HomeMy WebLinkAbout0085 BAXTERS NECK ROAD - Health 85 Baxters Neck Road
Marstons.Mills _P
A
"F SHORE RD.
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lilt
pU� DC 12934
WA8TING8, MN
TOWN O�F/BARNSTABLE
LOCATION XC e-rL'S /YeClc G1L, SEWAGE #
d56- b�G
VILLAGE D U/ ASSESSOR'S MAP &LOT z-
INSTALLER'S NAME&PHONE NO. -"f J C26
SEPTIC TANK CAPAC= lSOD 019
' nn r,
LEACHING FACIIITY: (type) Ca of/s (size)
4100 Qadlon-s
NO.OF BEDROOMS
BUILDER OR OWNER ides Lzhr - Lz�r p p - r1
PERMTTDATE:�aD- 57 COMPLIANCE DATE: l l
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) YIA Feet
Edge of Wetland and Leaching Facility(If any wetlands exist alA
within 300 feet of leaching facility) Feet
Furnished by- „ P TS�G1 F.n JpPPt'►n�
Az a7
A3,= 4i a ��
A qz L(7 a o
Q�= 3S�
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No. 'THE COMMONWEALTH OF MASSACHUSETTS r «� t FEE
BOARD OF HE LTH
/ OF
Appliration fDr Dhipviial 19.,�A,itrm Tonstrnrtion PPrmit
p ligation ishereby made for a Permit to nstall (/ or Repair/Replace ( ) an Individual Sewage Disposal System at:
Lucalion-Address or Lot No.
caner �Address�
Designer or Installer Address
Type of Building Size Lot ac'ne s §q-�et
Dwelling—No.of Bedrooms — 7? Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No.of persons Lo Showers ( )—Cafeteria ( )
Other fixtures
Design Flow 6S gallons per person per day.Calculated daily flow gallons.
Septic Tank—Liquid capacity 1560 gallons Length 1 t I o'� WidthfJ t Diameter Depth FJ`7`'
Disposal Trench—No. 1 Width �t Z4 Total Length Z� I Total leaching area �sq.ft.
Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft.
Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed b LDate ,:) _a-,)AA-7
Test Pit No. 1 _minutes per incA Depth of Test Pit 4�: 'i q Depth to ground water
Test Pit No.2 5 min tes per inc Depth of Test Pith`' Depth to ground water
Description of Soil 0"— r' 'so-L'I (: GCL*V,—
tI �Cl sl
3o" I�t
Nature of Repairs or Alterations—Answer when applicable
Date Last Inspected
Agreement:—The undersigned agrees to install the afo crt ed Individual Se 'sposal System in accordance with the
provisions of TITLE 5 of the State Environmental de.The usig ed her agrees t to place the system in operation
until a Certificate of Compliance has been issued the rd of H alt,
Signed </
Date
Application Approved By a �
Date
Application Disapproved for the following reasons:
Date
Permit No. 7 Issued _ �72
Date
NO. THEIC,OKMP NWEALTH OF MASSACHUSETTS ' k,' ? a ' FEE ~_/(�✓/ w
- RD OF HE LTH
ail OF
� ltr tier fn t���' ttl f tem T'un,itrurttnn Permit
Application is hereby made for a Permit to nstall (IX
Repair/Replace ( ) an Individual Sewage Disposal System at:
/��y- i� l Q clL _ mom_ c� e R6 yX0 I ;�b x 0 z,
Lor I t-Address or Lot No.
v to+ 3
caner Address
4:6,901 ANtW_
Designer or Installer Address
Type of Building Size Lot 1 t0 O C_r°5 -met
Dwelling—No.of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No.of persons Lo Showers ( )—Cafeteria ( ) t
Other fixtures
Design Flow gallons per person /pee�rda0.y. Calculated daily flow 31� allons.
Septic Tank—Liquid capacity. 1500 gallons Length I (o Width�.J` ' Diameter Depth �` h
Disposal Trench—No. 1 Width 13t y Total Length ZfD- Total leaching area sq.ft.
Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft.
Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed b V e u� Date
Test Pit No. 1 _minutes per incti Depth of Test Pit Depth to ground water�--�-
Test Pit No.2_ �' min tes er mcp Depth of Test Pit 14LI I' Depth to ground water -®-
Description of Soil 0"- `I nA �a
11V- 011 P, le � sa- cL—
A.
Nature of Repairs or Alterations—Answer when applicable
J Date Last Inspected
Agreement:—The undersigned agrees to install the afor gibed Ind tiv dual"S�rot isposal System in accordance with the
provisions of TITLE 5 of the State Environmental e.The up"Ralth
d fu her agrees t to place the system in operation
until a Certificate of Compliance has been issued the Board of H
Signed Z$ /
Date
Application Approved By -
} Date
Application Disapproved for the following reasons:
r Date
Permit No. Issued - 52
/' ' Date
.q--------...-------- —-----..----.—,—,------._ ------...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrttfiratr of'Tompliamr.
THIS IS TO CERTIFY, That the On-Site Sewage Disposal System installed or Repaired/Replaced ( )
on 9 - f '7 by 1_ LCe. 1-44, —v
for at __D' !r C', -S
Ile-
has been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the
application for Disposal System Construction Permit No. 7 - /��� dated O '9
Use of this system is conditioned on compliance with the provisions set forth below:
t
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on
/ /� Date
DATE Inspector ( �fiL�'� "( 1' ,1f �.�/.G!„�'a, [/� 0,
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
Disposal _105,y,strm Ton,strurtinrt Permit
Permission is hereby granted to 1�1r1f1.Q�/
to Construct ( � or Repair/Replace ( ) an On-Site Sewage Disposal System aced at
"'� ' Street
as described on the 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.
All construction must be completed within three years of the date below.
oard o(Health
DATE
r
FORM 1255 (REV.4/95) H&W HOBBS&WARREN TM PUBLISHERS - BOSTON
THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION
f
TOWN OF BARNSTABLE
LOCATION SEWAGE #
056- a
VILLAGE M )ASSESSOR'S MAP & LO'T/ xi) 1
INSTALLER'S NAME&PHONE N0. Vas PD!/ I'✓ U S'7
SEPTIC TANK CAPACITY 15OD �C.LS
LEACHING FACILPI'Y: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER Lohr — C / Q p
PERMIT pDATE: �- / 7 COMPLIANCE DATE: 'L' '12
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 ,,/,t
on site or within 200 feet of leaching facility) PVT Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by� � T'�f an Fn Ji�PPnnc
Fra=a�
, S
A `IZ 00
6�-30 '
RY
,k'�e c uc p
n TOWN OF iB�A.RNSTABLE
LOCATION q)S ��>( GCN: 00, _ SEWAGE #
VILLAGE IVI ASSESSOR'S MAP & LOT (
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY sC)C� �
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER �f�lf�, _ --
PCfTDATE: (D COMPLIANCE DATE:
Separation Distance Between the: ' i ;LO 1
Maximum Adjusted Groundwater Table om F`�''
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wedand and Leaching Facility(If any wetlands exist F`u
within 1100 feet of leachhing facility)
Furnished by P LLQ
2 �
� o
27 30�
Art1- 47
=.;. C01I\IONWEALTH OF NLkSSACHliSETTS
-- r, EXECLTWE OFFICE-OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE INTER STREET. BOSTON 1Lk 02108 (617) 292-iiOU
n%
TRUDY CO\E
Secre:an
ARGEO PAUL CELLUCCI DA�'ID B. STP. Hr
Commissicr.er
Governor
�5� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8
Q1`IY 4 PART A
CERTIFICATION
Property Address: `" ��� V-"+ Name of Owner
Aa2�.m`ll34@s
� Address of Owner:
Date of Inspection:. �( ,�+ , '/
Name of Inspector:(P1 ase nt)! ! •4 ci t j if�CC U k10
I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.00 .a
Company Name. A>y�t, �r i �a a^�'r.- u ..., t�u d 9`99 r
Marring Address: A,477g yG NP — 1y� �2-4 y
Telephone Number: SQ'i! (t 31-
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information►eportede�w iS�rue, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evalu By the Local Approving Authority
_ Falls ia . I
Inspector's Signature: Date
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEPlwithin thirty(30) days of
completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 KjtIoru .
