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HomeMy WebLinkAbout0044 AUDREYS LANE - Health 44 AUDREY�S LANE Marstons Mills A= 028 —060 - - - l TOWN OF BARNSTABLE LOCATION Z42 SEWAGE #z,�J-- Z13.2- VIIIAGE ,Q,[ r ASSESSOR'S MAP& LOT �e INSTALLER'S NAME&PHONE NO. aai�o ." S�r SEPTIC TANK CAPACITY Ogg 4e LEACHING FACILITY: (type) PVQ 6ro L ckwiYI(22. /U y 30 ')z-? NO.OF BEDROOMS BUELDER OWNER ' PERMIT DATE: 0-JX•-®-' CqW LIANCE 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9-7 r l S'O 70 Alf TOWN OF BARNSTABLE LCX,A`iION o SEWAGE # V!j LAGE O,[.n 17ra ASSESS R'S MAP & LOT :DgWG�`0R:5 NAME&PHONE"N� _ aai, �Zrr`721, ?�9 SEPTIC TANK CAPACITY` Q '41 7V A LEACHING FACILITY: (type) 0 Ad size) NO. OF BEDROOMS BUILDER OR OWNERS v - PERMITDATE: �f�/0 COMPLIANCE D TE: � . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 0 (� b f Do 0 Bb . No. r900 3 Fee CJ� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Wgpo or brae t (Comaruction Vermit Application for a Permit to Construct( . )Repair( +')Upgrade( )Abandon( ) O Complete System E!r<lividual Components Location Address or Lot No. Owner's�f fame,Address and Tel.No. Asses or's p/P Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: , Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building 8 AlCe No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ✓ gallons per day. Calculated daily flow 33 gallons . Plan Date ® Number of sheets g Revision Date Title 41 V dr _ Size of Septic Tank Type of S.A.S. Description of Soil �® zr,3® Z Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s ar He Signe Date Application Approved by Date 3 Application Disapproved for the following reasons Permit No. D-00&D q ,3 0�t— Date Issued 3 1 — — -------- -- ,tt No. 3 C7" _ $ Fee �Q THE COMMONWEALTH OF MASSACHUSETTS / Entered in computer: Yes r` PUBLIC HEALTH DIVISION --TOWN OF BARNSTAW&R AMASSACHUSETTS 0[p ricatton for ig ogaY �p�ten� Construction Permit • 'Application for a Pernut'to Construct( _ )Repair(�' )Upgrade( )Abandon( ) O Complete System L"'<ndividual Components Location Address or Lot No.//( �O�/� ,ol, Owner's/Name,Address and Tel.No. Asse �'sap/%k) Installer's Name,Address,an4 Tel.No. Designer's Name,Address and Tel.No. _ .. 4or I- 0V 7 Z - __ -type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(�� Other ,;� Type of Building �S� �dllc° No.of Persons Showers( ) Cafeteria( ) OOther Fixtures" `Design Flow 3,0 IY4, 3 z 41 gallons per day. Calculated daily flow 3 36' gallonQ� Plan Date r Number of sheets / -,Revision Date Title, / U :5 f1 Size of Septic Tank /d©y ,607X/,.j j`/eg Type of S.A.S. Z �� M-bscription of Soil" Nature of Repairs or Alterations(Answer when applicable) w-, r x Date last inspected: ' „Agreement: 4 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in acc6rdancerwith the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- ,; -~--w._..:cAte 4 Compliance has been issued:b ,thus Roard-of He Lh� ' Si Date Application Approved by _ Date Application Disapproved for the following reasons Permit No. f�) Date Issued 3 1 �— — ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER, IFY, that t Ott site Se e)ispo sal System Constructed( )Repaired(k,�Upgraded( ) Abandoned( )by ./' at VS A-0 has been constructed in acq(ordance with the provis' s of Title 5 and�e,for Disposal System Construction Permit N 2.` !x ,��dated �5 3/ I `7 Installer \ �'cj 10 I Designer The issuance of this permit 1 o le construed as a guarantee that the ystem i fun do as designed. Date "� Inspector �`� No. aUG 5 7 3�"`� -------------------Feed -� , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5po5ar bpgtem Congtruction Permit Permission is hereby granted to onstr ct( ),Repair v/4Upgrade( )Abandon System located at 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:Construction must be completed within three years of the.�date of this Date:_. CT� 71 '� Approved-b_y - - °F THE tI a Town of Barnstable BA ' � * Regulatory Services FoMa.1% Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 19, 2005 Mr Robert Shea 83 Pond Circle Mashpee,MA 02649 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 44 Audrey's Lane,Marstons Mills,MA was inspected on June 7ch 2005 by Robert J. Bortolotti, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Leaching pit was over full with sewage at time of inspection. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALT DEPARTMENT r 1A1/� COMMONWEALTH OF MASSACHUSETTS . r EXECUTIVE OFFICE OF ENVIIONMENTA �, F'FtI S'PST ,uE DEPARTMENT OF ENVIRON_MENTAL PROTECTION 2,g65 JUN 15 PH 3: 10 E! ISION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION fI' Property Address: V S Z 9�f Owner's Name' ✓o ,tP - Owner's Addre s: Date of Inspection Name of Inspect (plea a print) Company.Nam Mailing Address: Telephone Number: ? 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further.Evaluation by the Local Approving Authority ails Inspector's Signature: Date: r The system inspector shall submit a copy 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 repom 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 0. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: " Owner: Date of I pectio .Inspection Summary: Check A,B,C,.D or E./AL.WAYS 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 31O`CNIR•15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Svstem 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 determined(Y,N ND)in the for the following statements. If"not determined'.'please explain. The septic tank is metal and over 20.years old" or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration.or exfiltration or.tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of.Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup 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 ob_traction is removed disribution box is.leveled or replaced ND explain: The system required pumping mars than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with.approval of the Beard of Health): broker pipe(s)are replaced obstruction is.removed ND explain: 2 Nee 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A Owner:''1121"di-e Date of In pection: C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 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 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 I 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 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. 3. Other: 3 Y Page 4 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY'ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address• 7'/ (,�`(;(;Q ,eta? L xl(, .A Owner l� f V & Date of I spection -. D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Ye,Z 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 dire to an overloaded.or clogged SAS or cesspool f _ 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 V 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. _ I/ Any:portion of a cesspool or privy is within.a Zone I of a.public well. Any portion of a cesspool cr privy is within 50 feet of a.private water supply well. Any portion of a cesspool or privy is less-an 100 feet but greater than 50 feet from:a private water supply well with no acceptable water quality analysis. [This system:passesif the well water analysisj. 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.] (Yes/No).The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.301,therefore the system.fails. The syste.m.owner should'contact the Board of Health.to determine what will be necessary to correct the failure. E: Large Systems: 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 ofa.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 nitrog.,n 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 quesicn 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 Pase 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST P . Property Address: /9/g-ob..?p Owner 0 , Date of I spection:Q ✓+ '�, Check if the following have been done..You must indicate"yes"or"no"as to each of the following: Yes o - Pumping in 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) t/ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? V _ Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered,opened, and the in-erior of the tank inspected for the condition of thhee_`baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum V Was the facility owner(and occupants if different from owne-)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 determined based on: Y«es/no V Existing information. 