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HomeMy WebLinkAbout0212 CHUCKLES WAY - Health ----]212 Chuckles Way, Marstons Mills QA— - — - - - L J/ I ;1 V� I r5 I� 'J s ? ~` -� ik - Q N Y c a-0c) Wr ,7WMf C � n 7 1 - �l OL - -_ PL D S � I 1 7 4 it t i TOWN OF BARNSTABLE LOCATION �� c���'f�`r` "4"' SEWAGE# - P3 4' VILtAGE /0,-/ drASSESSOR'S MAP&PARCEL xoi - iay INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY��r'1'T"`G leo 0 o GA L. LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: 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 LY/"V L EBo E Uf GAAAGF A � �yao o-c9ox / A-ACA/r-C- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppIttation for Dttpo!5af *pgtem CuttgtrUction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. eo� C�GC�'!6�"S Owner's Name,Address,and Tel.No. aplo—f iQilp'otL! /�lo�-TE Assessor's Map/Parcel f / /eZ 9 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. LinsG d4&1oYi�J 6 ��Ti< <J'� cat v io Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building Gfc_If No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided -3 f`o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank c�X�J'li�'-G /000 1914!, Type of S.A.S.TW10'-''tom Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by C77��a F — Date Application Disapproved by: Date for the following reasons Permit No. aLo Date Issued C (r No. ego Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YeS Rpprication for Digoal *pgtem Congtruction Permit Application for a'Permit to Construct( ) Repair Upgrade O Abandon O ❑ Complete System rIndividual Components ' Location Address or Lot No.OZ!07 C/yGCi�lt r �'/ry Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ���G,c�o�`!i/r"�r�T/C' ✓`�¢6/fF o..9 v�o � �A✓'o�" RJ' 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) 3 � gpd Design flow provided 3�°� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �`X�f'� �" G /0 0 0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: +' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by 1A - Date G ' rs - f Application Disapproved by: Date for the following reasons Permit No. N Date Issued f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (v) Upgraded ( ) Abandoned( )by J"-'-- c d%e-e'e 0 /G 6 at -2 / C /f�Gc��t J' �Ay /ram! /yi. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 00/1—43 dated 6 Installer Designer i0 4!r I!>i¢rf`o /P ✓' #bedrooms 7 Approved design flow �j �� gpd The issuance of this permit shall,not •e construed as a guarantee that the system will(unctioma ed\ Date ( i���l Inspector ' ! -- -- ---- --- f; -----. ---- _ - _------ __ - -_----- - -} -- No. `�V( O-- Fee THE COMMONWEALTH OF MASSACHUSETTS ` c� PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Digpogal *p.5tem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this perm• Date Approved by (gal`^,�,,� TiDwn of Barnstable r o RegWatory Serviees x Thomas F.C'eiler,Director Public Health Orion Thomas McXean,Director 200 MAin Street,]Iya*s,MBA 02601 Office:.506-862-44644. Fax: 50$-790:6304 lg,,I Iler&Desi�n;er Cert icatiton I Orm Date. (p IIb 2_0! Desiper: 10 P.I. I a A In.st$}ler:. 9 ' Address: . CA551 P Address: 1 Nu,_57 was issued a permit to install a . (date) - (ins �} • septic system at based on a deli drawn. • (addxess) � by • dated (deaign,er) ' eertify Ihat the septic systeru refers ced above was installed substanfizglX ac �rdi zg`to " ,die deign, wbrch may inci�xde mmm approved changes such as late; locatxan of the d,�tri�ution,box and/or septic tank eer.WdW the Sept1C -was Yri9_ y1 g� 10' lateral reloa above to wi i'zxta .changes (3;e,, �? o�y vex#i�al'a'�og��itt li•of a�ay coz4pp�t of the.sepSae4ttstem)but izi�idmce with State& ocat egd]Iations. plan reels ax cued as-'bt t'by deoo*ti'follow. e y rDAVID- (7nsta�lex°s 3igixaiure) •' � ;, " • S- `.WoN • Ae '��►ITAM (X3 :er s Siguatnre) (AM + Stai`hp Here) pyyTEAU y.�/-�� RETURN 'l;Q 1B .- ,,..§�,W6,`.��i�7 LI �: ALTO 2 l.f:lA�MIf'� IANCE. .'