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0038 EBENEZER ROAD - Health
38 Eb nezer .Road Marstons Mills __- - - A-= 123-050 - - - -- - Commonwealth of Massachusetts 19 Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Ja uiline Kin Owner O er's Name information is required for aYS-F��S I S MA 02655 April 15, 2010 ` every page. City/Town - State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector . use the return key. " Septic Inspection Services-Co.' Company Name -189 Cammett Road Company Address Marstons Mills MA 02648 ,gun Cityrrown State Zip Code 508-428-1779 S 1 12855 Telephone.Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address ao �that the T information reported below is true, accurate and complete as of the time of the inspection The inspe�ctioncD was performed based on my training and experience in the proper function and maintenance of on;site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340rof Title 5(310 CMR 15.000). The system: r,0 z�a ® Passes ❑ Conditionally Passes ❑ Fails Cri ❑ Needs Further Evaluation by the Local Approving Authority April 15 2010 it ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 10-94 King.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 I 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "< 38 Ebenezer Road Property Address Jaguiline King Owner Owner's Name information is Osterville MA 02655 April 15, 2010 required for P every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, infiltrators had 1-2" of standing water. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 10-94 King.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 38 Ebenezer Road Property Address Jaquiline King Owner Owner's Name information is required for Cisterville MA 02655 April 15, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 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 ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass.unless Board.of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10-94 King.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 f 'Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaquiline King Owner Owner's Name information is required for Osterville MA 02655 April 15, 2010 every page. City(rown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert 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_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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10-94 King.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaguiline King Owner Owner's Name information is required for Ostervllle MA 02655 April 15, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 10-94 King.doc•OB106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaquiline King Owner Owner's Name information is required for Osterville MA 02655 April 15, 2010 every page. CityRbwn State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 1D•94 King.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 38 Ebenezer Road Property Address Jaquiline King Owner Owner's Name information is required for Osterville MA 02655 April 15, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No ,000 gal. _ Water meter readings, if available (last 2 years usage (gpd)): 1 13030 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10-94 Kin .doe-08/06 Title 5 Official Inspection Form: ub 9 0Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaquiline King Owner Owner's Name information is Osterville MA 02655 April 15, 2010 required for p every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Leaching system installed 1/4/08 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-94 King.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaguiline King Owner Owner's Name information is Osterville MA 02655 April 15, 2010 required for p every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 21- feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- I Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured i 10-94 King.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r` 38 Ebenezer Road Property Address Jaquiline King Owner Owner's Name information is required for Osterville MA 02655 April 15, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10-94 King.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaquiline King Owner Owners Name information is required for Osterville MA 02655 April 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is co attached? Yes No PY ❑ ❑ Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-94 King.doc•08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i r - ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 38 Ebenezer Road Property Address Jaquiline King Owner Owners Name information is Osterville required for MA 02655 Aril 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: Four Infiltrators. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Interior of infiltrators were video inspected through vent, found 1-2"of standing water and no signs of surcharge. 10.94 King.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System sal S 9 p y Form Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaquiline Kin j Owner Owners Name information is Osterville required for MA 02655 April 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): 10-94 King.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaquiline King _ Owner Owner's Name information is Osterville MA 02655 April 15, 2010 required for _ p every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Vent 35 , , , , , r ♦ r ♦ rrarr , rr , , , , r, , ,rrr , , a r, , , , , , ,r a r ♦ r r r r a r ♦ a r r r r a r , r rrrr r ♦ r a ♦ a r r a ♦ r a r r ♦ , ♦ rrrr r r ♦ r r r r ♦ r r ♦ r r r r , , , , , , r r r r a r r r r r r r r , , , r rrrrr r r r r r r , , , , , , , , , , , , , a s rrrr r r r r r r r , , , , , , r r r r r ♦ r r r r r r r : r r r r r r r r ♦ a ♦ r r r r r r r r r r r r r ♦ r r r r r r r , r r r r r r a r r r r r r r r r r r r r , ........ ................... .................... ................... --l—............. ................... .................... ................... ''I'll-............ ................... .................... Water ....:::::::... Service Ebenezer Road f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Ebenezer Road Property Address Jaguiline King Owner Owner's Name information is Osterville MA 02655 April 15, 2010 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 12-15 feet feet Please indicate all methods used to determine the 9 high round water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-.explain: USGS tope map and town GIS. I You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 30 and topo map shows property at el. 50. Low area of abutting property with no surface water is lower than SAS. 10-94 King.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 115 of 15 a No. . o4009'" 04 1 Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for �hgpozal �bpgt m Con5trurtton Vermtt Application for a Permit to Construct( ) Repair(�Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. 36 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 10) 1 Installer's Name,Address and Tel.No. Designer's Name,Address and Tel.No. Type of Building: / Dwelling No.of Bedrooms Lot Size ?d/©g sq.ft. Garbage Grinder ( ® Other Type of Building S e- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.require ) A42 gpd Design flow provided i3 y® gpd Plan Date Z //Ad ? / Number of sheets Revisiornn,Daie Title J`� ' L D Size of Septic Tank ��� �(/� �i�/'�� d� Type of S.A.S. Description of Soil .30 Q f 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 c Date — L-(`C) Application Disapproved by: Date for the following reasons pp Permit No. X0-0 O dd Date Issued ZOWN�- ooe No. . o 1 Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipprication for �Digogar 6p.5tem Conztruction Permit Application for a Permit to Construct( ) Repair(111/Upgrade( ) Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. 3 fje/?�:Z.L"f / Owner's Name,Address,and Tel.No. Assessor's Map/Parcel14 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o r fry��i �'C�l'lS�•7 7/ �..�� � �©rv� Ca/>�' 3�'Z -�/.S mil/ Type of Building: ti / Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder (14-11-741) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requir/�d) gpd Design flow provided 0 l gpd Plan Date �/z/// o 7 Number of sheets �/ Revision Date Title ///L/P S 11�lf�� � Size of Septic Tank 14 ,r+'(�t`/ X%Sr�,t�i 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 /A/ Application Approved by t Date Application Disapproved by: Date for the following reasons .01 Permit No. 01 dd - Date Issued'N--D THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THIS IS TO CERT.FY,that the O -siteSewage DD►isposal System Constructed ( ) Repaired ( li� Upgraded ( ) Abandoned( )by 'G` 1� l l/// f at c� $ ��/�!