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0173 EVERGREEN DRIVE - Health
173 Evergreen Drive.... Marstons Mills P F A = 125. 066 - - 2 TOWN OF BARNSTABLE I LOCATION J J ,JL=LE Y_A, ®�D2.N-.. SEWAGE # VILLAGE �� Y ' �''\�� ASSESSOR'S MAP & LOT 1, 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYci5��— LEACHING FACILITY: (type) , fe oT (_._ (size) NO.OF BEDROOMS �L BUILDER OR OWNER PERMTTDATE: 2-1 0 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 l�`� �^�� �:: �i '; �� � o �`` �� h � _. .: �' �,� .�� No. t FEE V - Board of Health, S���p� MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repai�� yy r�Upgrade( ) Abandon( ) 0 Complete Systedividual Components Location 11.,3 Owner's Name M w Map/Parcel# Address Lot# Telephone# Installer's Name Designer's NameFn Oft , Address --r�, Address TrkL 8 Telephone# 1 Telephone# Type of Building Lot Size _sq.ft. Dwelling-No.of Bedrooms 3 &Jru.ids Garbage grinder(qa Other-Type of Building No.of p sons�_Showers ( Cafeteria (j�K Other Fixtures Design Flow (min.required) gpd Calculated design,flow %esign flow provided 4'13,:+0 gpd Plan: Date A O` A Number off sheets \� Revision Date --. Title ��D(�� r �l��SiJCx � Sdz�iv1 � 5 Description of Soil(s) Soil Evaluator Form No. �� Name of Soil Evaluator ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS (DN 4' The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ees to no o ace a to in operation until a Certificate of Compliance has been issued,by,the Board of Health. .-JYv1V j,40 E�vlt;rl+utL �Ii 1 SUPE^`';' Signed G Date ''�STALLATION AND CERTIFY IN W-;T;: 00 ( - �— _Uy PYST-CM WAS INSTALLED IN --Lp�, L-- T)ne t'l Inspections ^T^`..",`�;'.-7"r.n.'rc�--� "•,.r"�.�''r.-v^-+`.r-.:a�""y,-�A.a+.J�.ti,�,�•.-'*`.��.f�.+f`t�^..-ry,_i:.�.�'"_'3'rralrl•Jilt'.��''>^'„r,.,ryrf;��'y��1',-C*r" �7d"s4't-.s7�,.,��" ...:.r'r')�raer..,,�.,�� y�.v ,. No �UU� ' �. .rr � ,: FEE S MA. Board of Health, s-NO.�V t.- APPLICATION FOP, ➢ ISPOSAL SYSTEM CONSTRUCTION PEPMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( 0 Complete System dividual Components Location M,`\ S y Owner's Name MA2)c WG >J - Map/Parcel# 1 A 5 In (' Address r Lot# Telephone# Installer's Name V -tS i�MC R Designer's Name F-0 01 AddressS T� �orl�v M Pr "J ress wC "I Lam. 4;� may ' �tfl Telephone# 1,L f 8 --5 1 ID " S Telephone# f Type of Building S l C?(l \ Lot Size Ss sq.ft. Dwelling-No.of Bedrooms` \t s)D 911n",05 1401 Garbage�bage grinder(A4&— ; Other-Type of Building Mn r a- No.of persons Showers (A!Cal%r a (4)e Other Fixtures �,L�Gc�tye'• i �C1.A1� �i r�� r�i✓te �, 'Design Flow (min.required) gpd Calculated design flow ' 'jDesign flow provided gpd Plan: Date `1�i L` Number of sheets ` Revision Date Title Description of Soil(s) �1rrt� Soil Evaluator Form No. � Name of Soil Evaluator'( Cc ryv_ Si-1DyDate of Evaluation Z} DESCRIPTION OF REPAIRS OR ALTERATIONS Cl`Cum The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrr'ee��s to notnto lace a syste in operation until a Certificate of Compliance has been issued by the Board of Health. Signed l �Gn �r� Date "' Lt`�`'1 004 Inspections No. UJ"1 ' 7 9 FEE 5 COMMONWEALTH Of MASSAC14USETTS Board of Health, I n5 iah)e MA. a CERTIFICATE Of COMPLIANCE Description of Work: Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired( ,Upgraded ( ),Abandoned ( ) by:at f"f 15_ � n Y has been installed in o acc�.o�rtlance with the provisions f f 3,10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 0 � �// dated a2—°�� Approved Design FlTL (gpd) � Installer .rt' 1'f�� c`�, `� f� TA Designer: �,1 Inspector: t,.}�I n', J-, Date: v v The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. D y y` o/ ? FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, t ! r�s'� � MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to';�C�or/nstrupct( ) f�Repair ) Upgrade S ) Abandon( ) an indi-6dual sewage disposal system at t� (_,�t"_ vld !�iC.��`C , i J�}� �� 1' as described in the application for Disposal System Construction Permit No. dated o2 y 4 Provided: Construction shall be completed within three years of the date ofV er it. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 2 IlaV Board of Health u Sep- 20-01 13 : 62 BARN-STABLE HEALTH DEPT 5pt3�yuo��•+ ` S2S%Oi NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM p tJ hereby ccrtify that the engineered pian signed by me ua;ec concerning the property located at meets all of the fcllowtno cr.terta: • This failed system.is connected to a residential dwelling only. There are no :omm--r:.ta! or business uses associated with the dwelling, • Tie soil is ciass:f:cd as CLASS 1 and the percolation rate is less than or equal to rr nut:s per inch. The applicant may use histo-ncal data to conclude this fac: or may _o�duut �re!im,::ar% tests at the site without a health agent present • There. :s no increase to now and/or change. in use proposed • There are ;to variances requested or needed, • Tht bottom of the proposed leaching facility will not be located less than fourteen aoove the maximum adjusted groundwater table elevation. f Adiust the nundwa;er table using the Erimptor method when applicable) Please complete the following: �,l fop •JI Ground S'JrlaCe Elevation (using GIS information) g; GAV Elevat:or, 0_ + :d;ustmen( for high G.W..�...�.., = ���► ,-).'FTFRE;rNt--T= BETWEEN .\ and B ^� i S:G',IED _ DATE: 3asec tine wove r.formauon. a reonir permit wil! be issued for �edr^orrs a .trr.0 r. -�+^ ;ddivanal bedrooms Ue authorized to (he future wi!hout en,tneerec :ept+ system plans. 