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 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property.Address: ( e Owner: Date of I spection: c FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):_3, Number of bedrooms(actual): DESIGN flow based on 310 C 1.5.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have.a garbage grinderi.yes or no): (� Is laundry on a separate sewage system a' s or no)�_ .[if yes separate inspection.required] Laundry system inspected or no)�(�? Seasonal use: (yes or no):/ J Water meter readings, if ava)ylable(last-2 yearsusage (gpd)): Ityil ul n'e Sump pump(yes or no):/)/0 V Last date of occupancy:� PlrY,/ G�/L> COMMER.CIAL/INDUSTRIAL// Type of establishment: Design flow(based on 310 CMR 15.202): gpd Basis of design flow(seats/persons/sgfi 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): GENERAL INFORMATION Pumping Records J Source of information: �J Was system pumped as part of the nspertion(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM i/ Septic tank, distribution box, soil aksorption.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): Appr,oxi.mate age of all components,date installed 'if known)and source of information. Were.sewage odors.detected when arriving at the site(yes or no i 6 . Pace 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(cor_tinued) Property A ress: Owner: Date of Inspectio - 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 Rrade: Material of construction: concrete_metal_fiberglass_polyeth�l_ene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a cop yof certificate) .Dimensions: 9"�^ Sludge depth: e Distance from top f slud-e 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 toWnda0tio6s',Qin11et o outlet tee or baf e: How were dimensions determine Comments(on pumping recomm and outlet tee or baffle condition, structural integrity, liquid levels elpted to outlet inve evi nce of leakag etc.): GREASE TRAoy,(&(locate on site plan) ?Zz .✓�/� � Dr�l 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: "'Z9Z A Owner: Date of I pectione-- ��—:2 �,=w�J TIGHT or HOLDING TAN Ctank 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: Alarm in working order(yes or no): Date of last_pumping: Comments(condition of alarm and float switches,.etc.): DISTRIBUTION BOX:' V(if press nt must be opened)(locate on site plan) Depth of liquid level above outlet inve-t: Comments note if box is level and.distribution to outlets equal, any evidence of solids carryover, any evidence of *a agerinto qr out of box etc P PUMP CHAMBER (locate on site plan). Pumps in workingorder(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances; etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��zdlwh Owner:" Date of I spection. l SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type ` _JZleaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: __.innovative/a Item ative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, `) y i CESSPOOL (cesspool must be pumped as part of inspect]on)(locate on site plan) Number and confisuration: Depth—top of liquid'to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool:. Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition-of soil,signs of hydraulic failure, level of ponding, condition of vegeiation,etc_): PRIV .(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: ka, _ l Owner: p Date of Insp ction: �"— 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 within100 feet.Locate where public water supply enters the building. a ct. le)n ove 10 FROM :down cape engineering inc FAX NO. :15083629880 \ Sep. 08 2005 10:06AM P1 Town of Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division ao ' Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form fl$`1 q3 Z Assessor's Ma \Parcel Date: Sewage Pcrmit# �� P Designer: �Jb�Jwh Installer: �Gr Jo� �✓'� ��o� Address: �3 �Zet Address: 100 . On �f- — was issued a permit to install a (date) (installer) septic system at 41q ause `' -- ! based on a design drawn by 04-L address) v�.?