// as�eenQc�onstructed in accordance with the provisions of Tittlye 5 and the foyrDisposal System Construction Permit No. �D` r7t�g dated e y_v . Installer l�y_1 (/ Designer p #bedrooms Approved desi ,"ow i / gpd a r The issuance°of -s permit shall not be construed as a guarantee that the system rfu ctionnjass dd`esi ned Date Inspector — No. r0C g Fee X� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Di5 pogal �&p5tem Con!5truction Permit Permission is hereby granted to C nstruct ( ) Repair (�) Upgrade ( ) Abandon ( ) System located at 3B C 19 e e r-, 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'prinit: Date t f`6� Approved by FROM :down cape engineering inc FAX NO. :15083629880 Jan. 10 2008 08:34AM P1 U?,aF9 Town of Barnstable Regulatory Services Tbomas F. Geiler,Director 'N° Public Health Division '� Thomas McKean,Director 0$ 200 Main Street,liyannis, MA WADI Office: 50$-962-4644 Fax: 509-790-630L In-,Wler & Desiarnerter ihCaliop Form Date: ��� Sewage Permit# fi.00; Assessor's MaplParcel ` Z �`� I)esi�aer: i ce' Installer: ±O 4 Address: c.3 I C tvr .... Address. �� _ j! oK pn /)yk$� �/©� S was issued a vermit io install a data) (installer j Senor,system at �c�e z..er based on a design dramm by (address) "t � dated � (0�51�7 x r certit! tbai the septic s�rsteM refe-=ced above u•as inStaIled substantialh, alydina, ► the design, which may include minor approved changes such as lateral rela..ation of Lft distribution box andio-. septic tail,. I certi4n, that the septic system refer-mred above was installed with major . anges ki.e. greater than IV lateral relocation of-the SAS ar any vexIical relocation of any compo�z�t oftbe septic system) but in accordance with State Local Regulations. P1 re�RsiQ�bor certi.ned as-built by designer to follow. rn Lj Ateg CIVIL. No.30792 . r+�S1^Fp��,Zl�� 4--FriDesigner's Stamp Here) PIrEASE RETLRN . .TQ BARNSTABLE PUBLIC HEALTH DI'VIC10N, CERTIFICATE OF CONIPLIANCE VILL NOT TT ISSUED VNT11. 3QTH THIS FORM AND AS-BUILT CA,R17 RE REC.EjVED PY THE B RNSTABL'E PUBLIC HEALTH D1 V1S10N. 'THANK YOU. n• u..I�hJ[nrnirlhr.�innerCenifscation Form 3-26-04,doc 1/0 15.220: Reparation of Plans ana Specifications.. The plans and specii6cations ior every on-site system shall be prepared as follows: (1) -Every system shall be designed by a Massachusetts Registered Professional Engineer or a Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a s tern designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203. An other agent a y of the owner..may prepare-plans for the repair Se of 'system Y P P P P a designed to . discharge not more than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are reviewed by a Massachusetts Registered Sanitarian and approved by the approving au rity; (2) Every plan submitted for approval must be dated and bear the stamp and signature of the designer, -(3) Every plan for a new system or plan for the upgrade or expansion of an existing system which requires a variance to a property line setback distance;'must.also reference a plan which bears the stamp and signature of a Massachusetts. Licensed Land Surveyor in Wacce dance with MAL.c: 112, § 81D; Eve an for a tystcm shall be of suitable scale(one inch.=40 feet or fewer for plot plans one inch = 20 feet or fewer for details of system components) and shall include d on of: ta) the legal boundaries of the facility to be served; ,/ (b) the holder and location of any easements appurtenant to or which could impact the '/ s .stem; c) the location of the all dwelling(s)or building(s)existing and proposed on the facility nd identification of those to be served by the system; '( .•the'iocation of existing or proposed impervious areas, including driveways and king areas; } location and dimensions of the system (including reserve area); (f) system design calculations,including design daily sewage flow,septic tank capacity quirsd and provided); soil absorption system capacity (required and provided); and whether system is designed for garbage grinder. North arrow and existing and proposed contours; (h) 1-cation and'log of deep'observation bole tests including the date of test, existing gra elevations marked on each test, and the names of the representative of the a roving authority and soil evaluator, 1 location and results of percolation tests including the Gate of test and the names of e.representative of the approving authority and soil evaluator, (j) name and certification number of the Soil Evaluator of record; (k) location of every water supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply wells, 2. within 250 feet of the proposed system location in the case;of tubular public / water supply wells, and 3. within 130 feet of the.proposed system location in the case of private water (/v supply wells; location of any surface waters of the Commonwealth, rivers, bordering vegetated wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone, surface water supplies,tributaries to