. :1 it3lJL'J7" �iT-RkNK . l Q:,�6R1686t o.31QI1CTCeT 2ca 7f);l '4fCL Y i:3 i t,.i �4`• t ii..,j;.� ?. { Town of Barnstable P it Department of Regulatory Services . au�rr�a� : Public Health Division DateMASR .639.6, 200 Main Street,Hyannis MA 02601 RFD MPS Date Scheduled 6 A,- 1l Time fi Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By:'--- Uj Witnessed By: LOCATION&GENER41,INFORMATION Location Address`'1 Or �/,�/p y�G., Owner's Name Y '1' I �+v1 1�v�^L-115 jE/��A Address y,��/n� Assessor's Map/Parcel: �//&M /•"� Engineer's Name 7 / � 9/�4 - NEW CONSTRUCTION REPAIR 'lam Telephone#510 Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area It Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Z I t_._ cl-I Parent mater'al(geologic) O V Depth to Bedrock O x,Depth to Groundwater: Standing Water in Hole: ^Y Weeping from Pit Face Estimated Seasonal High Groundwater © 1 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment fl. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time Observation Hole# '1- Time at 9" Depth of Pere I t --� Time at 6" Start Pre-soak Time C& /24al I Time(9"-6") End Pre-soak Rate MinJlnch !I '� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Put-tic Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICWERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,°o Gravel 1 O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. - Consistency,%Graven m ri-, 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# -....1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Rl - Consistencv%Gravel) CJ7 Cam ' ? .e.^: f:•..y E;: Flood Insurance Rate Map: / Above 500 year flood boundary No Yes Y Within 500 year boundary No 1 V/Yes Within 100 year Flood boundary No✓ Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occmrrmgg pervi u aterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of na rally occurring pervious material?q Certification IL �` I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro a Protection and that the above analysis was perf nned y me consistent with the required training,expe ise ex erience described in 310 CMR 15.017. 1 Signature Date L, Q:\SEPTIC\PERCFORM.DOC '2 ( Z_ TOWN OF BARNSTABLE LOCATION �4�f /O C�iuc/C11� cc SEWAGE # 39-495 " VILLAGE /I'/!J' AP-111 1XII/S S MAP & LOT I ASSESSOR INSTALLER'S NAME & PHONE NO. 19, 17.a J�,, SEPTIC TANK CAPACITY 1a042 LEACHING FACILITY:(type) /100 NO. OF BEDROOMS ,3 PRIVATE WELL OR PUBLIC WATER W � J ttL�/ic BUILDER OR OWNER Tool � C.1�G I/e � lPc��t C- �7�lie - DATE PERMIT ISSUED- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes -No "1 y,9 I y DV \ i TOWN OF B RNSTABLE LOCATION /e,-�- /C SEWAGE # VILLAGE yfla•,s /ytfrS ASSESSC3R'S. MAP 6i LOT Ai /z� e� nee� INSTALLER'S NAME Ss PHONE I�IO. �!� /�, /7 4 � SEPTIC TANK CAPACITY /Pare 941, L.Ia. C i� fir✓, LEACHING /�<� FACILITY:(tyge) t?oTa {size) ® J , NO. OF BEDROOMS :3 PRIVATE WELL OR PUBLIC WATER fgs he BUILDER OR. OWNER Jokm6Ag/!0 T. 44--o- C 9� DATE.PERMIT ISSUED: DATE COMPLIANCE ISSUED:. `JARIANCE GRANTED: Yes No I c4141es &r cy a ��EPr��Eb FnrnL �ANDr=i a c-aK0L MONT'G „21.� Gl�vckt_GS Wv�Y kkAe5Tonls MILLSf M4 _ DE COSTE REMODELING&DESIGN 4380 FALMOUTH RD. COTUIT,MA 02635 508-428-5740 lo u ELE✓aTIoN o2xlo FLoo D!ti I+a�C7c So�� /�"CpNcR�� COHSTRJGTI�IV PiE�r '`l�$FLaw GTZADe fi� OG z/S'klP �oSTs o1N POST s-,qog. 41 \ COMMON\N'EALTH OF MASSACHL'SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r, >) DEPARTMENT OF ENVIRONMENTAL PROTECTION ? ONE WINTER STREET. BOSTON. NIA 02108 61 7•292.5$00 TRUDY CORE WILLIAM F.WELD 8 9 Secretary Govemo: DAVI Bu ARGEO PAUL CELLUCCI l� D m HS Comm Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Rr commis er PART A '`�'EIV f© ✓ CERTIFICATION AUG Yv� ��r7 iAs 1 19 Property Address: �1 a cl�,zkk_s y, tons / ' Address of Owner: r0" 9T Date of Inspection: ,,_4- `17 (If different) � h6i1Typ pjrAB(f � Name of Inspector: J,�l��, /�• I& I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) A Company Name: 14,Ato l3u�kx,e Sorv,- ,y Mailing Address: o i, r > ^ /�S Y>% E Telephone Number CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete'as of the time of 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: V*" Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fa r Inspector's Signature: Date: The System Inspector Zall 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: A) SYSTEM PASSES: V 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. 