� �(( i � dated r) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic sy stem referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system;) but in accordance with State.& Local Regulations. Plan revision or certified as-built by designer to follow. q ARNE H OJALA '((InVstr'signature) Ca civil. N No. 30792 (Designer's i ature (Affix Des c FNStamp Here) pLEASERETURN TO BARN 17 LE PUBLIC HEALTH DIVISION. CERTIFICATE 01+ COM.IILIANCE WILL NOT 8_E 1SSURD UNTIL BOTH THIS FORM AND AS-BUILT CARD A3� RECEIVED BY THI:,BARN$TABLE PUBLIC-HEALTH DLVISI N. THANK YOU, Q:Health/Septic/Dcsigner Certification Form 3-26-04.doc Page 1 1 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner 7 Lc�' Date of I s ection: s P SITE EXAM Slope Surface water- Check cellar Shallow wells Estimated depth to ground water ?—'3'feet Please indicate(check)_all methods used to determine the high ground waver 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: Checked with.local excavators, installers-(attach documentation) _✓Accessed USGS database-explain: you must describe how you established the high ground water elevation: br 11 Permit Number: Date:_ Ccmpleted by: �� HIGH GROUND-WATER LEVEL COMPUTATION Site Location: / J J cam, n 7 y✓( �� 0 19/C'�S:/ `�Z�$_Lot No. Owner: �/' Address: Contractor:_ �//l�S/ Address: Notes: 4ew ! n l STEP 1 Measure depth to water table / to-nearest 1/1 o ft. .............................................................................:. .Date - month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and cetermine: t ➢ OA Appropriate index well............:. � ?::���;,�c��=:_:°::<::•'.;, CJ O'Water-level range =one .................. - STEP 3 Usingmonthly re r 0 t 'Gunn P -'Current - Water R e_ourc determine current depth to _ y.index;water level for 7�}� - - - 4 ~a mo'rith/year -- - - STEP 4 Using Tab e of Water- evel Adjustments for index well (STEP 2A), current depth =-- to water level for indet.w ell STEP 3 and.water-level zone (STEP 26) determine water-level zdjustment ............. 431 STEP ST 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water .. " - level at site (STEP 1) .._............................................................... � : . - k ' •_ ' ' L Figure 13.--Reproducible computation form. s. 1 15 - I i �.w_._..r..............�...:......,nx.�-..�.w wl�.;�;..-- ..�....�..�.a..._r«..........a,+.........a,...._.......ra...-�..a. .-.r,.:n n..r ._.»......a..+.a..r�y .�crane'IL.b.�.n.......u..r men.. l!f{�l/('r_rt-...........,..........._. i I ASSESSOR'S MAP NO. `PARCEL L A T ION SEWAGE PERMIT NO. YJ LL A GE P-3-7`t'11 s tv /L("C INSTALLER'S NAME A ADDRESS 6 U I L D E R OR OWNER v � 0 E /4e) � S DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � ( _ _ rr \ .. � 5 �� t i � ' �� ':3 y._ 4Y __ ` � _ °t"�'-� _ + L •w....................... ,.�,• " 11-1cU.............:......... - ✓ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ? ,•�,.,.. � LTH ..................o . ..................................................t G�F...�4Z . . D CPD AVVIiration for Di ipai;Ft1 iia1rltn �n]t�;trttr#intt ` rrutit Application is hereby made fora Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at• q— .... /...... .....tllr `.. .. .......... ... ..... . .. Location-Address : 2i�Is 2�eDD, own r Installer Address eTteo uilding Size Lot.% �. 1 ...........Sq. feet elling—No. of Bedrooms Garbage...............................Expansion Attic (410) Garbage Grinder Qof Other—Type of Building .Fes............... No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfix�gres .....................:.................................................................................................................... ............. Design Flow.......... .5..........................gallons per person r 4y. Total daily,flow........ .. .Q................ ......gallons. Septic Tank—Liquid capacityft. ..gallons Length.... `Z�,?.... Width.. .:S..... Diameter............: Depth ... ...JK........ Disposal Trench--No..................... Width.................... Total Length............. Total leaching area....................sq. ft. Seepage Pit No.....