surface watei supplies,certified vernal pools,private water supplies or suction lines, gravel packed or tubular public water supply wells, bsurface drains, leaching catch basins, or dry wells; and the location of any nitrogen nsi6c area identified'in 310 CMR 15.215 within which portions of the proposed tern are located. m) location of water lines and other subsurface utilities on the facility; ( observed and adjusted ground-water.elevation in the vicinity of the system; a.complete profile of the system; Ywhich note on the plan listing all variances to the provisions of 310 CMR 15.000 sought unction with the plan; e location and elevation of one benchmark within 50 to 75 feet of the facility is not stibjcct to dislocation or loss during construction on the facility, (r) when dosing is-proposed,complete design and specification of the dosing system proposed including but not limited to dosing chamber capacity (required and provided), ump curves and specifications,number of dosing cycles and depth per cycle; (s) when a Recirculating Sand Filter or equivalent alternative technology is required or roposed,a complete plan and specification for the system,including a hydraulic profile; t) a locus plan,to show the location of the facility including the nearest existing street; (u). the street number and lot number,if any, of the facility; and. v) the materials of construction.and the specifications of the system. �v-oIa CERTIFIED SEPTIC SYSTEM REPORT LQCATION 4H1TV3H 38 ENENEZER RD. 966T L T N n r OSTERVILLE, MA PREPARED FOR J U N 17 1996 SELLER - HEALTH DEPT. MS . JUDITH SENICA OFBARNSTABLE� 21 INDEPENDENCE WAY ROCKAWAY, NJ 07866 BUYER MS . JACQUELINE KING PO BOX 542 CENTERVILLE, MA 02632 PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 i Commonwealth of Massochusetts Executive Office of Environmental Affairs Department of► E P Environmental Protection WWlanr F.Wald Trudy Coxe S.a•ury GWAM r David B. Struhs Afro Paul CMlu=l Commi wn�r U.tiOAmor SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address 3 0 �6E.�//��CSC QG OST��v/�� Address of-Owner. a/ /(Ij)��otyd[�i�F_ G✓ Y (If different) Date-of Inspection: �3/�G S Name of Inspector. H/GL1�20 Company Name,Address and Telephone Number. ,00 eoK d r- G h'!/?t/[✓/GL/% . dui(„7- CERTIFICATION STATEMENT_ I oartdy that I have personally mspec ed the sewage disposal system at this address and that the information reported below is true, accurate and complete es of the.time of inspection. The inspection.was performed based on my training and experience in the proper function and main en°=e df=. ite-sewage,disposal systems. The system: ,/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspectors SiPaturre:. Date: �i/,,/y� The.System Inspector shall submit a copy of this inspection.report to the Approving Authority within thirty, (30) days of complsting 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 ZhaUL submit" be" report to the appropriate regional 0To,of the Department-of Environmental Protection. The orieg ai ahwid be sent to the system owner-and.copies sent to the buyer; if applicable and the approving.authority. INSPECTION SUMMARY: Cber}z,C,or D: All SY�STEKTASSES: f/I fie,not formd sny information.which indicates that the system violates any of the failure criteria as defined is 310 CMR 15.303. AM bilum criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY:PASSES: Om or mozl.system components need to be-replaced:or repaired. The system.upon completion of the replacement or.repair,.passes. •iaspsmoa- . Izrdi�ta yet,n0.or not determined(Y,N, or ND). Describe basis of determination,in all instances: If"not determined",explain.,why not') _ The septic.tanit.ia metal. cracked. structurally unsound. shows substantial infiltration or enfiltration or tank failure ia. izaminent. The system will pass.inspection if the existing septic tank is replaced with a yonforming septic.tank:aa..approved, by the Board of.Health. (revised 11/03/95) 1 orw."~.Street 4 Boston,.:Massaehusettr.02108 • FAX(61� 556-1049 • Telephone(677)2923300 Prmied on fiecKied Faye". A�JG2s 0 /r/.q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3,F f Owner. /zl5. J rxay Date of.Inepeation: g/3v/lyd Chack if the following have been done: Pumping information was requested of the owner, occupant, and 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. Z'As built plans have been obtained and examined. Note if thev 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. t,-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 baffies or tees,material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. v The size and location of the Soil Absorption System on the site has been determined based on existing information or approzimated by non-intrusive methods. // .The facility owner(and ocaupaats,if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised;11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address 3 B/L.r/ � � /�'� bST.C�.e:✓,�G G.0 Owner h S. S6oY Date of Inspection: 5/3/At FLAW CONDITIONS RBSIDEN'i7AI: Design flow: o?