Ci Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corlbrwed)
+roperty.Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, A C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more•system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health,will pass.
Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If "not determined",explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)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 a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipels)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health'.
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced -
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 ? aeetorll rt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of HealXnrde determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN A WITH 310 CMR 15.303(1)(b) THATTHE SYSTEM
IS NOT FUNCTIONING INA MANNER WHICH WILL PROTECT THE PUH AND SAFETY AND THE ENVIRONMENT:Cesspool or privy is within 50 feet of surface waterCesspool or privy is within 50 feet of a bordering vegetated salt marsh.
1
•
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(A( D PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PU LIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorp ion system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS 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 than 100 feet but 50 feet or more from a
private water supply well,unless a well/water analysis for eoliform 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. Method used to determine distance (approximation not valid).
3) OTHER ;
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revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPPOASRALpSYSTEM INSPECTION FORM
CERTIFICATION (co"Itinued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or ' or to each of the following:
Board of Health should be contacted to determine what will be necessary to correct the failure.
I have determined that one r more of the following failure conditions exist as described in Sat CMR 1 news The basis t this
determination Is identified b ow. Th
ed SAS or cesspool.
Yes No
_ Backup of sewage int facility or system component due to an overloaded or c gg
'Discharge or ponding o effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of
— — cesspool.
_ ibution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Static liquid level in the di tr
_ n 6" below invert or available volume is less than 112 day flow.
Liquid depth in cesspool is I ss tha
_ ast year NOT due to clogged or obstructed pipelsl.
Required pumping more than times in the l
Number of times pumped_• h groundwater elevation.
_ Any portion of the Soil Absorpti System, cesspool or privy is below the high
Any portion of a cesspool or privy
within 100 feet of a surface water supply or tributary to a surface water supply
_ Any portion of a cesspool or privy is ithin a Zone I of a public well.
privy is thin 50 feet of a private water supply well.
Any portion of a cesspool or p Y rivate water supply well with no
as been greeter than 50 feet from a P of well water analysis for
Any portion of a cesspool or privy is less than 100 feet but g
acceptable water quality analysis.
ls clIf the
els,ammonia nitrogen ed tand nitrate nitrogen.ach copy
coliform bacteria, volatileorganic
E. LARGE SYSTEM FAILS:
You must indicate either "Yes' or N la� a systems sch of enoaddit on to the criteria above:
to
The following criteria apply 9
_ 0,000 g
d or greater(Large System) and the system is a significant threat to pt
The system serves a facility with a design flow of 1
following conditions exist:
health and safety and the environment because one or more f the
Yes No
_ the.system is within 400 feet of a surface drinking wat r supply
_ the system is within 200 feet of a tributary to a surface d inking water supply mapped Zone 11 of a pub
the system is located In a nitrogen sensitive area(Interim W Ilhead Protection Area.IWPA)or a
'— — water supply well)
shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regic
The owner or operator of any such system
office of the Department for further information.
page 4 of 11
revised 9/2/98 ;. .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
r'Toperty Address: J� 't �
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 noTmal flow
41- rates• during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N!A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
`F 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. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.30213►Ib)I
The facility owner(and occupants,if different from owner) were provided with information on the propermaintesanca.of
SubSurface Disposal Systems.
revised 9/2/98 page SofII
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
r Address: Q
roperty '�
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: _g•P•d./bedroom.
