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HomeMy WebLinkAbout0074 WEST WIND CIRCLE - Health 74 West Wind Circle Osterville •P fi A -121 011607 u . e a a e ° n „ TOWN OF BARNSTABLE LOCATION �'� "J'54wild C,r SEWAGE # dW J,-(0 .3 `ML•AGE Oikrvtlle . ASSESSOR'S MAP & LOT f I- U11007- INSTALLER'S NAME&PHONE NO. /. M. e. SeP4,� SZT 773"8776 SEPTIC TANK CAPACITY 1 y00 (C. I..EACHING FACILITY: (type) Dr!Jwc/lJ (size) �O.OF BEDROOMS 3 PUILDER OR rk PERMTTDATE: ����a 101 COMPLIANCE DATE: 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 facility) Feet Furnished by %�� C-�P5 g ,, R =0� 4 � f � TOWN OF BARNSTABLE LOCATION � ��� � �� SEWAGE # va.LAGE C)r TW2I��� ASSESSOR'S MAP&LOT AuQ— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 000 " LEACHING FACILITY: (type) ®t� (size) 100 � ,NO.OF BEDROOMS 7> B3 ILDER OR OWNER P.E,F�DATE: COMPLIANCE DATE: 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 t leaching facility) Feet Furnished by C 4-1 Z �� �yt ►31 C° a No. v Fee 1-0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH ENVISION - TOWN OF BARNSTABLE.,MASSACHUSETTS ZIpprication for Migogal *pgtem Congtruction 3permit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 74 West Wind Circle, Osterville John York Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. w.E. Robinson Septic Service. Stephen Dunbar 781 -727-8320 P.O. Box 1089 Centerville 30 Madison Ave 02038 Type of Building: Fran in M Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(jo) 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 Alterations(Answer when applicable) Install a new title 5 leach system to plans of Stephen Dunbar 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 e Env' on al and not to place the system in operation until a Certifi- cate of Compliance has been issue by tbi and Signed Date`' Application Approved by Application Disapproved for th ollow ng reasons Permit No. 2 UU Y—G 7�3 Date Issued /.2 - No. duo L '& ` �'.L ..mod Fee 1 00 F THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUB t.LIC HEALTH DIVtSIdA TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Mtgogal *p6tem Con!6tructton Permit .Application for a Permit to Construct( )Repair( x)Upgrade( , )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 74 West Wind Circle, Osterville John York Assessor's Map/Parcel 1 21/01 1 -007 Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. 7$1 —7 2 7 8 3 2 O w.R. kobinson Septic Service Stephen Dunbar P.O. Box 1089 Centerville 30 Madison Ave Type of Building: r ran in t� Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder 00) 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 ;t Nature of Repairs or Alterations(Answer when applicable) Install a new title 5 leach system to plans of Stephen Dunbar Date last inspected: Agreement: The undersigned agrees to ensure the construction and mai ena a of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of ie En ' on tal and not to place the system in operation until a Certifi- cate of Compliance has been issu7,d by thi oard Signed Date Application Approved by k 1, ✓ J Date Application Disapproved for the following reasons Permit No. 2 LJ— 7 D Date Issued York THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( x )Upgraded( ) Abandoned( )by W.E. Robinson Septic Service at 74 West Wind Circle Osterville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ?�' 4 73 dated 2 - 2.2 r, Installer Designer The issuance of this pe t hall not be construed as a guarantee that the s stem 1wil' f ction as designed. Date ` �-21 V Inspector J AV i`--- t i Q' No. 2.UD L�4,73 ------------------,---------Fee 100 YORK THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS M!6pogal *pgtem Cow6tructiou Permit Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( ) System located at 74 West Wind Circle Osterville 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:Construct on mu/st be completed within three years of the date of this pit. Date:_ I a. 1 a V Approved by 4 Town of Barnstable Regulatory Services Thomas F.Geiler,Director- • B"NgrABLE • 9 MASS Public Health Division i679• ♦0 Thomas McKean,Director o 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&-Designer Certification Form. Date: a Designer: . Sle' en F Dafi AZP Installer: / df7lnSOCI s� fie,. Address: 3 0- W4l 91.Sot� /�(/� Address: w. J O Y ^ On lit/ 6tnvoii/ c 2fGwas-issued a permit to install a (date) (installer) septic system at 7q 'G Ies Iuo 10 y57;rGii A based on a design drawn by (address) . t# a �&J,P7 Ato ap— 'dated ( esigner) I certify that the septic system referenced above was installed substantially according t.o 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 jabove 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. DOD (Installer' ,, s Signature),�• . � � CAn. p gNiT A�� (Designer's Signature) (Affix Designer's Stamp Here) 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:HealddSeptic/Designer Certification Form' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M A� L DATA TOWN OF BARNSTABLE LOCATION �CSP"""J C,t' SEWAGE# '�7� VILLAGE C)5+��01I ASSESSOR'S MAP & LOT l 011-007.. INSTALLER'S NAME&PHONE NO. /.Jm Q®b�se�' se re S�+L 5a8 77f•d77� SEPTIC TANK CAPACITY /000 LEACHING FACIL=: (type) X � �' "'cIts (size) AP X aS X 2 1 O.OF BEDROOMS 3 UILDER OR O kJo fk /off 3 v COMPLIANCE DATE: I�" A-f o PEPMTTDATE: — Sf Separation Distance Between the: 6. Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility }� Private Water Supply.Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by l va Cat S �(oUSC K ATI® LLAGE A`. " .l4' Q "STALLI _ FDA "Lum tion D _ A; 11ate Watej �n site or, �e of Well, yithin 300 ushed by. CO`j, - -E.�tTH OF NWSACHUSETTS E\ECUT1VE.OFFICE OF EN- IRON.MENTAL AFFAIRS DEPARTMENT OF ENVIRO\MEITAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 bl?-_9_•`:00 17tZLL1ANt F.WELD T MY Cr i�,. 0 0 Scz%c Governc J 4 • - D?t` B STRUM'_ ARGEO PALL CELLL'CCI :�- Nx��VY r�Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM F '' Comrrissiorr_PART ACERTIFICATIONAddress of Owner: l�rCl Property Address; `� 2y��3► CAV i G6`ft �•\�` 1 Date of Inspection: J`I Of different) Name of Inspector: I`t'���.+,o 1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title 3 (310 CMR 15.000) Company Name: 17a 'e 67n r, r,,., Mailing Address: -PQ A(nx ia_37q!�i H t�-0 2C4_q Telephone Number. CERTIFICATION STATEMENT cer;ifl that I have pe•sonally inspected the sewage d!sposa' system a; this address and tha: the information reported below. is true. accurate and corriolete a: of the time of inspect,o�.. The inspec;ion vas pe^ormer based on,my training and experience In the proper fu^c�en and maintenance o on-site sewage disposa; systems. The cvs;err.: NPasses _ Concit.onaii\ Passes kleec_ Furtne• E•-a!u a local Approving Authontti ° Inspector's Signatur Date: T:ie Svs:e-7- Ins're:o• shai' submit a copy of this inspec-,en reocnito the Aporoving Authority within thir;v'(30i days of completing this inspection. It the system is a share--: system o• ha; a des,gn flow. of 10.000 gx or greater, the inspector and the sys;em owner shall submit the redo^ tc the aporopriate reg oral o^ice of the Depanment of Envirenmenta' Prctectior.. The crig!na! should be sent to the system owne and copes to the buyer, ii applicable. and the aporoving authority INSPECTION SUMMARY: Check A, B, C, or D. AI SYSTEM PASSES: .. , .. __XI have not found any information which in that the system violates any of the failure criteria as defined in 310 CMR 15.303. V ny failure criteria not evaluated are indicate✓' below. COMMENTS: BJ 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: Indicate yes, ne, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined% explain,why not.. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance lanachedt indicating 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 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 i conforming septic ink w approved by the.Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r. PART A CERTIFICATION (continued) Property Addmss: Owner. Date of Inspection: 91 SYSTEM CONDITIONALLY PASSES Icontin,,d Sewage backup or breakout or high static water leve! observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: ` 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 wi!I pass inspection ii Iw•ith approval of the Board of Health): broken pipets; are replace: obstruction is removed C] FURTHER E7VALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reauire furthe• evaluation by the Board of Health in order to determine if the system is failing to prole the public health. saie�•and the environment. 