HomeMy WebLinkAbout0048 CAPTAIN BAKER ROAD - Health trs 7v�s
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TOWN OF BARNSTABLE
LOCATION 48 QwA,an B*-Kcr QA_ SEWAGE# Z20 .aso
VILLAGE jMr_s4 r s rn:l l S ASSESSOR'S MAP&PARCEL J?L- .141
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INSTALLER'S NAME&PHONE NO. 3A, 0^ • q q 1.OLS3
SEPTIC TANK CAPACITY /Dt70 On.
LEACHING FACILITY.(t3W) s DUon l T;2 (size) 1.04x zS x Z
NO.OF BEDROOMS 3
OWNER -Thomas
PERMIT DATE: I I-N- ZO COMPLIANCE DATE:
Separation Distance Between'the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY '
At- ZZ 1
3i - 19'$
AV Z5'3." C yA,, ✓gFlor.
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A3' 28 8
Fro..
133' y8's op A
2910 I
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No. .� t✓` 3 �;o Fee /60.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye—
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppl tation for Misposal 6pstrm Construction j3Prmit
Application for a Permit to Construct( ) Repair(./S Upgrade( ) Abandon( ) ❑Complete System �Individual Components
Location Address or Lot No. y 8 CA?Ac,� ok• Owner's Name,Address,and Tel.No.-T Via rrno.S �0 dtrn
Mar0oms mtkks p
Assessor'sMap/Parcel 1-Lb 16y y� l,.aQ�o��n C�cs16cC �d
Installer's Name,Address,and Tel.No. t6I N £.x cad ot% Inc. Designer's Name,Address,and Tel.No. F tMw r It S'nvi ro.
33y Rome t3o Sandw�cl� So$- 49l•o"3 Po box S31 A .. 174, 9°1+ i1wo
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 10, 000 sq.et Garbage Grinder(No)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 O gpd Design flow provided 3 y 8 gpd
Plan Date 10 1301 2 0 Number of sheets 2 Revision Date
Title
Size of Septic Tank 0 n Type of S.A.S. 'Z) S00 20
Description of Soil -4-p¢ pkoL,
Nature of Repairs or Alterations(Answer when applicable) �q t-ate\Ogw d- boX o.nd SAS ronry CAN r1n
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.
Signed Date i' 'Loto
9
Application Approved by Date / -
Application Disapproved by Date
for the following reasons
Permit No.a,6.30 3W Date Issued
�T
No. ( t�— �� Fee 11X1,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t ,/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for MispoBal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(v� Upgrade( ) Abandon( ) ❑Complete System ❑✓'Individual Components
t
Location Address or Lot No. r f,(A, Owner's Name,Address,and Tel.No.7 ho rnc,
Assessor's Map/Parcel {-Z
Installer's Name,Address,and Tel.No. Q) � C'> c.x 1rg. Designer's Name,Address,and Tel.No. F 1r..bsP(t,,,
11,0 S0Z• ii-J'3.G1<S3 PO ('fox S sl 1Ac rvj,,k �1a_ 4l. 9q{I lltaly
Type of Building:
Dwelling No.of Bedrooms Lot Size 10, o o U sq.ft}! Garbage Grinder(No)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
k Other Fixtures„
Ifi �
Design Flow(min.required)//, Q gpd Design flow provided gpd
y Plan Date�1t1'Q got 7,0 Number of sheets 7. Revision Date
Title
Size of Septic Tank WOO ncMo, Type of S.A.S.
•-• Description of Soil c-pa
Nature of Repairs or Alterations(Answer when applicable) �n-,k G t\ h-ew A- boy e\" f.A A �'n n ry r i,nr,
Atv .0 x G
Date last inspected: v
n Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in t r
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. '
Signed (,'t 9�r nip. ._ . Date 1�I - ( 'Lott
Application Approved by --* ,,,/// � ��,� `- � /C--S Date
Application Disapproved by V fT Date '
for the following reasons
Permit No. a�),�/)� � Date Issued y�Z
f `
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by P-) lac r VIv0.A s or, ko, .
at 4 ,c� �...^` (t` k.n r ct . has been constructed in accordance
j
with the provisions of Title 5 and the for Disposal System Construction Permit No.m VX— dated ff/y Ialn
Installer '; ( _x r rau * !n r . Designer 1 Arc c��� J I,gn � Et1.atCr�mFc�lal
#bedrooms _Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the syste c ill fun as d s gned.