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page l of 10 DEP on the World Wide Web: http:/lwww.magnet.state.ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION (continued) Property Address: .7,�o? Owner: J,�, G, 1,M7 9 Date of Inspection: BJ 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 l `.'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 r j *. .•� ' 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 15 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 15 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. 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 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 20 f , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /,7 L AV.L/(4 w'•y /yJW-f�oN 3 114, Owner: f" L. A, Date of Inspection: D) SYSTEM FAILS: You must indicate either "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 the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cEcIgged 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 SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significam threat to public health and safety and the environment because one or more of the following conditions exist:. Yes No the system is within 400 feet of a surface.drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone tl of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatxraent program requirements of 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: Owner: p TO�'�'1 C. a4�`t7 Date of Inspection: Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes i 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 as part of this inspection. _. As built plans have been obtained and examined. Note if they a e 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 "vas 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. L -_ Determined in the field (if any of the failure criteria related to Part C is it issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L SYSTEM INFORMATION Property Address: d 0 6 4,-,c/` le-S c�V /Z/�� Owner: //., Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 1�0 g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage gru.der (yes or no):.A/O / Laundry connected to system (yes or no):�PS M y3� ddps:�/)(/y yS_ G�j/Oro 0.:P ./) Seasonal use ryes or no): .410 Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):�� Last date of occupanq•: 14, ✓r 1 yy COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day 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 idate of occupancy: OTHER: (Describe) Last date of occupanc)•: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes 6r no)__d/df If yes, volume pumped: rrs` Reason for pumping TYPE OF SYSTEM 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: �H Sla P� 7-.119 �9 S ee'•;�� Sewage odors detected when arriving at the site: (yes or no) 410 (revised 04/25/97) Pago'5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .242 <lA' kle3 v✓uy" ,0orf7`�'� Owner: j—Vhn L. %),, /fo V e. //V Date of Inspection: BUILDING SEWER: (Locate on site plan) u Depth below grade: '36 Material of construction: cast ironi C4O7PV�� other (explain) Distance from private water supply well or suction lire Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concret _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Cenificate of Compliance _(Yes/No) Dimensions: d J1' y t` X Sludge depth: d Distance from top of sludge to bottom of outlet tee or baffle: ; - Scum thickness: / Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ^14 How dimensions were determined: 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.) Spot c fu. 4: a,;vkL4 S,,41 Lair-to 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 04/25/97) Rage 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71d G�i.ick��s wU /t94--Sfv�,l "ol• ,16 .'0/9 OdG�/cF Owner: J-6147 c. �4 Ito $ �1, c. /9. �10 Date of Inspection: r 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/da� Alarm level. Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) I DISTRIBUTION BOX. +� (locate on site plan) Depth of liquid level above.outlet invert: / Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) wd; ,it/n Si iN S o � back-vd ' a 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 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 247 -+2"r `/X i Owner: TV/"') C. �4 //0 Date of Inspection: r. 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 condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan) 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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:._ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: - (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Pays 8 of 10 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 ti--C k i-s Owner: y/ Date of Inspection: Iq-ell - y7 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) r � i J i .3.3 i 3 13 P�hhe 3 yi 3e y 3 y (revised 04/25/97) Page 9 of 10 M INSPECTION FORM ` SUBSURFACE SEWAGE DISPOSAL,SY57E ECT O PART C SYSTEM INFORMATION (continued) Property Address: a�.� Gh�4/��� s tvu yfu�-3lo, Da4 Y1 Owner: J'j/ah C. Date of Inspection: Depth to Groundwater>j1 3Feet Please indicate all the methods used to determine High Groundwater Elevation: f>�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 1/ Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) Ia.Qyk Aos .1.r .9h or'y....�� .r�f�ls;,r &�v frv••� �'�'I'f O�G l /7„Q w✓/�cl�t• OT ` A�.b u i��,3 ,�D y6�Pr/� (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE : LOCATION �D� �O Ghuc�lls ��< SEWAGE # VILLAGE /ylArsac I��I�S ASSESSOR'S MAP Si LOT INSTALLER'S NAME PHONE NO. TO h 1 SEPTIC.TANK CAPACITY /Oo0 4 LEACHING FACILITY:(type) /000 NO:OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER: BUILDER OR OWNER J04nG 9 �� �' Rcg�� C 94 I DATE PERMIT ISSUED: ON DATE COMPLIANCE ISSUED: L_)_ r� VARIANCE GRANTED: Yes No 60. 64 C 62'i fot !0 63.9 S'I wccG18,oe-" _ 45'• j Sv, rvz \ Uate 6-6-8q b✓'. " L,;.c :icy-.;y>. � ;,�^ice:'. •_? m vpDa Q / %�tutred i/au J1'� rnd I .yt'• C.Pit � �. '...P t - (/J ya.an ice, r,a. 02601 ; I-6 f� 6 gyp' .,�l S - ;yl I.toite! �;� the IG'C +.lit .UOod�;One. Z• I z� �o t o o ,a ( l to ,I,at !O as ahown, en 1'a4:d C'oa tt -MOS4q rg: . ; i a I-F� ��('JJCLril.t7niJ. G/,Q OIL art a�L1rti1�P.d [L -.aUk. I... noCKf.+• O� riet I Ayer" `)edt fj"Lt# P-7282 The towuiati.on ahowps on th,i4 /)t,-t i !.ocat'4 _ I Cade d-18-€q Ott •tJze gA0:01d oa t e4"e�Jiot hon (. nee A,-A, the i- t r'. JCLL -t'uaclz �e . vcP�;.e�r�s O� tite Jown O lYo cua t.e t meow^ tP4c ja to 8-2-8 q m irt. p e't 1" I - �Z"s .t . . it a� � J%of M j�✓Os'e_L I + ,cCu� I 3yJ���� sq\V 3� 4x /r err o E H; Dh r Z' 9 •Ai1LNE lin Toy. ' ��� Boa oSJe MAl t� �� .. - t om71 Isf9 I 47.' . 1 t�, � v' - Vim. ,- .`.' . - • _ c2!. u ?n (hcicJ�.LP._ .Gt1 5y' 1 31 713 6t! Jot 10 / \ 45 cc �'r.�� v tr, I rl.�u , '17'� rod / ,qa Ccpe ,rllyf.l^P.e/'.itJ'f! I i '�7h; tot ( m, w-t r✓,C i rJle LG'C ,!Fria � Jo ¢ — z• � z� + r .. ��etcn , •CG.a. und n... i 90 t ;;o A. AGLto 1. i � . ai 4howrt on .ta^.d Cowtt :'kJON9 13; -r t rJia�:LAr7d at o►1 an - �-•w � t t Ja"te• -ewt. :iatrvLtuyZe�,.oar.�o�f ec�,tlt ! . neat /•iVi 1-7282 �hP owada#,tor� atown on-�tlui, ptan tit located. w. `(4de 4-1R=R`9- on fine �.rA;otd a� aI Zeon c,.td map,..4 the !due ..w tbacJ: 2e;�b.t/a?Ji:er'..i✓1 og the Town o f rlr:a.'f jAabt-_. No wtte-t; .encourt"ad Date 8-2-89 2 nun.