Number of bedrooms(design): Number of bedrooms (actuall:Q�
Total DESIGN flow_
Number of current residents:Q
Garbage grinder(yes or no): %kv-y
Laundry(separate system) ,�1 es_or no):�: If yes, separate inspection required
Laundry system inspected CLe r no)
Seasonal use (yes or no):_J�Lo
Water meter readings, if available (last two year's usage (gpd): -
Sump Pump(yes or no): tJO
lest date of occupancy:�� '
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: 9pd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)—
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspection:lyesor o) y
If yes, volume pumped: gallons
Reason for pumping:
TYQE OF SYSTEM
Septic tank ldistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous Inspection records,if any)
IIA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date Installed(if known)and source of information:
Sewage odors detected when arriving at the site:(yes or no)
revised 9/2/98 )P�gc6orit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
y� SYSTEM INFORMATION (continued)
'roperty Address: �J
Owner:
Date of Inspection:
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 line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_NS
(locate on site plan) .
Depth below grade:IZ�,
Material of construction: concrete_metal_Fiberglass _Polyethylene_otherlexplainl
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
�,
Dimensions: it
Sludge depth:__ 4
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: Ott
k
Distance from top of scum to top of outlet tee or baffle: si
Distance from bottom of scum to bottom of outlet t e or baffle:
How dimensions were determined:
'omments:
(recommendation for pumpin condition of inlet and outlet tees or baffles,depth of liquid leve�,in relation(to outlet inve t, structure(integr t�
evidence of leakage etc.) a
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 Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity.
evidence of leakage,etc.)
revised 9/2/98 Page 7orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:�S
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_ (Tank must be pumped prior to, or 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
Alarm level: •Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:—!Ns
(locate on site plan) i
I ilLrL�
Depth of liquid level above outlet invert:�y�.l1JCOtJ�9r flu
Comments:
(note if level and dist ibution is equ I, evid Ill ee of solids carryover, deuce of leakage into or out of box, etc.) _
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 P age 8 or ll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
,roperty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible: excav tion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number: `
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of h draulic failure, level of ponding,da solih condition of vegetation, etc.)
6 0 t ll
CESSPOOLS:IL143
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
9epth of solids layer:
)epth 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 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 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
PLY
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revised 9/2/98 page looru h'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: ��nJ
Owner:
Date of Inspection:
NRCS Report name -, - — ---- ----
Soil Type_ --- --- -----
Typical depth to groundwater__—__ __
USGS Date website visited Udv
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope S\t CFV
Surface water (JID
Check Cellar`p0L�
Shallow wells w( , !
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
vistCVCO 03 CP. �ur<
revised 9/2/98 psge11of11
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Date Scheduled L - ti� - 7 Time-g,4*vL Fee Pd. I r U
Soil Suitability Assessment for Sewage Disposal
t teformmd Dy: uC U/ �� •S• witnoased sr,3a tr u✓1 v+�h<y
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LOCATION&GENERAL INFORMATION
iocatiomAddraa ;�,:� Lj, Le.J o�trrct•sNwe ftlflr.`Eft:� �.>a�1Jfer
Addtees
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AssCMr'SMtIpJPmscel:—lp 6w•�(o 1s•�J•X�� EnBhner'rNaaelt9/u,y/Ylrt0hct
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`• Land Um 4"o, 7rrcel _ woes( I swimstw= N •fF
Dirtmrn iromt Optn Water Sody �-p Posslbk Wet Area N• A Dfioldrl;Witter Well
Drtunage W.y 1 A P+o�etty Line 0�_A tldte+ _R
". SKETCH:(Sys wq, i.ns otht usa iocwlons of teat hoks&pare teas.tonne wettemds m Dt'oxJmt;7r to idled)
I
i
ga�
Pmmat ravaial(Mlogltj 1- Dglh so wrack ----� —•
r�
Depth to Gwmadamter.Surding Went in Hole! "—'Q Weeping-%M Pit Fitt
F tvated Seafood lfi6h Orarndwalet
DETERMINATION FOR SEASONAL HIGH WATER TABUty
r�
Mahod used:
Depth OWrved sanding in obt.halt: fn _im Dw*to saii mvWox: ln.