1) SYSTEM WILL PASS UNLE55 BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFi:TY AND THE ENVIRONMENT. _ Cesspool or priv1 is within 50 iedt of a suriace water Cesspoo! or pri.,- is w ithin 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL LINLE55 THE BOARD OF HE-ILTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIOti1tiGAN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The syste n has a septic tank and soil absorption system (SA ) and the SAS is within 100 fed, to a surface water supply Or ,tributary to a surface water supply. The system has a septic tank and soil absorption system and the W is within a Zone _ I of a public water supo'y well. The system has a septic tank and soil absorption system and the W 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 thar. 100 feet but 50 fed) or more from a _ private water supply well, uniess a we!l water analysis for coliform bacteria and volatile organic compounds indicates that the we!I 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 riot va!id). 3) _ OTHER (r.vis•2 01.'25/77) page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: f Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "tio' as to each of the following: I have determined that the system violates one or more of the.following failure criteria a< defined in 310 CMR 13.303. 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. Yes No Backup of sewage into facility or system component due to an 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 hood level in the distribition boa 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 clay floe. Reduired pumping more thar. 4 times in the last year NOT due to clogged or obstructed pipe°s . Number o'times pumped _ a Any portion of the So!l Absorption System, cesspool or priv'• is below the high groundwater eieyanor. Am por:on o:a cesspool or privy is withir. 100 feet of a surface water supply or tributary to a surface water supple. Any por,,on of a cesspoo' or pri.-�• is %%Itkin a Zone I of a public well. An. potion of a cesspool or pri.v is within 50 feet of a private water supply well Any por,or. o:a cesspool or pri.-,• is-less than 100 feet but greater than 50-feet from a private water supply well with no acceotable water qualm analvs*. If the well has been analyzed to be acceptable. anach copy of well water analysis for coltiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate ei:ner "Yes" or "No" as to each of the following: The iolioN:r,g criteria appi% to large systems in addition to the criteria above: The system serves a iacilm with a design flow of 10,000 gpd or greater (Large System; and-the system is a significant threat to public hea!th and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the Focal regional office of the Department for further information. (revised 04/25/91) page 3 of 10 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addcess: Owner: Date of Inspection: ����� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No 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 Large volumes of water have not been introduced into the system recently flow rates during that penod. or as pan of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The iac:li\ or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components. excluding the Soil .Aosorpuon System, have been located on the site. _ The septic tank rnanhoies were uncovered. opened. and the interior of the septic tank was inspected for condition of bafiies or tees. materia'. o'construction. dimensions, depth of liquid, depth of sludge, depth of scum. The size and locat,on of the Soil Absorption Svstem on the site has been determined based on h _ The fac,lm ovine• ,anc occupants. r diiteren: from owner, were provided with information on the proper maintenance of `-C Sub-Suriace Disposal Svstem. ' (V Existing iniormation. Ex. Plan at B.O.H. _ beterm,ned in the field !i am of the failure criteria related to Part C is at issue, approximation of distance is unacceatabie [15.30231:bl] (revised 04/25/57) Page 4 of 10 l i SUBSURFACE,SEWAGE DISPOSAL SYSTEMJ\SPECTION FORM PART C SYSTEM INFORMATION Propert% Address: Owner: Date of Ihspection: 1�j n FLOW CONDITIONS RESIDENTIAL: Design floe. - zm p.d1bedroom for S.A S d Number of bedrooms t_r� Number o-'current residents n. ' F Garbage g-; der (yes or no!:- Laundry co-•^ected to system (yes or no!. Seasonal use ryes or no!:�V Water meter readings. if available (last two ;2: year usage (gpd): Sump Pump (ves or no) t: lac: date o'occupant% lswfi,j COMMERC i4L'INDUSTRIAL: Type of establishment Design fio% ga!ionsida\ Grease trap present. tees or no Industna! \taste Holding Tani; present. Ives or no :on-sanna-� Haste discnarged to the T!tie 3 system. ives'or no \\ater meter readings, if availabie Las:pave o; o cupanc. OTHER: Describe ' Last date of occudanc, L GENERAL INFORMATION