` p e2 i /I J v+.Of M ,- `C✓aat"'Cd. � ..-'I[G2CUle� ..... --• - _ ,. - _.`j�,�, �qC\ _ ���}` \� . ED% Hj l 3 MILNE 32440 ;;:s-., .>.; .. I I - .. .,... 7.�oF r •�6���' - �pkR( L1�N�SJ _ Iaf9 I 43.. _ Printed on Recyue0 raper Z ( Z TOWN OF BARNSTABLE 7 OCAnON ��f /,p cA.,khs Ulcc SEWAGE # $�`-99- VILLAGE /yl�vf/a��s �il�S ASSESSOR'S MAP & LOT /9/vi- /Z9 INSTALLER'S NAME & PHONE NO. JOA /7 /t SEPTIC TANK CAPACITY 941, LEACHING FACILITY:(type)_ I000 (size) '�X fd NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERO��G�G 9` IPn9t� C /go Ire DATE PERMIT ISSUED: DATE COMPLIANCE ISSUER: : r Xg VARIANCE GRANTED: Yes No �� ,.' ,� \�/e •` i \.` �` O ��., ', � a , y � ' . � - ' �• ,�� �� �.� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AVVftrFativai for Biupuuttl Works Tumitrurtiura rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � f....W&Cr kn-5,����-----....---•...............................-........•-•----------------------------------------- Location-Addr ss or Lot :�o. . h. . ._. .� �........................................................... �3 ..1! �� ��s. /�. f�.. a _5'f Owner Address a ..JjW .--_._ . If ..1!l�/.hit.ifr•:... _r� gGy� Installer Address /�o�¢ S feet U Type of Building Size Lot________________T___----___ q. Dwelling—No. of Bedrooms___________________+�.._____..........___.___Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of BuildingNo. of _persons............................ Showers — Cafeteria a' Other fixtures ............................ . W Design Flow................................��...>C___gallons per person per day. Total daily flow__-_`�.M ...........................gallons. WSeptic Tank—Liquid capacity/®s°lO.gallons Length._ =' Width.4 _ Diameter________________ Depth.S_"G.".. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------f"_... Diameter...ZC'o....... Depth below inlet.._............... Total leaching area..047...sq. ft. Z Other Distribution box (V/ Dosing ank ( ) aPercolation Test Results Performed by..ZfL.<.__., Date_..--./ .��1�--------- Test Pit No. I..__.Z-------minutes per inch Depth of Test Pit../3-tL_-. Depth to ground water.........-........... (i, Test Pit No. 2------G......minutes per inch Depth of Test Pit_f. '. Depth to ground water...... �.; .....................................--- --••-----•----•----•---••--•••-•---------- O Description of Soil ��' ..................... 0 w x ----------------------.................................................................................................................................................................................. 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/'1T r1'^ TTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ssu d by th/e�boaA�ofhh h. Signed-----••--- � _8 Date Application Approved By----------- (� .... -----•------------------------------ ......... "�- Date Application Disapproved for the following reasons-------------------------------------•----------------------------------------------------------------........._ ........................................................••-•----..--•--v•-•---•---------•-------••--------------•-----------•------------------•------------•--••••---•-----•---••-••-••----•-...._. q q --'-Date Permit No..........- ` a`k.,�.... Issued_ ...... Date FEx THE COMMONWEALTH OF MASSACHUSETTS BOAR®It OF HEALTH Application for Kliupusal 10orkg Tonuirurtiou Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:......4& Llf/i/. 19� --•.. ......�.1....1.�.�............................... /c>------_--•-..------------------••--- - - � hf - o - Loca ion-Address Lot �o. ..41?.✓l._.... r�.11..0...•...-•--------------•----•-............................. ••�- / /� //` Owner t_ Address a �J� h •_ l CG.l.l142 �7�✓ 1.� Sf..1 �1:ss h s 4f� Installer Address dType of Building Size Lot�___�: /--.---_-Sq. feet U Dwelling—No. of Bedrooms.................. ......................