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HomeMy WebLinkAbout0093 BARBERRY LANE - Health OA--- !� M t f No. D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes J� v Rpplitation for -MispoSaf 6pstem Construction permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.fI j er4e�Y�r I-A,' Owner's Name,Address,and Tel.No. 1441 i+d"5 A,113 Assessor's Map/Parcel vv `� 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 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd T`% Plan Date f�/ ��> Number of sheets j Revision Date Title / Size of Septic Tank Type of S.A.S. 00 �C�I�C�'✓(drCvK r°� Description of Soil Nature of Repairs or Alterations(Answer when applicable) /� 4 ,yew r)-hor ay d .2- 5-co 4/Apr✓ dmpen 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 Certificate of Compliance has been issued by this Board of Health. igne A m' Date (� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued „.�"`'} 4 � � •. -. - ��. ...,..:-..�:. Flit r` , t Ir !!!;• No. t � � Fee V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: „"�,... PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for 33isposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components l a. Location Address or Lot No.�3 � /�Z'/r y ��/ Owner's Name,Address,and Tel.No. /4,f,(146-3 *,//s fy Assessor's Map/Parcel /00- q_ IIn-sttaaller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: - Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) .� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' - Design Flow(min.required) gpd Design flow provided��,q% gpd Plan Date ////, t' Number of sheets / Revision Date sT Title r Size of Septic Tank exo iw C Type of S.A.S. rs OCR �G�/Gv✓��cr�+ /S� � '� Description of Soil Nature of Repairs or Alterations(Answer when applicable) zvpr l G eyinw d-boY "d 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 Certificate of Compliance has been issued by this Board of Health. 6igrie,'� Date Application Approved by Date Jl� Application Disapproved by �,� Date v Y for the following reasons R Permit No. P Date Issued / � N/ THE COMMONWEALTH OF MASSACHUSETTS 4 BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CER�jTIFY that the On-site Disposal system Constructed( ) Repaired(!- Upgraded Abandoned( )by at jj i ��i %ne. k /�/�.a,.2` �/�l/r has been constructed in acc TTT�e° �Z 7. with the provisions of Title 5 and the ior Disposal System Construction Permit No. a ted 2 U d Installer Designer #bedrooms Approved design flow°\ �r Q gpd oor The issuance of thl's shall notThe construed as a guarantee that the system will flan/tionF/as design!.-U. Date L11 .(} Inspector ;� — __ _ ____________ __ __v___ ____-___-_ ___- _ _____ ____-_--�/___________________________._______- No. ( r'✓? f Fee -"'�- `s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem ConstrULtion Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at CJ_f r��l�r��/y� L/L &.-Abj 4K and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must 64 com leted within three years of the date of this permit. Date / I A711 Approved b , P15 PP Y lJ r Town of Barnstable ji Regulatory Services o� Richard V. Scali,Interim Director : Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Sewage Permit# 00J)-01 H Assessor's Map\Parcel 2 Designer: )�� Installer. � U Address: Address: .. C•� 1 On A A k g© was issued a permit to install a (date) (installer)q septic sy stem at "rYy -+- based on a design drawn by (addr t ss) 1 �L dated ( esigner) 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. Step out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. ,Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constrmu t v�_��;�*,liance.with the terms _-- — of the IAA approval letters (if applicable) ►►II/'' . OF��gs •�* ' DAVIU 13. � MASON m " (Installer's Signature) ;� ,� No.toss a 4+: s41VI (Affix Desi"'�r s Stamp here (Designs s Signature A (. . g° p ) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS. FORM: •�= BUU,T=CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. . QASeptic\Designer Certification Form Rev 8-14-13.doc TOWN OF BARNSTABLE L+OCATION 3s&r� IAI SEWAGE#_�2= `0 4ILLAGE /I&- In'S i�15 ASSESSOR'S MAP&PARCEL O 5 2, INSTALLER'S NAME&PHONE NO.'7D A Arupo�� SEPTIC TANK CAPACITY � r��t LEACHING FACILITY:(type) ei�69 Il Aock4j;(S (size) /or S.X:ZT` NO.OF BEDROOMS. OWNER Cil/4/S/J PERMIT DATE: COMPLIANCE DATE: 1 10.ZU 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 //,l1 i A,D_ z _ t 2i'1 �A 36o �l6ef L parberry 144e. YOU WISH TO OPEN A BUSINESS? q For Your Information: Business certificates(cost$30'.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1'FL., 367 Main Street, Hyannis,_MA 02601 (Town Hall) � ;into v w �� DATE:S ph o�I ho a Fill in please. MA PRIM514. APPLICANT'S YOUR NAME: a 5ny� 1/J ��5�{' BUSINESS YOUR HOME ADDRESS: Sc' 3 3CA-Z?35 VA:11 2 a& TELEPHONE # Home Telephone Number Sog 2 -2.