Date ( (l ) 8` Inspector
No. Fee ff1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
isposal 6pstem Construction 3permit
Permission is hereby granted to Construct( ) Repair( ✓) Upgrade( ) Abandon( )
System located at 4 0. C,00i , n (k,,c+k e r 9 A. 44 r14
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 be completed within three years of the date of this permit.
Date �� L� i"� Approved by i y 1.44,4A P11,/,i�J' o' ."kilvi , '
Town of Barnstable
.� ' .� Inspectional Services
Public Health Division
NAM Thomas McKean,Director
nru►t° 200 Main Street,Hyannis,MA 02601
Office: 508-9624644 Fax: 508-790-6304
Installer& Designer Certification Form -
Date: 11-lG- Za Sewage Permit# 2Z0.350 Assessor's Map\Parce1_ ZG-,
Designer: Flohec-ka Installer: Q ♦ t3 ExcaLvo_-\i o n
Address: O Bay, 331 Address: ly'r"e a,` cmi L+J
Har W i Ck Fo rc slck a.I L
On i 1-y-Z O i3 rxcQ o=.A i o✓% was issued a permit to install a
(date) (installer)
septic system at 4% Cmn4;at\ Roger RC based on a design drawn by
(address)
.3aue dated 1 0.30- ZO
(designer)
I 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. Strip 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 constructed i co>'lance with the to rms of
M4
the RA approval letters(if applicable)
DAV_ID yG�
D. 1
LMERTY,7R. Ch
(I taper's Si re \`�No. 1211
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S'�/'vrl'gR\F�i
esigner's Signatur (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
WoMdeptAHEALTIASEWER connecASEPTIODesigner Cenification Form Rev 8.I4-13.DOC r
TOWN OFF iSTABLE LOCATION 1 Z3 t�t ✓, r�SEWAGE # /Q
VILLAGE Z 141'? r"/. �� ASSESSOR'S MAP & LOT 116 05 y
INSTALLER'S NAME&PHONE N0.;a
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 3 � � (size)NO.OF BEDROOMS _
BUILDER OR OWNER 4!�--AA
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: f
Maximum Adjusted Groundwater Table and Bottom of beaching Facility Feet
Private Water Supply Well and Leaching Facility M/y wells exist
on site or within 200.feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If an wetlands exist
within 300 feet of leaching facility) Feet
Furnished by a
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114E Tp��O
Town of Barnstable
Regulatory Services
BAMSTABLE,
9 Mass, Thomas F.Geiler,Director
�AIE%3.a`e Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Building Permit Procedure for Residential Addition Or Remodel Or Dock
1. Determine map and parcel number and enter it on application. (This information may be
obtained from the Engineering or Building Dept.)
2. Plot plan or mortgage survey required for any addition.
3. Historic District Commission,200 Main Street, approval required prior to
construction/demolition for any properties located in a Historic District:
• Old Kings Highway Historic District(11o'1 Uh of the Mid Cape Highway)
• Hyannis Main Street Waterfront Historic District(See map for boundaries)
• Historic Preservation(if applicable).
4. 4 sets of house plans measuring 11"x 1711, scaled 1/4"=1' & fully dimensionalized
are required. Plans must include a foundation, cross section, framing schedule, insulation detail
&floor plan showing location of smoke detectors (located with a Red `S'.) Once approved, 3
stamped sets will be retained wBuilding Permit for distribution to the Fire Dept.,the Electrician
&the job site.
5. Approvals from the following departments are required and can be obtained at 200 Main St.:
Health Department
Tax Collector
Conservation Department
Treasurer
6. Workers Compensation Insurance Affidavit form must be submitted for any workers hired. In
the event the homeowner takes out the permit, subcontractors hired must supply this.
7. Energy Compliance Form
8. Home Improvement Contractor Affidavit must be submitted.
9. Copies of the following licenses are required: Construction Supervisors License &Home
Improvement Contractor's License-if anyone other than the homeowner applies for the
permit.
10. Homeowner License Exemption Form must be submitted if homeowner is acting as general
contractor or builder for the project.
11. Fee must be paid upon submittal of application.
NOTE:No wall is to be covered before wiring,plumbing and frame inspection.