Depth to*'.aping Gem side of eba.hate. In. G'ronndwamr Adyntrmnt &
Index Well 11 Retdime Date; Index Well kvei Adj.factor Adj.0rMdwfi&Ld"C_
PERCOLATION TEST Date IMe„i(,_
Obwvatwn
111016 111 :2 'lime w B'
DeOtn at wro rime w 6"
5tat Pro-aoea Ttate j1-�S ram(9--on
end Fn�eaN 1�S et j i t o° *Q 11.13
Reee MiuA.1%
I
Vitt Suila6ility Assessment: Site Foiled �r Silt Failed Addki0d3 TestieaNn&d(YN
Qrtglnal: 1'UMic^rsslth pvNtnn Observation Hole Data To Be Completed on Back��
Con)': Applitau
TOTAL P.02
I 1997 09:24AM FROM YANKEE SURVEY TO 4777025 P.01
— DICEP OBSERVATION HOLE LOG Hole#
Depth hem 'Soil 110r'uan Soil Tcsture Soil Color W ONer
Surraw(itt.) (USDA) (Mtmscll) Motlllag SMicturr,84enes,9vuidereq.
sp v
Awr
10
DEEP OBSERVATION HOLE LOG Hole#
Dapth(win !Soil tkniton $oil TWAM Soilcotor Soil Othtr
Surfecc(in.) (USDA) ! (MUMIll Monblte CMm Stotts,eouldem.
1
f-141Y c 'AT.0fV to {0-6
DEEP OBSERVATION HOLE LOG Haie#
r)wh from Soil Ilorison Soil Twuro boil Coia 690 odw
Rtrllee fln.) (USDA) (MMsell) Motdiall SOnehna.StOM.Howdeks.
DEEP OBSERVATION HOLE LOG Hole# .
Depth from !! Soil Hot=n Soil Tecttoe Soil color Soil (fiber
Surfs¢(in.) (USDA) (MmuelU MoMin (Structure.Stones.Bouldem
DEEP OBSERVATION HOLE LOG hole#'
puptn r)rm Soil horizon Soil TcAlurc Soil Cetot WI Other
Surface(In.) (USDA) (MUMil) h(ontlng Bmtcture.Storms,Souldents.
i
, YSTE -PROFILE
NOT TO SCALE
TOP FNDN. ,cry,,, , FINISH GRADE
i 2-
EL . �-3 y FINISH FINISH GRADE OVER OVER TRENCHES GRADE 7Z- c� FINISH GRADE OVER DIST. BOX Jf- -�
..•,a-o°,• SEPTIC TANK_ o
�..a.p0
o`oAAQ 12" MAX.
C c Q• •' O•'a n� 4'::Q p• o . . bL o
ono.' p° TOTAL LENGTH OF TRENCH 2 -5
OUTLET PIPE LEVEL
.a 311
FOR 2 FT. MIN.
0 0. 0 0 . ,..
��6:
� pf, • '•w: . a: •..q..•�.® , '_b:.: ..o• .:d• b' b r•40
• p.•,�. QO �o. :w, "ll-IZE
, 04 'w'Q •'"• '•�' dam,
C. I. OR PVC TEES
•.-. .J• r
BSM a o
T FL . 1500 GALLON . '+ T T y y
o
EL
a� INSTALL ON LEVEL BASE
/� c �'+ /'+ c "O.00 GALLON DR YWEL L S "
PP CA J T C..+ONCRE TL- _
j•�•:• A
gb H �0 REINFORCED
_-
:�e wao v`:bc-o d,�•'o.'o:4�'G'.�b::�•®tl@ ti•;p,�D�r® �f+:a'�R'•a:4#7�4:
SEPTIC TANK TRENCH S EC T.I'ON
INSTALL ON LEVEL BASE NOTE.' EXCA VA TE TO EL EV V. OR
LOWER TO REMOVE ALL IMPERVIOUS
MATERIAL BENEATH THE LEACHING .AREA 4" DrAM. 12" MIN.