-7 NAME ;,k r ackc7C OF NEW BUSINESS �' s. S 4� - TYPE OF BUSINESS: IS THIS A HOME OCCUPATION' YES: N : . Have you been given approval from the building division? `YES NO ADDRESS OF BUSINESS AQ 2 Vu�'��s. N/�A MAP/PARCEL NUMBER1=0� 1 �� When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assistyou in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO NER'S OFFICE This individ al erg-bf�ed f ny�-permit requirements that pertain to this type of business. I�L Quthp S� ature* COMMENT - JY)in ICA c a 2. BOARD OF HEALTH This individual has n infor e o th permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: ZAp-d ous a-Aer of 6O A4 CfL. 6 t Ge Q 1 3. CONSUMER AFFAIRS (LI G AUTHOR Y) This individual has rmed oft a lic mg r uirements that pertain to this type of business. Author zed Signature* COMMENTS: VL :L Date:, S /ZZ /O(o TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ��-��� ��� � ;�fi�h��. n• BUSINESS LOCATION: 2?J B RQ'Ilh cal kv\ M;11-s KA k O2649 INVENTORY MAILINGADDRESS: PC. n 2y32 A- 02601 TOTAL AMOUNT- TELEPHONE NUMBER: •� n eL. 36Lk• 2-T3 5 G�( CONTACT PERSON: 0(N­ISk EMERGENCY CONTACT TELEPHONE NUMBER: 508' `(28 -Z135 MSDS ON SITE? TYPE OF BUSINESS: (_Q:vVk"C4 C42X0P!aZ,.(___-___ oA-)q INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: A20 Last shipment of hazardous_waste: — Name of Hauler: Destination: -- Waste Product: — Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. j Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW 2q USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): 4S Laundry soil & stain removers I�ni,lL1� ��►;wheCS (including bleach) _ 1h11M-,1A1AJ ­10 1 tnJ Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE LOCATION SEWAGEO �I VILLAGE o I S L� o R'S MAP S� LQT - - ~� INSTALLER'S NAME St PHONE NO. w SEPTIC TANK CAPACITY I ® f7 LEACHING FACILITY:(type) _ J (size) 10 0D NO. OF BEDROOMS _PRIVATE WELL, OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r/ r .� S �. 0 �� � ��� a a�" `� 0 �-� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ----------------------------- Applirattiun for Diipuual Works Tuntitrur#'tun 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair (4-10"an Individual Sewage Disposal System at• �..�t�9 �(• :�IS -•...... .............................................. •----..................� ...... ----•-------------- -------------------------------------- ------•---..... .................---• -- ------------- ..._.....c ion-Address or10 No. r� � --� ' Owner ddress '\ .!.^x..cg............... ....... Installer Address QType of Building Size Lot----------------------------Sq. feet aDwelling—No. of Bedroo ....................................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ----------------------------•-•. . W Design Flow...................................:.:......gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length___-___.•___---- Width................ Diameter_............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-,----------------------- 1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P -•---•...•-- . . 0 Description of Soil.............. .. x W --------------------------------------- ----{} . ---------------------..._. U Nature of Repa' s rRlterations—Answer when applicable. ` " �4 .^.__�3. __..._.. ��_ O to 1 --5'�� '-t-= ..... ® __ . w�Z�--------------�=- -•--�--i--�............---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS 5 of the State Sanitar 4iss%tAed —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e by the bo r of I h.4Signed.._. `�"� �_ -- L. Application Approved By................ � b •• `'t' -•----------------•----•-------- ........................................�� t Date Application Disapproved for the following reasons----------------•------------•---------------------------------•------------------------------------------------- ...............................-......................................................................................................................................................................... Permit No. Issued `�?--- ---q .... ...................1. a Date No........................ FBB.... v............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 7 . ........ .......... ., ...........OF.................................................. ..... Appliration for Diipoial Works Tontrnrtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at• I° } Location-AddressLot P .... s .. ..................................i� .'�. �r No. 1p�..........................C� � Owner �, � ( )i_ A ress ........................... ................................ ..._._._................ .. w Installer Address Lo Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__...................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ----------------------------•-• • W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length-----------_-- Width................ Diameter,................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a ,-4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Grq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ poi '­_5................................................................I.......................................................................................... D Description of Soil.._._.._ 1 ._..,._.