Q:forms:R addalt
122001
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No. 9t Fee $5 0 . 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
3pprication for Migogal *pgtem Congtruction i3ermit
Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 48 Capt Baker Rd Owner's Name,Address and Tel.No. 4 2 8—4 6 7 6
Assessor'sMap/Parcel Marstons Mills, MA Brian Chaulk
.Q 48 Ca t Baker Rd Marstons Mills
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
PO Box 1089 , Centerville, MA
Type of Building:
Dwelling . No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( n5)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil s a n d
Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching system
consisting of 3 maximizers ( stonepacked) and a new D-Box.
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 by t 's B and of He
Signed Date l o;7- C g
Application Approved by Date' ' -'
Application Disapproved for the following reasons
Permit No. e- Date Issued
-------------------------------`— — ---= —�
No. / , ' Fee $5 0.0 0
THE COM ONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISIO -TOWN OF BARNSTABLE., MASSACHUSETTS
rication for �'5 sal *p,5tem Construction Permit
ra
It Application fora Permit to Construct pqir(X)Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 48 Capt Baker Rd Owner's Name,Address and Tel.No. 4 2 8—4 6 7 6
Assessor'sMap/Parcel Marstons ;"Mills, MA Brian Chaulk
48 Capt Baker Rd Marstons Mills
Installer's Name,Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
PO Box 1089', `-Qenterville, MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ng
Other Type of Building. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date ;
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable Title 5 Leaching system
} consisting of 3 maximizers (stbnepacked) and a new D-Box. - -
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 by t 's B and of He
Signed Date`"oZ 9 T,
Application Approved by _ -% Date /" e
Application Disapproved for the following reasons
Permit No. r ..ate -,,Date Issued IV
THE COMMONWEALTH OF MASSACHUSETTS
Chaulk BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(XX)Upgraded( )
Abandoned( )by
at 48 Capt Baker Rd, Marstons Mills has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated f�
Installer W E Robinson Sept SrV Designer
The issuance of this hermit shall not be construed as a guarantee that the system 'll - tion as designed.
Date - 7 i`T Inspector
No.—�—� �-------------------------Fee 5$ O.QO
THE COMMONWEALTH OF MASSACHUSETTS
6
ChBti$k '
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwi!5poal 6petem (Con5tructiou Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 48 Capt Baker Road
Marstons Mills, MA
Installer: W E Robinson Septic Service
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 thi t.
''' f%Date: / �'' / Approved b '
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated /-,;Z e— 4 concerning the
property located at 48 Capt Baker Rd, Marstons Mills, MA, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in r c ge use p oposed
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map) J
i
SIGNED: ��, DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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LO-CATION ( i- SEWA G E PERMIT NO.
VILLAGE
I N S T A LL R'S NAME & ADDRESS
Ych o - * 7 7.3 f
B U I'L D E R OR OWNER
.1 o r �✓r .e
DATE PERMIT ISSUED
—�
DATE COMPLIANCE ISSUED
r
'e2oti
TOWN OF BARNSTABLE
LOCATION � �" d ' SEWAGE #
VII LAGS ' S ASSESSOR'S MAP & LOT O
INSTALLER'S NAME&PHONE NO.6 0/ d.4-- 77
:.SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) _N�6 i /� (size)
"NO.OF BEDROOMS r
BUILDER OR OWNER
PERMITDATE: •- COMPLIANCE DATE: l
<:Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of aching Facility Feet
Private Water Supply Well and Leaching Facility y wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If an etlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
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3 � .
Y
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
WILLIAM F.WELD TRUDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 48 Capt Baker Rd, Marstons Address of Owner: Brian Chaulk
Date of Inspection: %—A 7-9 g Mills (If different)
Name of Inspector: WM E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title athereD31rtedbelo?wis
Company Name: WM E Robinson Septic ServiceMailingAddress: PO Box 1089 , Centervi11e, MA 02632Telephone NumberY 0 8; 7 7 5—A 7 7 6 CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and true, 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 Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 4� Date: Z:- i
The System Inspector shall submit a copy of this inspection report to the Approving Authority within 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 the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I 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.
�U�MENTS:
BJ YSTEM 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Mwww.magnet.state.ma.us/dep
ej Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection: j_ 7_
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] F RTHER 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 -he 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) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
Y
stem The s has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ Y p P
_ 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 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 48 Capt Faker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection:
D] YSTEM FAILS:
You st indicate ei;!,er "Yes" or "No" as to each of the following:
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
he failure.