�llona�Di?, Number of bubmmms: .3 Number of currant residents: Garbage grinder(yes or no): Lomdry coanected to system(yes or no):YES Seasonal use(yes or no): VO 4S 8c1 �O r /94S' - �� / Water meter readings,if available /�9 Lost date of occupancy: ��S!c•�L% COMMERCIAL/INDUSTRI.Al- / Type of establishment: Design flow: lloas/day / Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non♦anitary waste discharged to the Title 5 system: (yes or no)_. Water meter.readings, if available: Lost date of occupancy: OTHM-(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECO Sd source of information: S//i/9� pit a Poi System Pumped as parr of inspections.(yes or noi.&,Q, If yes,volume pumped: gallons Reason for pumPir& TYPE O$SYSTEM (/8eptit tankABstrsbuticn bedsoil absorption system gin&cesspool OVerSow cesspool Privy Shared system(yes or no) (if yes, attach,previous inspection records, if any) Otbar(es:plain) APPROXDLATE AGE of all components, date installed(if known)and source of information: /�L�/°j�� 7 - Sa c:oi= G, oTo y/�pf� Sewage odors detected when arriving at the site: (yes or no)L0. (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 3d Rerez/x-ax/e Owner.. f"15 vrJ Q y �SA.t//G6/ Date of Inspection SEPTIC TANK: t/ (locate on site plan) Depth below grade: 7' Material of construction:_concrete L me _FRP _other(ezplain) Dimensions:_ Y'8" e 8'A Ye_P,2 X ZI%a '' De.EP Sludge depth:S N z Distance from top of aludge to bottom of outlet tee or baffle: f_/2_ Scum thiclmesa: O Distance from top of scum to top of outlet tee or baffle: 9 Dbunce.from.bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) r'�OTiy? GvyE?/LS ui��.� �rlftU a°o T/iV x GREASE TRAP: (locate on site plaa�' Depth below grade: Material of construction:_concrete_metal_FRP_other(explain) Dimensions: 8enm tbichaas: Distam from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) 1 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property.Addn" 3 6 .�ax,4 o osT,t'��//G Date of Inspection: �13��y� TIGHT OR HOLDING TANK (locate an site plan) Depth below grade: Mstsrial of eonstrctioa:_concrete_metal_FRP _other(ezplain) Dimansioas: capacity: ¢-Mons Design flow: asllons/day Alarm level: Comments: (condition of islet tee, condition,of alarm and float switches, etc.) 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.) r aU0 vo s/G,.v o/' A��G GmD f',� v. .�E,rL�Ti ! T//. P'Ul[P cHAI�>�x:� (kxate on sits plan) Pump is working order-(yes or no) - clainownts:. (note.00ndW=of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Ad&— 3 8 -1F6Cv,� Gait Date of Iaspsotiod S/3�/Y i15 Sou.ABSORPTION SYSTEM (SAS): (bate an site plan, if possible;excavation not required,but may be approzimated by non-intrusive methods) If not deoermiaad to be present, explain: Type: Isaehiag pits,number: lsachinB chambers,number:_ ltaehing Galleries,number: latching trenches,number,length: itching fields, number, dimensions: overflow cesspool, number: Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.) P/T li9S IiDT CESSPOOLS: (locate an site plan) Number and configuration: D*pLh-top of liquid to inlet invert: Depth of solids layer. Depth of scam layer. Dimensions.of aasspool.. l(stsriab of oom ruction: Indication of grvumdwater inflow(cesspool must be pumped as part of inspection Comments:(note oomdition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY.•_ (locate on site plan) Materials of canchuction: Depth of lids: Dimensions: Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -------------- (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property.Addres Owner. . /�J 5. r6/p,y cS��f//Gi9 Date of Inspection:. S J3//9l SE ME OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate aIl wells within 100' °�9 Pow o, s/ 7" DEPTS TO GROUNDWATER Depth to pv®dwatsr. $ f feet mstlsod.of d* miaation'or approximation: �'�.Q.liS1�t/3G�L �I S S/�2✓s TH2 rL.} l//�TIriV TJ �'C` y8'. 7&,C ASS16a GdA7`, 7/fR4-X �L,L g� c7iPs��-ivG S e.�S• Tif rtT7Z/1 T /f!_.f' i¢T G.�vAs7e s Th`� lie Gs o/l�/ft/Tim SOc.I S 3 /�, ) 7•a` TdtL vA/T A/ t?tz.