e�de 1 �r Yll�ei ��.JJ V�./ l O s'lRt✓-✓� t)� Address Assessor's Map/Parcel: jq ,Jo�,rce 0 J Engineer's Name an ger( blo-04S NEW CONSTRUCTION REPAIR Telephone# �� `� Land Use K Gs /<<a Slopes(%) Surface Stones IV Lot— Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) JAI- 0 Parent material(geologic) 6 U4 w a f Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Pace Estimated Seasonal High Groundwater ...... ............._...,.__....._.................. .. .... ..... ..... ...._...__.. _..._........... ..._.... DE 1'ERMINA TIONTORSEASONAI HYGIf.WATETt<TAI3LE Method Used. _ Depth Observed standing in obs.hole: _in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Dale: Index Well level Adj.factor Adj.Groundwater Level ''PERCOLATION;TEST atej3A Time /0 C Observation VZ/ Hole# Time at 9" „ Depth of Perc ,T 2 Time at 6" Start Pre-soak Time cQ /D O Y Time(9"-6") End Pre-soak /o / Rate Min./Inch Site Suitability Assessment: Site Passed L/ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back Copy: Applicant DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) I (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) 4 IL G —3 2 A, s/�f j2- 7� C f�Al ��y e '�y C2 s Ali, G,�a�wfv _ t DEEP OBSERVATION HOLE LOG Hole # 2— Depth from Soil Horizon Soil Texture Soil Color Soil s Other Surface(in.) (USDA) (MLMSeii) Mottling, (Structure,Stones,Boulderes. Consistency.%Gravel) 2-11. a w. 4n ay )4VAS� Jz- 74 C ,sv.;l /OYZ 76 -132. L "4xc �✓® CjYw�wry DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Bouldcres. Consistency.°o ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulderes. Consistency,°° ravel I Flood Insurance Rate Maw: Above 500 year flood boundery '.v Yc ,/� -- Within 500 year boundary No r Yes Within 100 year flood boundary No r Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? yef If not, what is the depth of naturally occurring pervious material? Certification certify that on % (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and xperience described in 310 CM 15.017. Signature A Date li R. . , a G 6A66 R.o. b-S n (o-o - /'� �'O Fw4 Go c + a z 1 1. ( .. t i�8 � 3 1 / l' A,3-0 Y7- 35A W . , F• _ �`. T cuCrsn— Relaa,.is it t * b• s • 8' alit r s I P (FIB s.k 5 AD_�YL� _— III vo co /,2a� ' 1 oS , � r # P 6`Q�� Y�I ZE/ x9'I6 Lvf— rbQO� Le` r u f z .y ,n 11 .+ , 1� M • +. Ta ,n a a i Sol BY sae K�oc(�S�e L t. is Kp� /2! i ' SCAIE OVED DRAWN BY �(A] )xj) sffoc2 / - jr F,Crstrn5 I r1 1 ._X { a fq1 DRAWING NUMB ' • .F .. .. r 1 , x �. Via•1 1 Aq ?.sis diursrwts cim-EvSm19 Zfcop-C06re- noEeZ . SIhO�Ie ed��J�t Ca�+19T-�d�•tY"-tre�min� lel�-.��C� � I i I 3 On Uo � I a � � e I O I I, CP Av 00 - .. i� -- /�� f�o�/-rce Qa/J -See �ala•�- �J D ' x `E O t/ Y y� 3n4crfdr meps�wE- are- -{U Lv\ps(, — SCALE. •/••— Ir APPROVED By, DRAWN BY�L� DATE V5 3rL Ave— ICennnu2�r�i5 2• d_ F�tra� ' DRAWING VMBEA - } N� � I I e . TF cre�..