Yes o
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 _.
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.
El LARGE S STEM FAILS:
You must in licate either "Yes" or "No' as to each of the following:
Th following criteria apply to large systems in addition to the criteria above:
T system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
p blic health and safety and the environment because one or more of the following conditions exist:
Yes o
the system is within 400 feet of a surface drinking water supply
the system is within:200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The owner or or
of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yet• No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
part of this inspection.ction.
as pa p
f 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 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:
_✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. 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) [15.302(3)(b)]
(revived 04/25/97) Page 4 of 10
r.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 48 Capt Ba.{er Rd, M_arstons Mills
Owner: Chaulk
Date of Inspection: J—a-7--T 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: y g.p.d./bedroom fo- S.A.S.
Number of bedrooms:L
Number of current residents: 3
Garbage grinder (yes or no):_,,4- O
Laundry connected to system (yes or noy!%f
Seasonal use (yes or no):A,D 1996 — 75 , 000gals
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):ZLo 1997 72, 000gals
Last date of occupancy:
C MMERCIAUINDUSTRIAL:
Typ of establishment:
Des
i flow: gallons/day
Greas trap present: (yes or no)_
Industr al Waste Holding Tank present: :yes or no)_
Non-sa nary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last da of occupancy:
OTHE • (Describe)
Last da occupancy:
GENERAL INFORMATION
PUMPING RECORDS and so rce of information:
System pumped as part of inspection: (yes or no) �3
If yes, volume pumped: /-0 br C gallons
Reason for pumping: vo 'R
TYPE ,FF �YSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: /VL�'✓ S s•
Sewage odors detected when arriving at the site: (yes or no) U
(revised 04/25/97) Page 5 of 10
• r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection: j—,X —
B UILE NG SEWER:
(Locate in site plan)
Depth low grade:
Material f construction: _cast iron _40 PVC _other (explain)
Distanc from private water supply well or suction line
Diamet r
Comme ts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: -�
(locate on site plan)
. 1
Depth below grader
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
� r•
Dimensions:
Sludge depth:_ "
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: O ,.
Distance from top of scum to top of outlet tee or baffle:_ `
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: a )9 k
Comments:
(recommendation for pumping, condition of inlet and outlet tees or ba les, de th of liquid level yt relation to outlet invert, structural
integrity, eviden of le e, etc.) ` 6 0- 4 � � w.
r • /t
O
GREASE TRA
(locate on site Ian)
Depth below g ade:
Material of con truction: _concrete _metal _Fiberglass _Polyethylene other(explain)
Dimensions:
Scum thickness:
Distance from to of scum to top of outlet tee or baffle:
Distance from bo om of scum to bottom of outlet tee or baffle:
Date of last pump ng:
Comments:
(recommendation or pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evident of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection: /-p-p-,7$
T HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(lo to on site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dime sions:
Capa iry: gallons
Desi n flow: gallons/day
Alar level: Alarm in working order _Yes; _ No
Date f previous pumping:
Comm nts:
(conditi n of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
/L«U /
PUMP HAMBER:_
(locate n site plan)
Pumps i working order: (Yes or No)
Alarms n working order (Yes or No)
Corn, nts:
(note c dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection:/_;,9--1-f
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:
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 conditio of soil, signs of hydraulic failure, level of onding, condition of vegetation, etc.)
�
CESS OLS: _
(locate n site plan)
Numbe and configuration:
Depth-to of liquid to inlet invert:
Depth o solids layer:
Depth of cum layer:
Dimensio s of cesspool:
Materials f construction:
Indicatio of groundwater:
inf:ow (cesspool must be pumped as part of inspection)
Comm
e s:
(note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on ite plan)
Materials onstruction: Dimensions:
Depth of soli _
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection: /--;.,J-c3 $-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1
W
J i
i
t.
14
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Capt Baker Rd, Marstons Mills
Owner: Chaulk
Date of Inspection: —A 7— q �
Depth to Groundwater J6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own rds how you established the High Groundwater Elevation. (Must be completed)
_ )� V/
6[L�
(revised 04/25/97) Page 10 of 10
07/ t—
No........3g�:....... Fs$...IV..................
_
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
ild ..........OF..........4 ........................................
Appliratinn -for Miip iiat Works Tomitxnrtion Vrxntit
Application is herebymade for`a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
--------
. on-Address / Ali:kL
.No �£C.�) ✓/o/� f��.