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria (s1 Other fixtures ---------------------------••••• . d ---......--•------•-----•---------------------------------- Design Flow :. ,- . g `..`.....__gallons per person per day. Total daily flow.:;::...::_�:!?............. ............gallons. Septic Tank—Liquid capacltyi4 .gallons Length__s--�"._'f__. titiidth._`?':......... D'iameter----------------- Depth_S : ...... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area---------: ---------sq. ft. Seepage Pit No..............Z----- Diameter.._ < Depth below inlet.....:'".......... Total leaching area.; ~� r _sq. ft. z Other Distribution box (I/') Dosing tank ( ) '-' Percolation Test Results Performed by..�J - ---- ___.t`�_: �_''__'.__. .<�'!.f:. Date_��_ -� :._ ......'.__._... Test Pit No. I....__�-�.........minutes per inch Depth of Test Pit-- Depth to ground water____ -_-__. (X Test Pit No. 2.....%r._._._minutes per inch Depth of Test Pit. . Depth to ground water--------=--- x _ ----------------------------------------••••. k••...••••-••••••--•-........`......._.._...............................-••-�-•-•-•--................-•-••--•-•----•-••-•••. ODescription of Soil...... 'e `.. ���!1 ,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: 1 i iE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation untii.a'Certificate of Compliance has bee4* ed the board " heal hSigned ....------••---••--•••...--• •......................... Date Application Approved By•-•-......O�-��"+ Z-- ................................•--. ........ ",- Date Application Disapproved for the following reasons--------------------------------•----•-----------•-------------•----------------------------------------......••. ...............•••-•.........•••••-----•-••-••••-••••••••-•-••-••-•••-•••----••••--•----•....•••••---••---••-.................--•-•••---•-•••••••-•---•---•-•-••--••••••-•-••••-••---•--•••••--•----..._ Date PermitNo.......... ..... - ------------------- Issued_....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '1!'1......OF............. ................................. uprrtif irttte of Toutplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed &A or Repaired ( ) by_......... .... ...................................--------•------•-------------------•----------------------------``----------- �; l Installer at G f{lZ e� 4.....ih of t has been installed in accordance with the provision T�TIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit �'o.•p_`��__ ................ dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL UNCTION SATISFACTORY. DATE.................X..:._ .... ............................. Inspector..............-.-' - --------------------....----------•---------•------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF...... ....................................... G-'"'' No.... __ ,� FEE-__..:�,1...•----------- ElispooaXivi�dual u Cron lion rrmft Permission is hereby granted.......... ---------------------•------------------........-•••••••......--•••••--.•---- to Construct � or Repair ( ��) anewn a Disposal System atNo..........4...ez*-----1_47-------0—- ------� _ «-..-.M----------------------------------------------------------- Sweet as shown on the application for Disposal Works ConstructioY Permit No.j9X. Dated........................................•. ...................................... a-D. _................................................... DATE............................................................................... Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Gfi i I t tl 60'.0 +-F ' 3' d Cluticl� Way 13 i.33 - 6� a ;u 9,_ -T-i SO r wide- �-,/C�1(0-0 8 8 S 9 - tiu'I-6 �x 6 t,• � F ., it p -E ' 4 F,A j r• L t�trtz 6 1 9 n �.et ,per vd.ed 3_ . r ; . . ;-! Sept c 3e�c�vt 1_I �- No. b aJ-,toon a. 3 = j- C�1".a ted itow 330 cpd J teach si a�cea 267 !?ewe rr 267 rt _I CapaaL'.l 549 cpd 64.c G34 . _ 9073 e4.4 �. 7,eit OPEN - s 3AC£ �• T�t A U Cape Cn c�� _ 1 ' . 