�e SCALE: Vt(I,, I I APPROVED BY: DRAWN BY->-D ATE: 3-U DRAWING NUMBER ibYAM `��,I��nS ,3 ,� F3 �M� ��2s+�✓ Ca-3Sr 3/ypl� Tr�j I.�etNai tsZ-t��a.5 (k5pna���Cce0 P::q F44:dl �� Ca�c•e{c . o�rt�n•�v5f�e� �r„ti R.6e1-�S��1� 5 • �i Crtt�Alo .Lhueslm�� i `` . I� SCALE: yl - t APPROVED BY: DRAWN BY�[ DATE pp //•�� I q� � / f DRAWING7UMBER • - g. - G t.UtI113NVLS �vS�t()YV` U:I.cif"y`.CU qF �oSv st<h( - qi. Sa»t 2tu �.w�1 D or 2�,�t I I r $ot�io S Z OC� , nn " 6CALE.r YI!z I I- APPROVED BY: `` .DRAWN BY- y� " - - DATE • - - r� II ` ^,� f I DRAWIND NUMBER —�ry l,U t�l lc~!1!S (n��SYnrt 1J�11ir1nr_S_. � / A i i a CC I APPROVED BY• DRAWN BY�((� DATE: N J] 3rd aue (�1erJ, �� hlAcm _ SYSTEM PROFILE TOP OF NOT TO SCALE FOUNDATION FINISH GRADE EL. =_ �.� FINISH GRADE OVER SEPTIC TANK ems• 2 FINISH GRADE OVER = 9 DISTRIBUTION BOX FINISH GRADE _OF TO ,o of OVER TRENCHES 7s z. OF FINISH GRAD•, ( -.1,-0= ,, l.',I, `r...,,'p;�r.,'�.1� _^ol � OI'• 1•\ 1,', Or 1. PRECAST CONCRETE MIN.SLOPE 1% 3" MIN. b RISEIS TO 6" b' H-10 REINFORCED ORCED LOADING =o \o_ 3 6" -' MIN.SLOPE 1% OF FINIH GRADE - OUTLET PIPE(S) LEVEL , _ MINFL_ o FOR 2( MIN.1 /o SLOPE TRENCH LENGTH = 42 0 21 BEYONDVN 13"MIX LENGTH = 8'-611 14" 0 i o 0Ij 16-S1 ,0:1 1 0:1 i ,1 0 1 �, _ _ c J UMP o o of :1 �,. .,1 PVC OR CAST IRON TEE `y 71• o •1 , 1 , " 72 H /l. h�'10� � /. `i 1 ` 1 'i OOf' al ,1. •�'` 1 .!' •( GAS BAFFLE1 } �0- DISTRIi3UTI0N BOX �,;�o -lo �� W 'I �i•• '1 :1 •4 10 1 .I 10.1 , %' I 10'1 1500 GALLON MINIMUM INSIDE DIMENSION 12" 3l4'1"HED211 3l4"- 1-1/2" DOUBL q, BSMT.FLR. a:_ :�: PRECAST CONCRETE OUTLET INVERTS;_ BELOW INLET INVERT q WAS CRUSHED WASHED CRUSHED ELEV. Q, `y I o' I. MINIMUM CONCRETE WALL THICKNESS 2" STONE STONE s> ��-10 REINFORCED o .1 INSTALL ON COMPACTED LEVEL BASE J J , ` ,e , " ., / I\ • I ,I.. 1 I 1 1' 1 1 , (1 , L ,. ( h. .. 1�1 `I �• o - ' .�'d:l; TRENCH SECTION SEPTIC TANK NOTE: EXCAVATE TO =C= STRATUM IN ORDER TO INSTALL ON COMPACTED LEVEL BASE REMOVE ALL =A= & =B= IMPERVIOUS MATERIAL WITHIN S OF THE SAS. REPLACE WITH CLEAN, 9" MIN. 3" OF 1/8" - 1/2" CLAY-FREE SAND 4" DIAM. 36" MAX. DOUBLE WASHED PEASTONE "��' � " 1 p. g:l �9 y� 3/4" - 1-1/2" DOUBLE 48" 5'-211 " WASHED CRUSHED STONE _ TRENCH WIDTH 13'-211 y NUMBER OF TRENCHES 1 NUMBER OF DRYWELLS 4 GENERAL NOTES: � o I F. Tyr.., r N s/ i 1. ELEVATIONS SHOWN ARE BASED ON ASSUMED76. y 2. ALL PIES IN THE SYSTEM MUST BE CAST IRON OR SCIiEDULE 40 PVC. 3. HEALZH AGENT/CAPE & ISLANDS ENGINEERING MUST BE WHEN 75.8 q TE PRI OR FIED TO BACKONSNRGUCTION IS "FeH ,�.. K I AYE 77.9' OBSERVATION PIT --`r ,���+� y BY CAFE & ISLANDS ENGINEERING AND THE BOARD S E/. 