PUMPING RECORDS and sou of information. System pumped as par, of inspection: tees or no. i If ves, volume pumped gallons Reason for pumping TY OF SYSTEM - Septic tank/distribution box/sod absorption system Single cesspool Overflow cesspool ,- Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? ' Other _ APPROXIMATE AGE of all components, date installed (if/known) and source of if 16 �L� a Sewage odors detected when arriving at the site. (yes or not , (revised 04/25/91) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEh1 INFORMATION (continued) Property Address: 74 Owner: Date of Inspection:'3 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 h-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: tlocate on site ply, Depth below gradeZy %laterial of construction: concre:e _me:a _Fioerglass _Poh•ethvlene _othenexplam If tank is metal. Iis: age _ IS age confirmec o% Ce-t;iica:e of Compuance _(1es.'No Dimensions Sludge depth Disiance from top o: s'.udge to bottom of out;e: tee o, ba-�:;e Scum thickne5s' p Distance from top of scum to top o'outle: tee or ba^ie ( Z. Distance iron bottom o scurn to bo-o-^ o;outlet tee e, bane- 11 How dimensions were determined %ka,myu-cli Comments. trecommendation for pumping. condition o,. inlet and outlet tees or baffles. depth of liquid level relatto to utlet invert, strupurral (� ire ntv, evidence of leakage. etc.t �� l ked +7) ri'4( � 7S C f S + , GREASE TRAP: (locate on site plan; Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.; (rev,.xed 04/25:97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem Address: OH ner. Date of Inspection:It ��( TIGHT OR HOLDING TANK: "Tank must be pumped prior to, or at time, of inspections (locate on site plan, Depth below grade: Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain) F Dimensions: Capacuy galions Design floe galionsda. Alarm level Alarm in %%orkmg order _ Yes. No Date of previous pumping Comments (condition of inlet tee. condition o- a!a,m and float switches, etc.) r DISTRIBUTION BOX:6j doca,e on site p-an r7 Depth of Iiauid level aoove ouue: m\e^ .� � Comments ya�e :f leve! and dish.ib;,t. r i- Pauz evidence of s Inds ca o ' r, evidence�Qf leakage into;or out of box, etc.( QT cd " PUMP CHAMBER. (locate on site plan. Pumps in working order: (Yes or No' t Alarms in working order (lees or No- Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) i (revised 04/25/97) .Page 7 of 10 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-ss: •7q, wit Owner: Date of Inspecuon:31 -7 1c,�_<, T SOIL ABSORPTION SYSTEM (SAS): (locate on site-plan, if possible, exca,. tion not required.-but may be approximated by non-intrusive methods If not determined to be present, explain: Type: leaching pits. number.1.11, leaching chambers, number:_ leaching galleries, number: leaching trenches, number,(ength: leaching fields, number, dirnension.s overflow cesspool, number Alternative system Name of Techno(og% Comments. rno corldition of soil' signs of hydraulic failure, level of porying. con non of v etat , etc.t .CESSPOOLS: _ (locate on site plan Number and configura:.on Depth-top of liquid to inlet urver, Depth of solids lave, Depth of scum layer. Dimensions of cesspool Materials of construction Indication of groundwate- inflow tcesspool must oe pumpec as par, of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 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 04/25/97) Page 8 of 10 ° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of In3pection: 17) _ z SKETCH OF SEWAGE DISPOSAL SYSTEM: a include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i o � ► , Ja. a 34 (savisa'_ 04'25!57) Pago 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertm Addres-• L'vtJt;.(/Jfttt t Owner: Date.of Inspecilon:.i°�,�`5� Depth to Groundwatereet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation.of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Cnea with local Board o' nea!tr Chec:. FENAA nlaos Check pumping records Check loca! excavators installers Da-.a r Describe in %ox o%\- v.oros no'.% \c: es:ab!!shed the 1-iieh, Groundwater Elevation. (Must be completed Irw.a�C 0�,'25'9' Page 10 of 10 7 fL0 C T 104 i) SEWAGE PERMIT W0. VILLA aE or �� ,,. IXS7ALLER'S NAME A � � � � 55 Y 3 UIL0f OR AW9EN DATE PERMIT ISSUE ® aA7E G0M .PLiANCE I S 5IIED___ ai.p 8,6 _ Ad 0v' qt` T7 �/ Lof No..,.............._%�. F�s..P. ...._................ THE COMMONWEALTH OF MASSACHUSETTS �vl BOAR® OF HEALTH i� ..........................................OF...................................... Allp ira#ion for Disposal Works Tomitrnrtinn amit Application is hereby made for a Permit to Construct �f"1'7 or Repair ( ) an Individual Sewage Disposal Systemat: Y Location- or /Adr�s �/ reg -.- ---- --.... ----------------------- - ......................... � Installer Address Type of Building Size Lot... feet �-, Dwelling—No. of Bedrooms__.----____.3----------•--_--__-_--_.-Expansion Attic ( ) Garbage Grinder ( ) Wa Other—T e of Buildin yp g Q..�,q/.�. No. of persons........ _ Showers ) — Cafeteria ( ) Other fixtu s W Design Flow...................... ..................gallons per person per/day. Total dail ow........... __ .6..................galle s./ WSeptic Tank—Liquid*capacity&'.gallons Length__.1V..6_... Width----- ...... Diameter________________ Depth.... x Disposal Trench—No..................... Width.......I............ Total Length................ Total leaching area___.__. ___.____....sq. ft. Seepage Pit No---------(_.__. .. Diameter......... ....... Depth below inlet..._....------- Total leaching area...0f, "_sq. ft. Z Other Distribution box (, Dosing tank ( ) Percolation Test Results Performed by--- ....... Date.................................:...... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water___ GL, Test Pit No. 2................minutes per inch Depth of Test Pit___.........__...... Depth to ground water Q. ___ I� Q' ---------- ------- Description of Soil................... ............! 1 ............................................. ------------------ V .........-•-•••••-•-•-•-----•----......•----------------•-•••---•-•-------------------------•...-------•-•--------•--•--------......•----•------....--•-------•--•-••••....-------•-....------......---•- W V Nature of Repairs or Alterations—Answer when applicable...................................................:........................................... y •-----••-----------------•-•--•-------•---•------------------------•---•-----------.....----.......----•----...------------------------------••-------------------------------------•-••-----......-•-- Agreement: , - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLI 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beej issued by the boar of hea . Signed. _ . .------ ..7� ............. ------••-------------••-•------- /Date Application Approved By..................... ............ . ......................... -•------ 6/�� � Date Application Disapproved for the following reasons---------------------------------------------•--•------------------------------------.........••-••.....--------- ------------------------------•---•------••---•---------•----...-•--------••------•-•---....------.......---•-------------•---•---•----•--------•••••-•--•-•---•--•-••--------------•••-------••-•.----- Date PermitNo......................................................... Issued....................................................... Date 6: No....................... FElic......5....................... I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , It- 7 ............... .. ...................OF........................... ...................................................... Apphration for Bhiposal Works Tomitrurtion 1hrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal syst at - ---------- Location-Address or NO: A ..........*. ...... ------ ....... ....C.0.................Y,4y 0 Address .... .................... Y./;,a, .......................... Installer Address Type of Building Size Lot.11-�e-&--'sq. feet U Dwelling—No. of Bedrooms............3:...........................Expansion Attic Garbage Grinder P4 Other—Type of Buildin g No. of perso ns........6---------------- Showers Cafeteria Other fixtu es . ...... ....... ....... 0 Design Flow. per person perld�y. Total dai .............gallOns.,,,, 1ow--------- ------I.- 1 Ix Septic Tank—Liquid capacity/i9joLgallons L&igth._/+*.6.... Width_._._`.. .._..._. . Diameter---------------- Depth... W ..3 Disposal Trench—No_.....................Width......I............ Total Length................?... Total.leaching area............-------sq-. ft. Seepage Pit No Diameter.... ....... Depth below inlet........ ...... Total leaching area..h.f.�71.sq. ft. F P-� Z Other Distribution box Dosing tank Percolation Test Results Perf6f-med by --------------------------------------­---------7------------------------ Date......................................... Test Pit No. I................minutesperinch Depth of Test Pit.................... Depth to ground water LL, Test Pit No. 2................minutes per inch Depth of Test Pit-----...............Depth to ground waterX Pd ...... . ..... .............................................................................. 