REPLACE EXCA VA TED MATERIAL iWI Tip: 3" OF 1/8"-1/2"
CLEAN, CLAY FREE SAND o4';v."6.;'p• .v 4Q•app, b:6,b.:o;; �°ragti
- WA SHED PEA S►TONE
314" — 1-112" WASHED
CRUSHED STONE o-e
ll
T — 'TRENCH WID TH
1. ALL EL EVA TIONS SHOWN ARE BASED ON ASSUMED NUMBER OF TRENCHES ?
2. AL L PIPES IN THE SYSTEM MUST BE CAS T IRON -
' NUMBER OF DR YWEL L S 2
v --- --—
/ ° u �` �° ti OR SCHEDULE 40 PVC. �' / T T
3. THE:BOARD OFHEAL TH MU S T BE N B
OTIFIED
._ • � THEN CONSTRUCTION IS COMP'LET E PRIOR s9B5
N/S., '32'1s"E o / TO BACKFILLING PERCOLATION RA TEL �-a y, .,,,%„�, _ ae�' r.s '' �-
ce n 196. 16 en __.__...._. ..._ __.
4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <5 MIN.1IN.
BY THE BOARD OF HEALTH AND CAPE G ISLANDS WITNESSED BY.°
3 i SURVEYING CO.. INC. GERRY DUNNING
' 5. MA TERIAL S AND INSTALLATION SHALL BE IN/ COMPL IANCE WI TH THE S TA TE SA NI TAAY — BARNS BRO. OF HEALTH DESIGN iI DA TA
'� CODE — TITLE V — AND LOCAL APPLICABLE DATE. FE8. 25Pt / � 1997
,� �, / RULES AND REGULATIONS o
6. NORTH ARROW IS FROM RECORD PLANS AND A L c% ,� ,o Y R 31, NUMBER OF BEDROOMS 3
' 4 — GARBAGE DISPOSAL NO
T S NOT TO BE USED FOR(NON
PURPOSES
Q� / O a o• 22- / 7. FL 000 HAZAAD ZONE C (N®N—HA�ARD/ Lon rN y $c. d d Y fL y�G
TOWN WA TER 3G,., DAIL Y FL Oita 330 GALL
�o. o _ { ®. #A TER SUPPL Y SEPTIC TANK PEG 'D. 1500 GAS. .,
/ d e' 0)
CO wSEPTIC TANK PROVIDED 1500 GAL
LEA CHING REGUIRED 330 GPD.
Nr 15DEWALL AREA = 152- S.F.
S.F.X 0. 74 GIS.F. = 112 GPD.
h y� - _� 0 BOTTOM AREA = 329 S.F.
329 S o F.X O. 7�F. = 243
���? �. GPD
f
LEACHING PROVIDED 355 GPD
/ IV a L
a-r-_-3 ; 72 PROPOSED EL EVA TION ri'h „ /v, �-, • ,� r-.
7Z -- EXISTING CONTOUR
241.65 I OBSERVA TION PI T
SINGLE FA MIL Y RESIDENCE G
S 51 '32'16 {✓" �.
- ' 0 DISTRIBUTION BOX r
POSED SE AGE DISPOSAL SYSTEM
° �a: PREPARED FOR
tlltl�
.Mg
•� o a.
y o o Coro a Cea a N p p
+; K: a o SEPTIC TANK L OHP CONS TRUC TION
o m
W Eagle aX.�w L O T 3 (HOUSE 85) DA X TER 'S NECK
pWav oV C./ i RESERVE AREA RD .
Pond su WFo,s, ;; Av DA RNS TA DL E — CO TUI T — MASS.
Northi� � -Jr �
W Q
- - PIPE INVERT ELEVATION DAVII }
� P Point a r(...;ARL�=S lµ=Isabella �, <��a DA TE:'M<s r
CAPE d' ISLANDS ENGINEERING 2-?0
PLOT PLAN �, 7
,; - w� -,r �a x o, ,.- ,. �� ' SCALE AS NOTED 133 FALMOUTH ROAD — SUITE 2E
a SCALE.• 1 ;�'� ,3 8 1- 1 R� ; �.
95 Old H n a�e u c�z.. _,
Cntul _ Landing MAP SEC PCL LOT HSE ` �r ? ! 7 lyASHPEE, MASS.