<_ S v V ......-••---•-----...-•••---•-•---•---•.....::",�...---.~--..---- ---- --- ---•-•-- -- .-• . . . -• . . •---• ....................... ------------------------------------------------------------------------------------------------------------< -------------------------------=- �'--------------•---_-- U �Nature,of Repairs or Alterations—Answer when applicable__ , `! --:---._ ` �'..............................PAS. ......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 5 of the State Sanitag,Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e� is ued by the board of health. Signed. ti. ........................................................W "�� ................�� .7- . 1�ate �y Application Approved By-••---••-•---• ....... ..... Date Application Disapproved for the following reasons----------------------------•----------------•-----------------•-----------------•.............................. ........................................................ •--------•••-•-•...-----•-----•.............•--•--••-•---------•---------•----•••-••--••-•-------•------••-----•-------•-------••-----•--•••--- (92 Date Permit No. Issued rah- .............................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................OF....... .............................................................. :! .�' ............................................................. 9rdif iratr of Tontplianrr THIS V TO C TIFY, That the Individual,Sewage Di' posal System constructed ( ) or Repaired kl� by » ``... \ .. e... ...... 1 Installer t C3 at e' ?.=- = ----------- ---r a...._------------. ......-----� ...` .....---------------------- has been installed in accordance with the provisions�,of TITLE 5 of The State Sanitary Code as described in the. application for Disposal Works Construction Permit No.........FY_-----t_ ?......... dated.......... ..................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ —.f_ .^» ............................ Inspector........------. e.-D---•---•-------------...---•-•••---.....-•---.--•-- THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 6 No.. � j.trF FEE.....ate-..0......... �i��o�tt� ork� C�on,��r ton� rrmTu'Permission is hereby granted.. ..... .... ...: . '._._.______.._._._.__.__`! .`r'`. .---.......... •-•---------•---•- to Construct ( ) r Repair ( an Individual Sewage Dispost System _ ......................... ......... -----•-- -- ........................................................ Street a `0 as shown on the application for Disposal Works Construction Permit No '_1 . .... D'ated_______ _______�..`.......0........... ............................... ........................................................ Board of Health DATE------ --- ............................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - C91 ri 19,96. BORTOLOTTI CONSTRUCTION,I C� A` 765 WAKEBY ROAD,MARSTONS MILLS,MA,a2 48 �t 508-771-9399 508-428-8926 FAX: 508428-93 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO R PART A CERTIFICATION Property Address: 3 Date of Inspection:_ fnspector's Name: / er's Name and Address: cG'o��vQ, Q r cam,. [Q 7/2 a Z21Zof e` .CERTIFIC'ATION TAT MENT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal,as+stems. The System: Passes Conditionally Passes Z Needs Further Eval tion By the Local Aproving Authority Fails Inspector's Signature: Date:/y The System Inspector shall submit a copy of this inspection report to the Approving authority within thin ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 go or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY* A)SYS') M PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed.- C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER ' SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING.IN A MANNER THAT PROTECT THE PUBLIC HEALTH'AND SAFETY AND,THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface € water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health. should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water°supply well. W 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 local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: f/ Pumping information was requested of the owner, occupant,and Board of Health. ri None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been . introduced into the system recently or as part of this inspection. l/As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ,,--'The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, . ' depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION FLOW CONDITIONS $ jpENTIAL: Design Flow:_ga}lons Number of Bedrooms: Number of Current Residents: 3 Garbage Grin ed r: A/ Laundry Connected To System: Seasonal Use: i✓A Water Meter Readings,if available: Last Date of Occupancy:C'c- COMMERCLALMDUST IAL:/l O Type of Establishment: '! Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informati n: Tim 0 - System Pumped as part of inspection: If If yes,volume p mped: gallons Reason for pumping: TYPF,;OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): PROXIMATE AGE of all components,date ins led(if known)and source of information:. i Sewage odors defecWd when arriving at the site: Alb -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction:P-­'concrete metal FRP Other (explain) Dimisions:F. 5',►'(� ,�S Sludge Depth: 3 It Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: ,3 Distance from bottom of scum to bottom of outlet tee or baffle: 3 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) 5 2 /Doo qa , n :G G Cu i OU ve d a! 2K, GREASE-TRAP: Depth Below Grade: Material of Construction:—concrete—metal FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX; Depth of liquid level above outlet invert: r 4 AU e Comments: (note if level and distribution is ual,evidence of solids carryover,eviden a of leakage into or out of box,etc.) s�n� /1 �� �L��S C.Krr�iy! L/mil G PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): !/ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leachingits number: Leaching chambers,.number: Leaching alleries number: p ggg , Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comm nts: (note condition of soil 3.signs of hydraulic failure vel of pondin ,condition of vegetation, ? et .) ce /245 0 ( i� CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 66r a �' 0 DEPTH TO GROUNDWATER: / Depth to groundwater: 16 Feet Method of Determination Approximation: -a lo/- �efo -7- ' A53SEJS0RS MAP : �`��� , HOLE .. "� 1) The installation shall comply with the State Environmental Code Title V and Town of ice° i5lr4�� PARCEL ��r- '� .. _._. ..�. -----� Board of Health Regulations. , FLOOD ZONE: --- , a°�I � ��'��-�ATOR' �'�Y�'p �� � `���' 2) The septic system as proposed on this plan shall not be installed until a licensed town installer WITNESS . applicable town. receives approval:end an installation permit from the app' REFERENCE : > .� DATE � /" �'Cam/ PP cL�-- �--{'- � f © •.. .. -1- .._ -.. _. 3) Prior to Installation,the installer shall verify the location of utilities,sewer inverts, sewer lines PERCOLATION PAT'; , � s, . { and existing septic components prior to installation. `� f' � . ' r' 4 All gravitysewer piping Is to be 4 inch schedule 40 PVC at 1/8 per foot. The first 2 feet out of j1 07- J c TH- 1 TH-2 the distribution box shall be level. All piping connections to be glued. . —-- LJ7&,/1 C, i L vvv u"1`'.I3 5} This septic design plan is not to be utilized for property tine determination or for any other ID /D ',_.` " I ) purpose other than the proposed septic system installation. In -'�, , 6) All Title V components are to meet Title V specifications. f��lEi �A� � �,+' i� 4 � �, �� � � 7) marking shall be prohibited over Title V components unless components are H24 loaded. I,,DCA }t A ��t,�� L��� - d ' _ 8) The existing leaching or cesspools shalt be pumped and filled with material per Title V abandonment procedures, Leaching and cesspool(s)and contaminated soils within the proposed SAS shall be removed and replaced with clean sand per Title V specifications. 9) Septic components are to be 10'from a water service line.Sewer lines crossing a water line shall i be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water service � 1 E } J fine or the septic line can be sleeved with the sleeve being a distance of 10' on both sides of crossing the line. 10) if a garbage grinder exists In the structure, it is to be removed if the septic system is not � ^ ��► �,„;, designed to accommodate a garbage grinder. ------ _ �'i 11) The Installer is responsible for care of excavation around all utilities on the property and ��- a E P T i C` SYSTEM DES protecting the structural integrity of all structures during the installation process of the septic system. FLOW ES 3 MATE 12) This plan only represents that a septic system can be installed on the property meeting Title V 102- . requirements. w __ ._ r' �( �(�(„ V • ER4OS AT " AUAYRE "00 '" CAUY 13) The property owner shall review design criteria to approve the total number of bedrooms and design flow. Installation of the septic system as proposed and receipt of payment for the design SEPTIC TANK };� �`� ------ - - --�- shall be deemed approval of the design criteria by the property owner or agent of. 14) The validit of this plan O ali expire with the expiration of the town installation C.AL/DA x 2 DAYS �° GAL Y P P' p hermit issued for l �,; this plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance rl U5 E' ,° :�ALL0N 13 E) T I'C, TA1�I<Le� �i�T , f, issued for the installation of the proposed system on this plan. .01 #w wAS;sCpPsi'I ON SYSSTEM. f 47-0 SIDE AREA: -�° /2r YzC ice' /y� >�t+)► 4 _��,i BOTTOM .ARE, � ��?� � � o,"7 =� IT,4�1" ' � � 4 ®AVID �•,. ti��, B. IVIASON } ram- 1• C ` r a ! ON�€ cam',-s . . �. `'���� c;• r,� ..'r"^"'^"" S 1 �r�� �� d..,�•p,'s.. Y71 _✓ Y°.��SV�.f� ��4 '....�� q� r _ _ R }.J iK` .� rr oGAL � - SEPTIC TANK i �✓:u! �1 .. �?� - 7� 2 _ I C� __ , _._ _ _ _. _ _ FLOCAT ION : - SITE AND SEWAGE PLAN ---- PREPARED FOR : � M SCALE ...,� DAV I D B . MASON, DATE:! ���.p. ' DBC ENVIRONMENTAL DESIGNS n DATE HEALTH AGENT x