6 . . ................................................................... 0 Description of Soil:.. .......... ............. ........... U .......................................................................................................................... ......................................................................... ......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .............................................................................................................................................. ................................................... A greement.: The"undersigned agrees to-install install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTAP 1E 5 of the;-State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of lie*, fl. Signe_74_14, X, . � Application Approved By....................... - 4 .... � ..... ......... ..... - - 41 ----------- Date Application Disapproved for the following reasons:............................................................................................................ ........................................................................................................................................................................................................Date PermitNo......................................................... IssuedL......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT .....—le ......OF. . ............. TpWrftfiratr of Tomphaurr THIS IS TO CERTIFY, That the/Individual Sewage Dispo§al,system constructed O or Repaired y---------------------- -------- -------------------------------------------............................... In taller at....VZA14 Ir..... .g4'.11...... i_:je Ilel ........... e ---------- has been installed in accordance with the provisions of TITLE of�Qe,.State Sanitary Code as described in the application for Disposal Works Construction Permit No............... ........ ....... dated___._.__._._-_-__________.__.__..-_.:_.____.____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... ..................................... . Inspector....--_. _Za-wel,&----------__--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.......0'6!..5A;.t FEE........S. ......... Rspaoal Works Conn ion Yanfil Permission is hereby ranted.--......0­4� 'V7 44....... ..........C-0.......... fell I ....... to Construct L-L.Al X Z I j or-�R Individual Seer ge Disposal Swtem L e at ...r------- ......W.4� No.. Street as shown on the application for Disposal Works Construction Permit No. ated.......................................... ell I.. .... ......... ----------------------------------------------- oard of Health DATE........................................... Z FORM fC255 A. M. SULKIN, INC.,*80S TON FL EV: 39010 c_L.Ev. _- -.••� G tza.l E 2 nc._ �— ALL Ec.Evi 5Nn4i a, A+C1c M�ACv SE a, L��EL• (1(,? `�: „_ � � �;.��31-JJr� ----�' r - /^ ii'�.c.SC-t� cy►� U�y^..i�4� G�..T t.e� PL.�,►.l� P17r-t4 AL_ LIMN A ",&Ajmol? oo` If6`Al-,ra_7j G fI IED. A LA_ Fa r P�`S TAD A t,l>a t.al T 1 \% � -bN M SHA.k_I .. C-A OJT 14�D>� L7 ►W 1�U ti l� '1' -- A.LL SEPC4C TA►JK$, DitT2t8Jrlo.j la0k. A"ID ,r ' T"` _ �__ -- -_� 1 Q Er ✓E Au._- U> Jso,r�,8� MATErZIA. 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'v lJ lU ReGCO2 w tTti+ r8�Epp-rFCT�.� 3TgTL: t A 7Y P 1C A,%_ ClI ST2litpurl C.10 E50 fL n �^ 1 a� '1 ---- ----- - - i _ � ) Q �l r '� `f c�o>` A s[.� A,�y LeKaL > S N cs-R T#O '.�a.0 A L E L_ I ' - _ .,.-•�."_ FF # _ OrT� tJt vrL l�svr�n+,i HOr r.vv ►o©p =ao.t ►Yf'at o 4 1600 C%M.. �EYt'l` _�r..J is ���'Lt r�>•f �a�.�►�ti ti 1 P IT f I1A f/T5 15Ci't [ AMfE f,.. x by .Kic.,.J ►," R"S SG4l- - ►.i©T To SC,.L E OR 6E Cr V P-1. 1.i��►f�: >n t a K S aQ t.s FctcGE O T/+e�..i;r v.;T �+ �!►,P�i< t 4/I/F ,4a /7Z. rrry r w2A OQ3E�vA o 0, I �.4l trn'+�- E'bft�ef-zTT6'orMFr'$-�1E tC7to�i./�EE.aC:p r jiL1SDS S i�•4VEtiYL¢�0G�mPV9nla r TlT-�+E .Jt T, 4e0 luC?Tlf�:/fGG� l9 MAIvHO( 9 S".W a Gta"TIG TAtK ;,�/n l6a.r>�rtwC. t';"+'S TO P}c FWILT VP Tc7 )'1'�.k,}l!~"S �Jt- 1 BE1.c,w1 Gatitl'y►a G+i's�7R ,aJh/t, ,. � - r-.v �-•--TOf' t"bV�t LEA TtC?w Flrt�Svlsa,_�+f l t�11 Srt `��.L�E F t�tlSk E,¢i► �Dyl�� G��` fFj,u*,4 GE'^m. V'4** tact[ m"kc� .