7 , u l � sJ� 76.0' OF HEtiLTH. P-10,688 75.0 5. MATERIALS AND INSTALLATION SHALL BE IN PERCOLATION RATE: < 2 MIN./IN 75.4' ` COMPt!ANCE WITH THE STATE SANITARY CODE + 751' P-10 •f WITNESSED 9Y: DAVID STANTON e� [TITLE J]AND LOCAL APPLICABLE RULES AND BARNSTABLE BOARD OF HEALTH TF69 / 219.52 N �G REGULATIONS. 7s.2' 6. N0E?T'.AE?R0l�1 IS FROP��! REC::RD r11 All C A".D IS DATE: MAR.30,2004 74.T _ . � ' + w 76.6' 54.T NOT INTENDED FOR SOLAR ENERGY PURPOSES. 78.7' + 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. TH#1 TH#2 DESIGN DATA 74.5't ? '76.0' =A= LOAM 24.00' 8. FLOOD ZONE C [NON-HAZARD] 0' '�: o \ 75.0' \ ` �� \ 9. FLOOD PANEL: 250001-0016 D DATED: JULY 2,1992 =A= LOAM � , 75.8" �, 10. THISPROJECT DOES NOT INVOLVE ANY PHYSICAL 10 YR 2/2 10 YR 2/2 N \ GROUJD DISTURBANCE OR VEGETATION REMOVAL 6" 6" NUMBER OF BEDROOMS 5 1 EXISTING pROpOSE� 77.4 WITHI4 100' OF WETLANDS,INLAND OR COASTAL =B= SANDY LOAM GARBAGE DISPOSAL NO �\ . DOG GARP'GE S_ \ + BANKS OR FLOOD HAZARD ZONES. =B= SANDY LOAM 74.0 LLIN I 10YR 5/4 10YR 5/4 DAILY FLOW 550 GPD. SEPTIC TANK REQUIRED 1500 GAL. \ 73.8'+ �' 75.7' 75.7' 3211 32" SEPTIC TANK PROVIDED 1500 GAL. 7>6' 1 LEACHING REQUIRED 550 GPD. IPBo ,N \I 75.8' =C1= MEDIUM SAND =C1= MEDIUM SAND N\ cK ;g B' 10YR 7/4 10YR 7/4 SOIL ABSORPTION SYSTEM CALCULATIONS:, \ wIPROpOSE� DE - N 76.2' 76.0' 76" 76„ `74.0'+ ION -12:00' o SIDEWALL AREA = 220 SF. �il)'% 0 1� ' T =C2= FINE SAND -C210YR FINE 220 SF. X .74 G/SF. = 163 GPD. 7 . �"\ 10YR 7/3 BOTTOM AREA = 553 SF. 15.93' _ 1 553 SF. X 0.74 G/SF. = 409 GPD. �z I \ 132 NO GROUNDWATER 1 32" NO GROUNDWATER LEACHING PROVIDED - 572 GPD. 74.2' 75.0'+ + \ 737 _ N v 1 • w ' \ 7��5+ � �� e \ � 76.5'+ o r T 4 73.3, \ \ 73.81 73.8'+ \ a 75.8'+ \ LEGEND 73.8' + 73.8 \ 52 PROPOSED CONTOUR \ \ GAUGE 'N 74 --- 52---• EXISTING CONTOUR 75.7'+ \ �73.9' i 73.9'+ 74.5'+ OBSERVATION PIT ❑ DISTRIBUTION BOX 1 142.41' o 0 o SEPTIC TANK 73 3'+ 73.8' - SOIL ABSORPTION SYSTEM RESERVE AREA PROPOSED ADDITION & SEPTIC SYSTEM UPGRADE Ln Ile el col a �i , O t 22.26 PIPE INVERT ELEVATION "`'�� PROPOSED SEWAGE DISPOSAL SYSTEM PREPARED FOR t J JOHN WENDELL Se, Ost erviil aQPye ;. nf- F"e Fi T1E ' ISTA °aj 0s � •a o�a .� �y HSE.NO. 45 THIRD AVENUE ella OSTERVI LLE,MASS. u�el cool 9,01 P9 ' Rn o� tiI P' ? 5 ACADE ,.t. 6 \ PLAN NO. 033104 SCALE: AS NOTED a�� Bf l dam~ t WIA � 5 ;,�j �' y FILE N0. DATE: MAR.31,2004 T(T L ES =e, GULF,, ,o s°��I��o- _ el�� �� PLOT PLAN i, N {-;,:,. �•s,..3 SEPTIC FILE N0. 74 PCS FILE: thirdav45 I S L, N D - ;�"'pv 11 �. �� v, I ` e 11 1 z �. V `': SCALE: 1 = 20 � ��.,r,, r z z z 2`,�a5 , %� CAPE & ISLANDS ENGINEERING A Pd 026: O O O �r r J) a� o lar140 2 & 5 45 �;srEM1 800 FALMOUTH ROAD, SUITE 301C p° Se-ay v c, NU ; MASHPEE,MA 02649 (508) 477-7272 MAP SEC PCL LOT HSE - *-Iw-