- a6- 7 - 4 c7 - G= 8:33 (revised 11/03/95) .9 ON LOCATION SEWAGE PERMIT NO. VILLAGE��l�� �r 6 S I N S T A LL 71 NAME ADDRESS � ,4& 4 4A BUILDER OR OWNER A A DATE PERMIT ISSUED DATE COMPLIANCE ISSUED. /����� �� '� �� /�iQIL., ����� N ..:�:��+� _ Fmc-.3. ... THE COMMONWEALTH OF MASSACHUSETTS -' BOARD ALJH Appliration for Uhipvii al 19orkii Coma rurfiun rjernfit Application is hereby made for a Permit to Construct pel or Repair ( ) an Individual Sewage Disposal System at: ....... .�� --------------------------- .... --• .. ........ —Jk ' Aoc tion-Ad ess ® .Lot s/) ......................!' .!.!:..........�.f�l►......�V..-_ :......................... .....,F---------ti�'r-- ...•.........................� .fin._._..._...._ wdner t Address Installer Address e� Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms............................ Expansi Attic S/p/ Garbage Grinder ��� ar Other—Type of Building ............................ No. of persons._.! .........._.__..._. Showers (/) — Cafeteria ( ) Other fixtu s -•---------------------- Design Flow................ ...... .........gallons per person per day. Total daily flow------ dons. WSeptic Tank—Liquid capacit •-_-___----.gallons Length................ Width---------------- Diameter/d-___--__ Depth. .... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_-_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box �) Dosing tank ( Percolation Test Results Performed by--------- L ............ ..��,Av_ .......... ��, aTest Pit No. 1_ ,�� ...minutes per inch Depth of Test Pit__/Z. ...... Depth to ground water.:���4 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' --- ----- - 0 Description of Soil......... _ _.___v ��, ------------------------------------------------------------------------- ----------- r- --� .... ---�:374 -------------------------------------------------•-------•----------------------------------- �r � UNature 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 JI i Lu 5 of the State Sanitary Code— The undersigned furth gr not to place the system in operation until a Certificate of Compliance has b n issued by the board of ie th. Date Application Approved By ...-•'. -- ............................. 'Date?��' Application Disapproved for the following reasons------------------------------------------------------------------------- ....................................... -------------•----••-••-...--------••-----•----•••---•••-----------------•---------•--.......•--•-----------•-••---••-----•--•••-------•----•---•••.................................................... Date PermitNo.......................................................... Issued....................................................... Date N /of d V FizB-3 .................. THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF H fALTH ...........'.............................OF............. /!w...:.. ..._....................................... Alip ira#ion for ElWpooal Works Tonotrnrtion Urrmit Application is hereby made for a Permit to Construct,,(-` or Repair ( ) an Individual Sewage Disposal System at: ?, .... .......•-��:�. '�=---- �'.............................. ............................... ---- ----- -------------- Location Add ess n or I.otq / r d+t'!L� i !S f i t1 V Owner ,!f/ Address fir ' / ..#1s'` ................•-•-•---..... 1 ��' !1_.._. ��f:........................................................ Installer Address �, � f QType of Building Size Lot___________________l......Sq. feet U Dwelling—No. of Bedrooms_________________r ........................Expansi n Attic sw o Garbage Grinder pa Other—Type of Building ............................ No. of persons__: ------------------- Showers Cafeteria ( ) dOther fixtures ;; - ---•---- ;__........ Design Flow................3. _..•...._--___gallons per person per day. Total daily flow.__.., ._ dons. WSeptic Tank—Liquid capacit�__,..__...gallons Length................ Width---------------- Diametey.. ......... Depth .. _ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--_____---•_-------sq. ft. Seepage Pit No......................Diameter-------------------- Depth below inlet.................... Total leaching area.........r.........sq. ft. z Other Distribution box¢( Dosing tank ( ) rY+ Percolation Test Results Performed by......... ...... -LR: r. .__..t` r?::!:. .......... _ / rr �r - - -- Date------_-----�-t-..�----=------------ Test Pit No. 1'5..F:.___-minutes per inch Depth of Test Pit_:9........ Depth to ground water Test Pit No. 2............:...minutes per inch Depth of Test Pit.................... Depth to ground water......_................. --------------------- A ------------------------------------------------- O Description of Soil........__ . -_ _..__-�� :..