�i�� ovee-cp acm z. lE'AGNawaG ot'L`. p 1,0 or 4 120 of t,, = _ m ® O ••_ I2 >~� •� x / �(D C © m . ~ ► " 100o a�� � ® .0 (� - �u'S►•�E fa eTo+.tt Pic l#J Focc.r'p CA-"C- DIST 130aCc aQ �'���'•-�l.�_�:,+.1 r, t� G l� G � �(3arr+rraNt 'Qr'►'. o +I j ,.{� N �N +1 C �'�:[d/+•Gf 51S•is M P2a t<r fr 6 .jOT T<n SC..v L ISS Z-�A r, r 44 LOT 4 0) MA TION P,4RCE�; Q T ADDRc P SEC SS '57 x IOF DES rGN C,2/��l .40V AAlA4 9 E�@ DF BEr%�.(CcaoM 5 _., a00O Eri-3r was" 6�v ,��� !iOURT =` �'"/� L.�l` OSE SG #AGE �7/�C� 1, Y. / C/ I ti F'E,Csa n/5 t'E,t dE l�,�OD M _ '�° ,KD E. RAYM Ire ° oFae P,4 r C I _ t v✓�, T �1/ '�I L.° ! :,,C'. c4Altcu/S no. �15r13 :�' � r,.- r• W. i LEA U1in�G �'EGl ur« G P Oe s�,e .p. , 4V G FCf;?c F,.- 4�� J 5' M` j-L`� h L,`:�i lit -iw . _`tl PK'OF'c�Sl�D L=�ACNIhIV AtT � _ ,as � �.5''Pt...1 GA0.1T . � t "� MV'c 100% E XPA t,l t,10 tl isd ( _ L{ r'�1 L, � J �'"' i ra.r'f �� :`�,� ���#!.� ��♦� tia.. ROM E. �l . YARMIoi.ITV1 +I-, j �D><11A�L �QCA ?KTfedx4t• YZ , 5" 2 u►'17 U RAYMQNf�' �t3aTTQw,� rtv.Ar I�X t tw.198'5 H SCALE: U111'L: 1tE�- d 1.G = .n I1�P ' wa I + 'T-aTA L 4-Z.7 GPC> _. �' �`' AS ,r1/QTE,G' N1^�( t8).t°1bQ I Cr 455_\ct.li e_ APPLICA.T! 01-1 )404 � 3 AL DPAWN GY c"Ka ar 'A"0 WY PILAn P O r. To o Slab Fdn -- --- FINISH GRADE • , , �,r P - -- -- --- - - min.- -�. - -T- --- - - -- _ 2 ercent slo x .9 FIRST 2 FEET p pe-� ; EI. 45 Dlstrl_ t� -- ,; „; 4; 52 Existing -__ .-- --- --- - - ----- _ Minimum20 12" MAX. OF DISTRIBUTION - }�- _ LINES TO BE LAID 50 1000 Bo r , gal. ___ _ - -Lin 2 =11 ----- - - -- _ r� MANHOLES LEVEL 2" LAYER OF 1/8" to 1/2" STONE ___---- -- -- 12" `min., not including topsoil( 3 ft max. cover) S min. _ .02 1 _. �._ _ T. T ,� - Septic Tank _. --- --- - __ ._._.._. f - 9„MIN. - S min. _ .01 - ...._.._...__.-..._ _._.___ _-__._.... _�.. __.. ___.............__-.. _........__._ -..._... .._..__ ` - .... --- - - - Tl �. -....... - -._-_ ---.__. .-.-. .,ter __ "T`� ,ac. :.. s5 � >2d i i- rr PRECAST sv` +r, ,,ti�`�;.� z� y' _._.___ ' ,"'.'. 500 g I. -- - d 5 ; , `'�� _ .�^ 2 2 9 - 3i4 011/4" st re - ryy�yy , .. --- -- D ft d in. BOX DISTRIBUTION ; = -� I,t, DRYWELL 42 .- _ Leact�l ._�a1te Exlstin Ground fi ) : 6 min. crushed ,. � � � .� z F ,- ----- -- - - - - Finish Grade . - Outlet Tee with stone base r;x r: , r A .. -- -- __...._ ____ -__. __ �.___ _ Gas Bade 12.5 ft .__ D 5 19 4 _ 6 24 �t 4 ft �' t i - I PRECAST 4 10" -1 -f _. ... REINFORCED 7 29 ixfi 7� rs 1: CONETE ;; 8 34 - ` � ___ _.- SEPTIC TANK LEACH I N G GALLERY ` r to ,, L V v'' 1.3 L J ( N D VIEW) O-,C'r nc ry t _CCU yC,7 �.. \ O - r` E W , ± o 6" min crushed - Co Lin stone base 25 0 N ►�► s; �• � �; LJ _ • _ _ __ ----__ -_ S E ITT I G TANK -__ _, V E R T 1 i r�. _ fit. ) 1 TEA/1' G.B. w,'DH 1000 ' ' 8, - 6,r 4, - 0r, e " � M - : 4 Cam, ? L. E ,A� E _ ;rT N1 5o.c mlw 4' ©, gr �,r �. HORIZ: 1 in. - 2,0 IFt ELEV PEPC' ";I L. AT ION TE S' T DATA DEEP r.)F--;c')Ei:�' VATI(-Jl',] HOLE LOG HOLE A Hale No: DH04-1 Dri_.TH 55' r In G2` �TF DATE: � �`�D CAC ILLATIGN!S VICINITY h1a� <2 min./rnch ( 24 gal. applied) --- ---- --- --- �ATE. 12/2/2004 `r Stephen W. Dunbar, P.E., Dunbar Engineering, Franklir, MA OCCUPANCY: 3 BEDROOM DWELLING BY Stephen Dunbar, P.E. w TI ,t `,:�Lu E Bill Robinson, Wm. E. Robinson, Sr. Septic Service DAiLr( SEWAGE FLt_)W:110aa1 x 3 BR = 330 .i. 0 O 5' _ 0 1N1 ir1ES✓E_0 Br'r Bill Robinson PARENT MA. [[ i=`',i_. Proglaclal Outwash PFPC- -ATION RATE: < 2 min:°inch Wm, E. Robinson, Sr. Septic Service - - -- - r„' �,"E NCE PATE 'r_ _ LJI]rDEV\�ALrL A�EAPTA _ _._....-- CEPTH SOIL USDA SOIL SOIL COLON; j `SOIL 74gai sf (INCHES) H4"-7011 TE'A'TURE (M1_T,ISELL) P (-_)TTLIHG C.!THER BOTTOM AREA: 74�aai. sf STONE 3' -9" L- -------------- - ---- -------- -- __ r - - LE��Ir'1% AF'k F :. rIi_�Fj, WALI . 2 ( 25ft) + 2 (12.5ft)) x2ftdeep =150SF ..... GROUNDWATER ADJUSTMENT 0-12" A Loamy SAND 10YR 2/2 NONE D0 .TT0M 5 ft_x 12. ft= 12 SF DAILY SEWAGI:. FLOW CAPACITY' PROVIDED WIGGIN CONCRETE 500 GALLON PRECAST( H-10) 0 Groundwater level based on Town of Barnstable 12-26" B Loamy SAND 10YR 5/8 NONE IDES^BALL: 150 SF x 0.74 GAUSF= 111 GALLONS DRYWELL LEACHING UNIT OR EQUIVALENT BOTTOM: 312.5 SF X 0.74 GAL/SF = 232 GALLONS / N \ G15 Dept. records = +20.0 mlw TOTAL 343 GALLONS 2 EFFECTIVE DEPTH / \ 26--36 G1 Med. SAND 10YR 6/8 NONE 10 percent gravel SEPTIC TAI`�I� RE(�?UIREi�1L_ , r , LEACHING GALLE"Y DETAIL \ USGS Index Well: A1W230( OWmax = 2051, CAPACITY: 330ga' K 15 = 660 14. _ G2 Med. SAND 1 YR 5/8 NONE OWr 4.84) 36-58 0 SEPTIC TAI"1K CAPACITY PFCIVIDED 1000 ,:Ijal. OWc = 25.03( November 2004) rr ( existing) 58-144 G3 Med. SANE) 10YR 7/2 NONE NOTE: if septic tank fails inspecticrl, replace with 0.35 acres Assumed Sr = 4.2 ft _ _ L_. -___- -- _ - -_---- __ _ a 1,500-gallon tank imin. required E j Title 5) � OW Adjustment( Frimpter) = 3.9 ft NOTE: No groundwater or mottling observed. ( p ) Bench Mark To of G.B. El. +50.0 mlw estimated from USGS Quad sheet. •9� O Adjusted OW = +23.9 mlw - _ ✓� �7� Existing Leaching Chamber ; 0� To Be Abandoned 29 ft x 12 ft x 2 ft In place LEACHING GALLERY I �I H-10 UNITS PLAN BOOK 290 PAGE 55 ASSESSOR'S MAP 121 PARCEL 011-007 47.6 / PLOT PLAN Existing D-Box 18" pine NTS 47.3 and pipes _-- H04- to be rem ed 18" pine LEGEND 7.3 3 / d EXISTING CONTOUR 46 - - - - - 46 47.3 W00 �\ lI PROPERTY LINE PRESSURE WATER: LINE W .� Above Deck 2 � \ ELECTRICAL UTILITY LINE E NOTES : Ground TopafSlab \ Pool Fdn El.45.9 \ � pine ` GAS UTILITY LINE G 1) This plan depicts the location and design of the sewage disposal system p only. Property lines and building location are graphic only. _ \ 1 EXISTING SPOT ELEVATION 47.3 WOOD � � \ !F .^ FINISH SPOT ELEVATION 46x0 2) Conformance with local zoning by-laws is the responsibility of the owner. 7•3 Existing ^� ' i prohibited without written approval Dec iy� \' � `� 4 INCH DIA. SCHED. 40 PVC PIPE 3) Deviation from an approved plan s p pp 3 Bedroom �'' EXISTING SEPTIC TANK (1000 GAL.) from the local Board of Health and the design engineer. wellin �` 4} System NOT designed for garbage gr inders. g \ " OPRECAST DISTRIBUTION BOX (H-10) ,' Garage / 5) Topographic features shown are as of the date of the survey. / � j � DEEP OBSERVATION HOLE � DH 04-1 '� PERCOLATION TEST HOLE � A 6) It is the responsibility of the installer to verify locations of all underground utilities before performing excavations at the site. 7) It is the responsibility of the installer to notify the design engineer of discrepancies 0G between the plan and observed site conditions prior to installation of the system. g) Preparation of an as-built plan is required by the local Board of Health and must / / be coordinated with the design engineer during installation of the system. All system W // / W components are not to be backfilled or concealed without inspection by the Design Engineer. The installer must also certify that the system has been installed as specified. / g) All elevations are in feet above MLW. Permanent benchmark (BM) is the top of a / G / concrete bound property marker along southwest edge of property. BM El. 50.0 / DATE REVISION BY estimated based on USGS contour data. 10) Existing Leach Pit to be pumped, collapsed, and filled or removed. LO 11) Septic tank to be pumped dry at the time of system repair and checked for � W / structural integrity. Install PVC outlet tee fitted with gas baffle. / 12) All components installed shall meet the minimum requirements of Massachusetts Title 5 / Septic Code (310 CIVIR 15). / / N Dunbar Engineering Inc. 1 I 13) Lines exiting D-box to run level for 2' - 0" before pitching down. - Professional Civil Engineers 14) All fill for the system shall conform to Title V, Section 15.255. All stone shall be hard, MINIMUM OFFSETS (FT) r durable, washed stone free from iron, fines, and dust. SEPTIC LEACHING 15) Loam boulders, and organic matter shall be stripped from the leaching area and SITE FEATURE TANK FACILITY SUBSURFAGE SEWAGE DISPOSAL g PLAN fora distance of feet around the area. 16) System area shall be staked and flagged from date of installation WELL 50 100 Scile:l"_20ft Y STEM REPAIR until Certificate of Compliance is issued. PROPERTY LINE 10 10 17) Installer shall provide a minimum 2 percent finish grade slope across CELLAR WALL 10 20 74 West Wind Circle the leaching facility to prevent ponding. SLAB FOUNDATION 10 10 LOCATION: sterville, MIA 18) Vehicular traffic, parking of vehicles, stockpiling of materials, and storage NOFMA of equipment over system components is prohibited at all times. 2 O ST E John $ Lisa York 19) Installer shall rovide precast inspection riser(s) to within 6'' of finish grade PREPARED FOR: p i474 for the septic tank inlet & outlet, D-box, and each leaching gallery. sio4 Q " West Wind Circle a� � � Osterville, MA 20) Reproduction of any portion of this plan is prohibited without written consent of Ffiss/Of�tAl-� DATE: December 7, 2004 SCALE: AS SHOWN the design engineer and firm. DESIGN: SWD DRAFT: SWD CHECK: JOB NO: SDS O4-01 DWG NO: SHEET 1 OF 1 E:\York\yorkv8.dgn 12/10/2004 04:27:08 PM