�'........ amete4b .. �® .. epth below inlet....... Total leaching area��.......sq. ft. Other Distribution box (� c,( e [� Percolation Test Results Perfor . ............................................... Date.:���.�............... Test Pit No. ]Jt ......minutesepth of Test Pit.................... Depth to ground water........................ Test Pit No: 2................minutesDepth of Test Pit.................... Depth to ground water........................ ............... . Description of Soil.......................Sl.;V.......QQ/ ............................................................... .................. ........................................................... ..� ........D?... . ..... .0' ?Q ......................... ...... .............. ..._.................. ............................................................................................•-----.......... Nature of Repairs or Alterations—A swer when applicable G p"... . ....... '►..oa�... .............. .... ....: ...r, . ................. .............................. ..... .. .............. Agreement: ►�` t ram, -1p � l, The undersigned agrees to install the aforedescribed Individual Sewage isposal System in accordance with the provisions of A I'L U 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 health. Signed.................... .......•-•---•---...........---........................---...... ................................ • � Date , Application Approved By.........r .S .........`. !... . .. ` Date Application Disapproved for the following reasons:.............................................................................................................. _ I .................................................................._...........................---..................................................................................----................ Date Permit No.........-` 3 4191 .......... Issued-....................................................... Date ttas�.r _ — THE COMMONWEALTH OF MASSACHUSETTS No...... Q 1�'xx............................, fi '# THE COMMONWEALTH OF MASSACHUSETTS ' 7�w BO/�R c. LTH ..................O F.....................................;....--.............................................. Iirtt iurt for DiulIuutti Evr,049ptuitrurtion rumit. Ag� is lgby n% rn}it to ruct ( ) or Repair ( ) an Individual Sewage Disposal Sytom.a...: ``„CI,CI .... ............................................... .... .. ......................... Location-Address o ` 1� v` ✓ �Cl / -- ........ .................. ..f..�Add.e....... ... ....... ............ ............ Installer 3 Address / Type of Building �U Size Lot.................... .....Sq. 64 Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type ikilding .......................... No. of persons............................ Showers ( ) — Cafeteria ( ) Other xtures ---- ....--•--. � _. �f� . - ...................................gallons pepers SDesign Flow......... day. TotalQ� 4 _... flow............................................ allons. Septic Tank—I_ papacity.............gallo�� Length................ Width...... ......... Diameter................ Depth................ Disposal Trench--No. _.. ._ Width. Tot Length......•__...... Total leaching area.. ......sq. ft. Seepage Pit No..................... Diameter............. _._. ep elow inlet.._......._......... Total leaching arf ........ ..sq. ft. j Other Distribution b Percolation Test Results . Perform .. .................... Date........................................ Test Pit No. I................minutes Inc Depth of Test Pit.................... Depth to ground water........................ Test Pit No: 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... Descriptionof Soil....................................................................._........ -••---....---•••---....................._...............:........................... .......------•--•-------------------•-....-•---�.,_.................--•-•--•----••-•---••-•-•---.........--- --- - ...... ...---- Nature irs or eons . Ans rc wh r - e ............ .................................... ................•--....._....................-------•----------....................................---------••--•--•--------•--.......--------..............--•..................---••••--•-•........._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. si ------------------------------------------------------------------- ................................ � a D Application Approved BY.......... �--...••..........C." Date -Application Disapproved for the following reasons:.............................................................................................................. ...................................... :^• r1 . ...--------......-----.............-•-•--•--••-......................................................••Date ............ PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAF2 TH { / ..........................................OF...................................................................................... ., Trrtif irntr of 05amptianu S. CERTIF iat e Individual Sew, e Disposal System constructed ( ) or Repaired ( ) .:........... .......•d�•---... . ......f..... ....- t.�/ ..................... ........ ' Installer has been installed in accordance with the p isions of TITLE t ' f The State Sanitary Code as described in the application for Disposal Works Construction Permit `r'o _.......! ............... ............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC N ATISFACTORY. DATE.................................. ...'�:...../ .............. Inspector......._.7.. .............. THE COMMONWEALTH OF MASSA HUSETT�PP �c .� BOA H T ..........................................OF....................................................I.....................I........... to ,dr union Vrrafit Per �ii by .n e . . •••-••-•-•-•-•-•-- ....---• .....::..................................... to Co - Re di�Scwage Disposal System atNo. . ••••....................•--........... ....... ----•-•.............-•---••-•••••--.•..... ...............-•-.................-•••----.......................................-- as shown on the application for DI sal Works CQ2! r-uctinn�-reim ....•---- a=0 ------------------ •--.• Board of Health DATE:--•-------•...............•--•...-•--•---•----••••........--=•••--•...... FORM'1235 ,A• M. SULKIN• INC.. BOSTON TOP FNDN. AT EL. 85.4' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE ENGINEER: LISA LYONS, RS MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM D. DESMARAIS, IRS 84.2 WITNESS: 2" DOUBLE WASHED PEASTONE �- WAKEeY ROAD ELEV. 82.6' RUN PIPE LEVELI] DATE: 8 f 15f 05 /-FOR FIRST 2' 3' MAX. PERC. RATE _ < 2 MIN/INCH EXISTING ]000 r GALLON SEPTIC 81.2't* 81.2' ( 11048 eROVDAs TANK H- 1 CLASS SOILS P# .x AN ( 0 ) GAS 80.53' 80.7 ' moo © C7 O 0 O O Cl og LOCus u .. RE-USE BAFFLE o 80.39' Ec: I-] 0 0 0 Il 0 O 6" CRUSHED STONE OR MECHANICAL go , � C �' 020CIO � C3a0C7 0 78.39' ELEV. COMPACTION. (15.221 [2]) 8 1 84.1 2 31 Av DEPTH OF FLOW = 4, ( 1 % SLOPE) ( % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE 0" Q84,1' p" Q 83.9' TEE SIZES: A �X A INLET DEPTH = 10" �S /LS OUTLET DEPTH = 14,. 3 1OYR 5/4 3 2.5Y 5/3 LOCATION MAP NTS B B S 18" 2.5Y FOUNDATION FACILITY EXIST. SEPTIC TANK 44' D' BOX 16' LEACHING /L ESL/ ASSESSORS MAP 28 PARCEL 60 *THE INSTALLER SHALL VERIFY THE 6' 20,E 10YR 5/6 C1� LOCATIONS OF ALL UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS �LS PRIOR TO INSTALLING ANY PORTION OF PARCEL 59 v Cl 27" 2.5Y 5/6 SEPTIC SYSTEM TOWN WATER S�T LOAM ,C2 THE INSTALLER SHALL CONFIRM MIN. SEPTIC TANK �//�// /M/CS SIZE AT 1000 GALLONS AND ITS SUITABILITY FOR 2.5Y 5 6 RE-USE 72.4 28„ 2.5Y 6/6 81.7' S5" / �//3 k83.64 C2 SILT LOAM +93.89 ��.` FAQ >, PERC 2.5Y 6/2 MCS/ 80 77.2, 0,84.63 / ����\ �` 2.5Y 6/6 C4 / I M/CS 0y 0/3.72 wai - 83r84 1��;` �Fs /Ak ��`� 1.78 � 132" 73.1' 138" 2.5Y 5/4 72.4' NA s\ 4. 