�- �''� . ': -- - - x .......................................... ...............--•--"y``y ..., '�X''!► ---------- •------------ •-------------------------------- --------- •--------------------- 01pe"' W ......................................6.11 'a �....+............................................& A'1 ,....................................................................................... UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- r, ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with !'tT�'1=^ the provisions of '� t I.�. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health ned° ............. ........... •-•--- ......................... . � .� ' Dat Application Approved By.... .-- ---.. +r�= '11�/- = zl.. . Date Application Disapproved for the following reasons:-------•----------------------------•----------------------------.......------------------------._......----•--- ...............•---•--•------....._..----•---------------•---------------•----••-----....._..---------------•--•-----•--------•-----------------------------•----•---•-----------••----•-----•••-•-•-••- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD_„Of HEALTH ..........................................OF..........f,.. �.. ..................................... Trr#ifi6ir of Tontphatt r T IS TO ERTIFY,wThat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer at........... ........ �. ........... -------------•---................................................... has been installed in accordance with t e provisions of TI r. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No 0424V.................. da.ted-_............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / ........ Inspector--••-------••-------------�/'� 8k---------•-••---•---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H - pp �±�•'--(P� .................1 ......_....................... .� ... FEE::!.'.. .......... Mops 1 Workii Toptr ion rrntit Permission)iKereby granted------ !-------�!,�e +G ---•- to Construct �✓) Repair ( ) an Individual Sewage Disposal System atNo. �'� ........... .... f' ..................................................... Street as shown on the application for Disposal Works Constructio Perm it�jNo..................... 11ated.......................................... Q A�of h DATE.....................-_X, -----------------•--------------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r a 2oIt7 s,F A �W 1 �Goy`. p,'s�• 6 xro, �� � , t'i M , M m ~ 100opal �. (Ivy � 9 43 V Q 0 zo s � 4 ~s LEGEND EXISTING SPOT ELEVATION OjiO ' ti���" °F qs CERTIFIED PLOT PLAN �4 ROSE T s4 c L d T7:: EXISTING CONTOUR --- 0 --- o y FINISHED SPOT ELEVATION �-M s +' FINISHED' CONTOUR ---�- 0 <, 32 S �"+ '' � r ' co No.22162 Q IN �. APPROVED BOARD OF HEALTH ,srE�6?�`` ss�ONALEN SAXA'SUAL A ,* T DATE AGENT = SCALE � � �"Q � DATE DREDGE ENG/NEERIN6 CCU IN . CLIENT '" CERTIFY THAT THE �ROPOSEIj3 `? 7—N a1STERE REGISTE 0.. 67 0 Z3 BUILDING SHOWN ON THIS',.PLAN J48 N0. CIYIL` LAND CONFORMS TO THE ZONING, LIDS v G N R UR 0 DR.By pd OF -BAR BLE, MAGI: 712 'MAIN ST CH. BY - HYANNIS, MASS. � SNEETJ_ OF : DATE REG. LAND SURVEYOR } o o y y �3��' r� m n y A ° i D Z 'tl i7J V •. O I� � 1 1 •'1 V" cr. _ y � 111 A ° ? O61 O o �.qb r fh Id tj ago a � . . . . .,� . . . 41 to y th �"' R► N�o y � Q �D y �� � �� �T _ n qj Lh Co TOWN OF BARNSTABLE LOCATION T P f+l, : �Z. SEWAGE#�0,0�490r v�ZJ` VILLAGE �S/r_�Z,�1r/`�' ASSESSOR'S MAP&PARCEL /Z 1 , -0i INSTALLERS NAME&PHONE NO. C;C �� SEPTIC TANK CAPACITY /0,10 Ih LEACHING FACILITY:(type) 4 —YO fib?-0 (size) /0 'X,f0 2(z NO.OF BEDROOMS OWNER PERMIT DATE: —Or 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 m i y p TOWN OF BARNSTABLE LOCATION Z444-1 Of/t /f�y SEWAGE # VILLAGE ASSESSOR'S MAP& LOT ga?3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 14017- (size) 46?f"C NO.OF BEDROOMS 3 BOOR OWNER_�f S. �7lTH SZ e--lGi9 PERMITDATE: �3a172 COMPLIANCE DATE: 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished by i I �r_�qn( t � � � �� .��� r ' �G ' i ti 4,� � 1 �� �� �q - `7'� ��J TOWN OF BARNSTABLE LOCATION `=bZX-P—Z-e,r k2J P. VII;LAGE 'Fef y t ASSESSOR'S MAP&PARCEL IN8;M;bEV.=S NAME&PHONE NO'.-' 1-r 1L� ov�►u•L'� - 17� SEPTIC TANK CAPACITY l 000 LEACHING FACILITY.