4q Ida�cbo�t :<oad ''°�'¢,s/lL /,aoi.tCe 80 scams I4ya� , Ma. 0260� _. I /000 v L L r. f Sketch p t an o Xand in ria&dton �. &V1,2 r(a got Oo A. Aa l to Loz 10 �towr2 on �avcd Coutit ,`tlOS 9 l3' : t ' 4 !•Cation. ate-, on at � da ti+,n. 4 Beat P n-7282 riade -18-89 - ... No watet evico� . �i SIP I SI,p 2 6Z.4 T14 ►x edi,c.u•, r,=�ecLi.urn � ' ' ! !- t .Ji ' �� �CNd j 1 C tGUn c C--aue� ,�/�t\� h'r ,yk f ygs�q - _ — ,� � cy � r" 'MILNE a. ` CISTERE� i d 4 , av; ;_I•. - - -.-- b4J. �' f L — r [ N , 9, I tt r I � 7,�c �.. 1 ! I: ! 3 j a � to ,. 5.. t r :f 1 { PiEz Ls?C�M 41 cl 17 r 24 0': . I , j <<t ) C5 stoat o. `5 v F� .... Ef. [yl : 'w o a5•�. ;E}F1M 1' ns �OP 6 ght 2002 a O r�i'ai5' . '!a yhcd serve , 1 P ! - 3 el rrninary pl a.ns'.a nO Izy07 by O.C.D.ere he for[h'e se of ilr Custom r,only Any otriei us . . e'i s[n[tly rghi'd t2 R. .. -- f - Q I - I �-.niV.P.Ctsi:.YdcC'S t?EC K h,Lua U!,: .o - i�' 1� ��✓;_Tk7:�'H".1-4,�[`'�11 �_- � ` \ - � SCALE� P E . �1 '.. _ fn : .:':_L;315.5THICt'::F!?C)!'A'T'R✓,.R; 1Z5 a,iahss:>If/ 508.428 6791 ' S iLe vlfn (Wstom - - III S �es ign copyright tD 7p02 \ver 45 .5[c":R,tnSvi'... .'. .S19 F..•.50,;:54�e?K[:a,,C,. .. - All Rights Reserved .. I Gu's�FLG4R'ID Mi+7 F EJt!PT I.V 5 . ^+�1-VT "Q -Jo- /S3 _.P [.-:nary plans ana iayooi, by OC.D a e or [ne u e DC'the ":ome s orify gnyb[hei a sniF[iy -omti�!e L-� � T-CX- ASSESSORS MAP : TEST HOLE LOGS NOTES: PARCEL: I2� �! FLOOD ZONE SOIL EVALUATOR: I�.�pl ���(,1C 1) The installation shall comply with Title V and Town of Barnstable Board of WITNESS - • REFERENCE:�L � 0 2 Health Regulations. _� DATE: tf-4 I ) The installer shall verify the location of utilities, sewer inverts and septic . PERCOLAT ION RATE: Z,U11`1V'] components prior to installation and setting base elevations. ---------- ) gravity p piping " 2 3 All ravit septic i m to be 4 inch Sch 40 PVC at 1/8 per foot. The first — ,TH-2 two feet out of the d box to the leaching shall be level. TH- I D � 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. l-b►�(ti l �jl i:{ ' LD �y l 6) Parking shall not be constructed over H 10 septic components. t� 0 �� lb 7) The property is bounded by property corners and property lines. _. LOCATION MAP A� 6� 1 - �Ov`�" 8) The property owner shall review design considerations to approve of total / design flow and number of bedrooms to be considered for design. Receipt YD of payment for the plan and installation based on the plan shall be deemed CInio�-� l/ approval of the design flow by the owner. 1�11 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall � p p p p be removed along with contaminated soil and replaced with clean sand per C ( P\ Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPT I C SYSTEM DESIGN line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the / FLOW E5T I MATE owner to ensure such. / 12)The installer is to take caution in excavation around the gas line if such N70;2749"E' exists. 131, 33' LBED'ROOMS AT 1(O G L/DAY/BEDROOM - �j� GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer � J lines exiting the dwelling prior to the installation. --- --- — � _._ � � PT It TANK 14)The installer is to determine if other sewer lines exiting the structure exist GAL/DAY x 2 DAYS - GAL and if so, to be re-plumbed or tied into the septic tank. 6� USE 100f) GALLON SEPTIC TANK �eyj II,.(. y 0 .o' 6.6' SOIL At3SO PT I ON SYSTEM I ou t, 0 SIDE AREA: Z -1- I�j 'X Z.. X Oil -/0?67, , BOTTOM AREA: x - /z zabi , 1 IJ o� -�i -i--i y 4 7 �`���'= �L SEPTIC SYSTEM SECTION \/ /rye I ` � I 1 -�':�-�':� , dL, co w q Q,�SU,i, ='-'6'• — 41.2' p I I`b�/ ,510W�--�4 IN p �� F� `rTt�- i�r al �AX " I000 GAL _ SEPTIC TANK _ .. L `Z_. �8,7�j v ' . .� 1�' I Zy "x/3 k N7027'49'�E AO, 73' - SITE AND SEWAGE PLAN LOCATI ON : ,� Zlz, /AG( PREPARED FOR : 6Z971 C. 0 SCALE: I DAV I D B . MASON R5 DATE: 12 0 z DBC ENVIRONMENYAL DESIGNS77- W EAST SANDWICH . MA W DATE HEALTH AGENT Z ( 508 ) 833- 2177