8 �k � NO GROUNDWATER ENCOUNTERED NOTES: roY APPROX. NGVD //+a �� \\ 1. DATUM IS �� 4.0'1 s DRIVE �8 sz.54 SEPTIC DESIGN: ( AI'�?AGE `DISPOSER IS ":CT ?.LLO;"«D� o�. DESIGN FLOW: _3 BEDROOMS ( 1 10 GPD) = 330 GPD 2• MUNICIPAL WATER IS NOT AVAILABLE Irt/ 3 7s a z 83.7a 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. / _k EXIST. DWELL 8 0 �`�cF USE A 330 GPD DESIGN FLOW 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 TOP FNDN = 85.4' \ 46 SEPTIC TANK: 330 GPD ( 2 ) = 660 5. PIPE JOINTS TO BE MADE WATERTIGHT. -*84.2 1000 - 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. DECK/ h PINE USE A _ _ GALLON SEPTIC TANK (RE-USE EXISTING) V 8� / 3.51 ENVIRONMENTAL CODE TITLE V. #�4.27 -� �a4.10 LEACHING: 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT / SIDES: 2(30 + 9.83) 2 (.74) = 118 TO BE USED FOR ANY OTHER PURPOSE. 84.49 10" CEDAR 30 x 9.83 (.74) = 218 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 84.18 84.48 4.04 BOTTOM: APPROX. WELL PERT OWNER !// 8 .47 454 S.F. 36 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT TOTAL: .F. GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED o .63 BENCHMARK: USE TOP OF USE (2) '500 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH. 84.1 O EXIST. 1000 WINDOW WELL AT ELEV. GAL ST + :`� 84.7' EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED SAS + 3.67 e 2�, BETWEEN UNITS 3.35 84.19 TH2 + .86 n LEGEND TITLE 5 SITE PLAN 84.36 3.73 PARCEL 64 100.0 PROPOSED SPOT ELEVATION TM, $4 VACANT OF s4 44 AUDREYS LANE + 100x0 EXISTING SPOT ELEVATION ROP. D'Bo a4.32 IN THE TOWN OF: 100 PROPOSED CONTOUR M A R S TO N S MILLS) B A R N S TA B LE 5 REMOVAL OF UNSUITABLE 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI SOIL MAY BE REQUIRED 85.42 AROUND PERIMETER OF CONSTRUCTION/SHEA LEACHING FACILITY, DOWN TO SUITABLE SOIL LAYER. 30 0 30 60 90 REPLACE WITH CLEAN MED. BOARD OF HEALTH SAND. (NOTE PARCEL 61 INCONSISTENCIES BETWEEN MA SCALE: 1" = 30' DATE: AUGUST 16, 2005 THE 2 TEST HOLES) APPROVED DATE -�50. REMOVE ANY CONTAMINATED SOIL IN AREA OF FAILED off 508-362-4541 LEACH PIT fox 508 a62-9880 OF 1448, � jjOFM4 0=� ARNE cyGNc� Tow" WATER down cape engineering, inc. o ARNE H. oyG o PARCEL 65 OJALA OJALA `" C(VIL EnAPPROX. WELL PER OWNER o No.0792 � 0 o0e26340� CIVIL ENGINEERS U � � LAND SURVEYORS ���`'QFGI 939 main st. yarmouth, ma 02675 sl�_6-105-- 0 - > 78 AR H. OJALA, P.E., P.L.S. DATE i Cl3�R l pircH 1.'S vf4 f? �r a' i'?' ►4iti' P T'L TAM S tIJ✓t kT p; aaVt+��Kt• � EK,�! rar&$� , ;R Q •k c 4R 3 7 L_ ! I. PROF I LE OF SF P i I S YST EM j r p i D GENERAL NOTES - s A DESIGN DATA y4.1 / •' r uUNf3ER 4F $ED ROOMS --3 70 TA L f;C D W/ 3 3 0 P ► $o UGH [.CAC111N4 AREA �'6- 5 5C,F7' i 4E ACRIN6 AREA 56�Fl t GARSAGE DASPasA t� Ato 0 TA,c .0 EA Cqi MC AREA c J spa f,r Ll? vJATEP Eti'COUAI7E/TED RERCWA710A-1 RATE 3_ _ r CALC ULAWVS V.t CAAJf = 3• /•� Zg` L;' 78 ��PO ja /J)i7 5Ide- ' '' I , / / , \ • -._.' •wM. +► Y_rr_•tiYs•...aY.. +i r_._Yr...Yv...as. wr+Y M.- .w+,emu .rur.wtYY..r1.y_+ pi' L� l t- S3 w f ' 3 G$ I - i r 13Ea Roon �y �V °yam } j 066 / Oil 8�9•YI7Q 809. 096 �ATC/l d NV E-1>r! Of 7A'AVELED WAY /-A NC t f 6 PREPARED B y (,/P " AIGINZERIN6" R CA PZ i�: A , F0 /30K 54A,JWiCN 1'14 r L_ / _ FOB Air V/ /`1A/Al 57R x H YA AIi17S i`4 J O ., L ._._.....,..._,...._...y.. .,.............._,,.,.......,....,........_,,...moo......,,....» N = SC A�E DA FE 814 �" �a!yATAA�P� .,•`� ` vRA�/N D'Y ASP q•wA 1p ....,.... ,.s or OIL; T- VE � CavtRE7� COvl4J�S � ,s,5l� 40 L—IT E: .lc RT bX� FP TIC 'TANKrL `E A/JfRT pr '�� �� ' rWvEAT-- T tlo, :., s,� ys/ /6IV'37 � PROF I LE OF' - ' SEP'TIC SYSTEM `("IIL C)C, GENERAL NOTES r�•,� �tr ' zY Lsaly DESIGN DATA NUHRER OF BEDRWA4y5 70TAL IC40U/ .33 BO TTO H L ZACH/NG AREA Z- SO FT f � SIDE LEACH IAA AREA f S(a GARBAGE D,�sPr�sA �o s1�uR°�;- J 7'0TAL 4EACRIAiC AlfFA 2\6.3 � SQ FT Lei' Tef' E�COU.v1E�LE�O PERCULAT/ON /PATE. � f. U �, ____ HIND' lti'. f CALC ULATi©AlS oA/i ACAn,'� k t 3, i•/ (���� t�,��fT /_Lzgr,., ..r6PG 3oi TpY— , F1 14 a ?// too 1 / J ✓ .tF ► .. Q 1 2 1 �, t i 13FD 400r9 �y 'r Welk •/E L!_ I i r ore �. BoRioP� - -- FLr( Or !/FA'/FLED 1�/A)/ 8,'9•Y27Q - '� i Ric LAN 1 , • 10 I1,� i _ -- .-------- --- --- - PLAN 0 F L 0 T 8 er�Et 1 A 11-14 N� I I6A 41 &Z z PREPARED B y �/1DP,�R CA P �Al G IIU� R/l�6 ' Pv 3oX io/6 FO:P DACE `/ HO/YcS �L SCALE DArE 814 " , TAA\P� . .._ ...... .+..+^ w. .....w;waw........ .r_ .�4 •M, r._ +..f. _._. s.... •wwnL r..-. . ...r.wM-e+'• M'�nF �.. ._T