(type) L -1/� Try rS (size) NO.OF BEDROOMS OWNER t PERMIT DATE: CRATE: 15 'Ib 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 Vent_ . _ 4f4f\f\f\f\f4f\f\'f4ftf414/\f\/\f\f4/41\f4 4 \ \ 4 \ \ \ \ \ 4 4 4 r r ! r r ! f r f f 1 ! f ! f f f 1 f i •' .1. f ! f'f f f f f f f f f fff r f f f k,.' \ 4 4 4 4 \ 4 \ \ 4 \ 4 4 4 4 \ \•4 \ \ \ "� 4 4 \ 4 \ \ 4 4 4 \ 4 4 \ \ 4 \ 4 4 \ 4 \ 4 4 \ 4 4 \ \ 4 4 \ 4 4 4 � • 4 \ ' ` f f r f r f f f F f 4f\f4f4 4 \ 4 4 4 \ 4 4 i f F i f f f J f f f f F f F f f f f F SYSTEM BE SYSTEM PROFILE T pE OR COMPARABLE MEANSSFFOR FUTUURRE�LOC�ATION MAGNETIC NOTES TOP FNDN. AT EL. 52.4' ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (WT Tod APPROXIMATE NGVD ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE (SEE VENT NOTE ON PLAN) 1. DATUM IS O LOCUS 51.0' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING 2x SLOPE REQUIRED OVER 47.5' *W�. INLff 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. RUN PIPE LEVEL *EXISTING TM oIFr FOR FIRST 2' 2" DOUBLE WASHED PEASTONE 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS TO 3Q ff'**EXILSTING 1000 OR GEOTEA, FABRIC BE AASHO H- 10 EXISTING GALLON SEPTIC TANK 48.8 f 42.5 GAS 43.02' 5. PIPE JOINTS TO BE MADE WATERTIGHT. a BAFFLE 43.19 IP 43.0' 0 2.8' AT SIDES 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 6" CRUSHED STONE OR MECHANICAL COMPACTION (15.221 [21) 2 0.8' AT ENDS MASS. ENVIRONMENTAL CODE TITLE V. DEPTH OF FLOW 4' 41.0' N I_ TEE SIZES: 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO INLET DEPTH - 10" BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. 3/4" TO 1 1/2" DOUBLE WASHED STONE Route 28 OUTLET DEPTH = 14" (17.5x sLoPE) 0-x SLOPE) H-20 "3050" 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. FOUNDATION EXISTING SEPTIC TANK 32' D' BOX 4' LEACHING 5.2' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP OBTAINED FROM BOARD OF HEALTH. SCALE: 1" = 2,000't *THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING LOCATIONS OF ALL UTILITIES AND .ALL SEPTIC TANK SIZE AT 1000 GALLONS AND DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 123 PARCEL 50 BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE BOTTOM TH-2 EL. 35.8' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO PRIOR TO INSTALLING ANY PORTION OF LOT 27 COMMENCEMENT OF WORK. LOCUS IS WITHIN GP OVERLAY DISTRICT SEPTIC SYSTEM 20,168f SF 0.5t AC. 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND PROVIDE VENT WITH CHARCOAL FILTER REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. AND BUGSCREEN (FINAL PLACEMENT WITH LEGEND HOMEOWNER CONSULTATION) 1�p4� 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED BENCH MARK - CORNER OF LEACHING FACILITY. 100.0 PROPOSED SPOT ELEVATION CONCRETE PAD EL. = 51.8 +100.00 EXISTING SPOT ELEVA110N o _...s _ SYSTEM DESIGN: 100 PROPOSED CONTOUR C' a` N `'' GARBAGE DISPOSER IS NOT ALLOWED 100 EXISTING CONTOUR DESIGN FLOW: 3 BEDROOMS 0110 GPD = 330 GPD USE A 330 GPD DESIGN FLOW SEPTIC TANK: _330 GPD (2) = 660 **RE-USE EXISTING 1000 GAL. SEPTIC TANK LEACHING: TEST HOLE LOGS ` o SIDES: 2 (30 + 10) 2 (.74) = 118 GPD M TH- / ENGINEER: DAVID FLAHERTY, R.S., SE2755 P` BOTTOM 30 x 10 (.74) = 222 GPD / O S VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH WITNESS. •DON DESMARAIS, R.S. ( `� MAY BE IMMEDIATELY GRANTED BY THE BOARD TOTAL: 460 S.F. 340 GPD DATE: DECEMBER 10, 2007 � \ OF HEALTH AGENT OR BY HEALTH INSPECTOR • USE (4) STANDARD H-20 "3050" INFILTRATORS PERC. RATE _ < 2 MIN/INCH EC 51 S2 PAPERWORK AND HEARING REDUCTION WITH 0.8' STONE AT ENDS AND 2.8' AT SIDES PROPOSALS APPROVED BY THE BOARD OF CLASS I SOILS P# 12034 ' HEALTH REVISED DURING A PUBLIC HEARING HELD ON NOVEMBER 15, 2005 EXISTING 3 BR MA 4 ELEV. Ems' POSSIBLE 5' REMOVAL OF DWELLING 3) FAII ED SYSTEMS ONLY - SOIL ABSORPTION p" 47.0' 0" 46.3' THIS AREA OF LEACH SOIL NIRED IN TY, TOP OF FNDN EL. 52.4' SYSTEM INSTALLATIONS PROPOSED MORE THAN APPROVED DATE BOARD OF HEALTH DOWN TO SUITABLE SOIL LAYER. THREE FEET BELOW GRADE WITH PROPER FILL FILL REPLACE WITH CLEAN MED. SAND. VENTING (PIPED TO THE ATMOSPHERE) AND - 34" 24" WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS BE LOCATED MORE THAN FIVE FEET TITLE 5 SITE PLAN A A / 1E BELOW GRADE. OF S S 10YR /3 2 10YR / GRAVEL 3 2 . / 38 - EBENEZER RD. " " � � 41 B 3o B / DRIVE o (OSTERVILLE) BARNSTABLE, MA o. LS LS p��/ PREPARED FOR 60" 1 OYR 3/6 42 0' 36" 1 OYR 3/6 43.3' / R=120. 0, BORTOLOTTI CONST./ � L�2. JACQ UELINE KING C C - DATE: DECEMBER 11, 2007 PERC 1- ` 5$94 MS MS: off 508-362-4541 10 60, �V_ of SS'c o�y'`��ARNE S�Psc fax 508 362-9880 � 6 23, � ARNE H. yG o� H. N� 2.5Y 5/6 2.5Y 5/6 �@2• o OJALA - OJALA y E @�- CIVIL N 348 down cane engineering, Inc. 120" 37.0' 126" 35.8' RO a No. 30792 � 1 ENCOUNTERED Cl VIL ENGINEERS Scale:1"= 20' a ��sFoi ss a e o ssS`E'�°� LAND SURI/EYORS NO GROUNDWATER s 0 MmmL10 20 30 40 50 FEET 939 Main Street - YARMOUTHPORT, MASS. DATE ARNE H. OJALA, P.E., P.L.S. DCE #07-299 07-299 BORTOLOTTI-KING.DWG (DDF)