�^ ......
Ow - /��,,�, .- Address -
......--•..... ..........)�Y14..... .. .. .. Y'��..................... ...........--•--• .................... .-----••.!� r!v'."!A•.------------•--•-
Installer Address
UType of Building Size ......Sq. feet
Dwelling—No. of Bedrooms ......... ..... Expansion Attic ( ) � ,�bage Grinder �'1�ry
aOther=Type of Building __f kt9 No. of persons............................ Showers �(� - Cafeteria ( )
Otherfixtures ----------------------------------------------------------------------- ---------------------------------------------------------------------
W Design Flow----------- ..........................gallons per person per day. Total daily flow.._......__._...._..........................gallons.
WSeptic Tank—Liquid capacity/Oea-gallons Length---------------- Width--__----.-.--- Diameter---------------- Depth.-..-_--_-...--
x Disposal Trench—No._______. _.. Width.................... Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No._1 0OO_ Diameter.................... Depth below inlet__-________. __... Total leaching area.-_----__-.--.•_-_sq. ft.
z Other Distribution box (�) Dosing tank
Percolation Test Results Performed by-------- -------------------------------------•-------•------------------- Date---------------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..-.-__-.-._-.----.----.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.--_----.-_--__-__-- Depth to ground water-_.------__--_---_---. -
- ----------- --------------- --- j`�
O Description of Soil-------------- . sr"', - ;r
-----------------------
W
----------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable.-.-............................................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued by of health.
Sign ..��'
�....
Date
Application Approved By---"--��----- - - ---- --- --- _--------------------- ......a2..-` '- 7
Date
Application Disapproved for the following reasons:.................................................................................................................
...---•-•-•--------------------------------------------------------•---------------------••---------------•---------•----•----------------------•------------...----.....:------------------------------
Date
PermitNo......................................................... Issued.........................................................
Date
e.
........ - --`------------------------- W<i�
07//
No._-•••-•......................... Fic$.../X...`...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......1/ n-..---- --.OF..........�C- .......................
Appliratiou -for Ui,npuiittl Worko Tomitrurtiott Vrrmtit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S st
Y �
Ate-- ................................. 7� Z �.`..�-- /
ation ess or Lot No. e�t
W ow4 Ad� e ress
'(.lil _ __ _ __-•--------------
Installer Address
Q Type of Building Size ---------Sq. feet
U Dwelling—No. of Bedrooms. _ p ( ) g If e)
//.., '______________________E Expansion Attic Zr age Grinder
pa-, Other—Type of Building -- __"� .fl•.. No. of persons___________________________ Showers-f(,�— Cafeteria ( )
QI Other rtures / '
Q
W Design Flow__________ _O___________________________gallons per person per day. Total daily flow............................................
WSeptic 'Tank—Liquid capacity_1MQ_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 ( ) -Oh. - /` /' 74
aPercolation Test Results Performed by----------------- ---------------------------------------------------- Date________-•---------------------•-------
,� Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---------_-______-_--_..
GT. Test Pit No. 2----------------minutes per inch Depth of "lest Pit-.____-___._______ Depth to ground water_----_.-___-_______----
9 ' __
_____ _________ ___ ____e`(
---__ -_ _ _ ________________._..__..____..________rc___.___. .__
0 Description of Soil--------- --- `_. i'-zJGt% �'1 �% u - - - -.
- ---- - - --
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
-----------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bAissby the boa hea r�Sign -•-_ - ---------•--- •----`- ••-•----- - iF
r Date
Application Approved By--- f= /� -----••-•------------- ------;2-'-1,�'- 7-7___.
/i Date
Application Disapproved for the following reasons: (-----•----•-•-----•--------------•-•---•----------•-•-----_••---------------------•-------
•-----------------------••--•--------___------------------------------------•----------•-
Date
PermitNo......................................................... Issued-------_----------....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. .....Q"Zs 7......0 F...... � 14E!1!Z?tr. ........................
Trrtifiratr of 101111utpliattrr
THIS S TO ERT Y t t e vidual Sewage Disposal System constructed (�r Repaired ( )
4 ..........................., �/by _
°� d �L[ alley 4 ---------•--
has been installed in accordance with the provisions of A&XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------------------- dated..--____!�_��_-•__".�_�__________.
THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL fUNCTION SATISFACTORY. � F
DATEf� Inspect / ------- ••'-• ---•------•-•---••------••'--•'-•-- ---•---•••-••-•-
THE COMMONWEALTH OF MAS SETTS
1 �F BOARD Of HEALTH
Zr2s ...........OF........, .�.:..... r.rt ---•--•----•---------------- �*sJ
No......................... FEE......1�5..---
Dt5pofial orkg Tottitr viott Prratit
Permission i hereby granted - -= �� 2 ��=�..... :,.......
to Constru. ( .---- or Repai ) an Individual,Sewage. D' posal System /
at No....^c r -
f � - �i-------•-�...<=l--•--;-----•- J •---'-`-- -------------�fr�:J---.�_-•� /' �f-S�- �P_.��b`tv �-d f s�
Street
as shown on the application for Disposal Works Construction Permit�N'o-______f__.____r Dated___��_'./ -----27-------------
1 / L
E -- � I o
DATE................................................................................ Board ealtyir
FORM 12555 HOBBS & WARREN. INC.. PUBLISHERS
TOP OF FOUNDATION COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE FlahertyEnvironmental Services
BROUGHT TO WITHIN 6 OF FINAL GRADE
EL. 58.0' EL. 56.0' (not to scale) INSP. PORT W I 3" OF GRADE
CLEAN SAND P.O. Box 331
2" of e" to�' DOUBLE WASHED EL. 56.0' Harwich, MA.02645
4 PEASTONE OR GEOTEXTILE CAST IRON or EQUIVALENT FILTER FABRIC 774.994.9166
MIN. PITCH 1/4" PER FOOT
:; 4^SCHEDULE 40 PVC PIPE 4"SCHEDULE 40 PVC PIPE
VENT IF REQUIRED
•• FLOW LINE (A/st2'to be level)
:.'•; L. EXIST —� ®
14" f o°o 0 oc
0 0 0 0
EL,EXI 000
5 .7 ' o°o°o°0000°°°0000 .' NI C0-00ooc i.
�•' EL.53.03 °o 0 000000000 0°0°o°0°c 2_0'
EL.53. ' o00000 0000
EL.53.0' o°o°°0 0 000 00 �® ®� . ® 00000000c
J GAS BAFFLE (H-20D-BOX) °o 0 0 0° o°o°o° ' • ' •• o°o°o°o°c
.. " 00000000 a• ,
..: .
0000 EL.51.0
6"CRUSH D STONE OR SOIL ABSORPTION SYSTEM
�• ' '.: MECHANICALLY COMPACTED (2) 500 GALLON H-20 CHAMBERS
(DATUM: ASSUMED) 1000 GALLON SEPTIC TANK 5.5'
WITH 4'STONE AROUND IN A
jEXISTING) 4" to 1' DOUBLE WASHED STONE
54 `��" a 2" 12.83'X 25'X 2' CONFIGURATION
56
BOTTOM OF TEST HOLE EL. 45.5' EL. 45.5'
USGS ADJUSTMENT: N/A LOCATIONMAP
QO 11.9' GROUNDWATER ELEV: N/A
eO TH-1
2115' a`' BENCHMARK: R Lane
A'l / ~O .t j6p TOP OF FNDN
S9LOCUS
21.9'\/ N TH
Q"♦� )aj obi
��••,�, N
V 5
EXIST. SAS �!
\ O
{ \ EXIST. S.T. NTS
EXISTING %
3 BR
OSH DWELLING jk•tf �O2 � �.
OF
RIVEWAY✓ �
56 \ GARAGE DECK LOT 26
20,000 SF*
MAP 126 LOT 54 $�NtTAR►►
• 30 �
-T 16�Op' �h0� DATE.'f0/30/2020 REVISED.'
LEGEND SITE AND SEWAGE PLAN
FOR
-6 6 6 6 GAS LINE •
B D B EXCAVATION, INC./
W W—W 4 WATER LINE THOMAS BODEN
-E E—EE E— EXIST, ELECTRIC / 48 CAPTAIN.BAKER ROAD
99 EXIST, CONTOURS (MARSTONS MILLS)
99 PROP, CONTOURS SCALE ■ 1 - 3 0 BARNSTABLE, MA
u0iE "SE— UNDERGROUND UTIL.
i REF•PB 274 PG 34 PAGE>OFZ
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