1run!C:0v pvmtrnp Permit Number: Date: Completed by: HBGH GROUNDWATER LEVEL COMPUTATION Site Location: eWf1�.���� -�1 \� Lot No. Owner: Address: �V Contractor: Address: V21\ Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date C� n month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... �' OBWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... P, SID. 5 mont /year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ..............................................:.........•................................. ' STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ......................................... .. Figure 13.--Reproducible computation form, 15 f ' TOWN OF BARNSTABLE SEWAGE # LOCATION r' �/iS�{`;'��-S� — —oLc VILLAGE-S,��� ASrSE_SSOR'S MAP & LOT — 6 INSTALLER'S NAME&PHONE NO. y � SEPTIC TANK CAPACITY 'OV LEACHING FACILITY: (type) (size) �x (c I dP• NO.OF BEDROOMS. BUILDER OR OWNER ..PERMITDATE:. ��' COMPLIANCE DATE: ;3sl6—d 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 I on site or within 200 feet of leaching facility) Feet i Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Ali �S �- /i�. ��, qq ' r Town of Barnstable �tNE Tp� do Regulatory Services Thomas F. Geiler, Director * BARNSTABLE, 9q,A S. `0� Public Health Division 039. ' Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 3/16/04 Designer: Shay Environmental Services Installer: Roberts Septic Service Address: 34 Thatchers Lane Address: 5 Trenton Street East Falmouth, MA 02536 Yarmouth, MA On 3/8/04 Roberts Septic Service was issued a permit to install a (date) (installer) septic system at 173 Evergreen Drive, Marstons Mills based on a design drawn by (address) Shay Environmental Services dated 1/9/04 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF ------------ ( nstaller s Signature) MCAIR INAEN tom. 4 U PNo. (De ner's Signatu (Affi x i � ` f "Here) 6 A'.°�,... ra i PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form L,,9 C A T ION SEWAGE PERMIT NO. V.4 L A E �45 arts' 1i LC I N S T A LLE NAME i ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED " DATE COMPLIANCE ISSUED n6717495 yi O . , T/Z, �y u 1� 15��° -! 3F$............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O� F,1HEALTH { ....................0 F.. r.... ��!"Is- !5, -.X....................................... Applirafion for Dispasal Works Tnnitrnr#inn ramit Application is hereby made for a Permit to Construct (Vfor Repair ( ) an Individual Sewage Disposal S stem at .........._.......... ............ ocation• dress .........._. or Lot No. --------------------------------------------------- Owner Address a �/�l rocs 57 y -----------------------------•----------......-----------..................--•-----...-------•--- .c_ES_... Installer Address Q Type of Building Size Lot.___ Aa..Sq. feet V Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------- W Design Flow............ .._....... gallons per person er da�y. Total c it flow................. ...............gallons. WSeptic Tank—Liquid capacity- gallons Length...0-__ Width,,:' .. Diameter________________ Depth... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ iameter-______-_-.-__----__ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ") Dosing tank ) 7 a Percolation Test Results Performed by 6L. . tr... � -. ......_ Date___3_ -�.` -11_ Test Pit No. I..... ------minutes per inch Depth of Test Pit......�..____.. Depth to ground water......'�1:.............. (i Test Pit No. -------.....minutes per inch Depth of Test Pit------ ..... Depth to ground water.___-"' ............. Ra --------------------------------------...................................................................................................................... 0 Description of Soil--------- = = = ft x ----- w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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:TTL% p 5 of the State Sanitary Code— The undersigned fu l:er agrees not to place the system in operation until a Certificate of Compliance has be i ued by th Signed.--------•-- ------ --------- -------------------------------------• �� ...,/� Application Approved By------....U."/C----------------------------------------------------------------------------- % ---------- Date Application Disapproved for the following reasons---------------------------------------------------------•-----•--•------------------------••------•------------. -------------------------- ---------------•--------------------------•-------•-------------•-------------•--------•---•-------•-------------•-•---•-••----•--•---...•-•------------••--•-----_...._..._ Date Permit No......................................................... Issued.-----�= Date i Fmpo c.............................. Nc�....................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ............ OF...~. ----------------------------------- ' Appliratinn for Dispiml 19ork,5 Toustrnrtiun thrmit Application is hereby made for a Permit to Construct ( of or Repair ( ) an Individual Sewage Disposal System at: d . b r�'t"` "` ' �- Location-Address or Lot No. 1-!t f .32 . ............................................. Owner Address SZ'!N4:7--------------------•---•---•---•--------- -•-----•-•-------------------.----•--------•-------.------.-------•j:----------•-•--•---•--•-••--- Installer Address d Type of Building Size Lot..... _r .c ,_ __Sq. feet . Dwelling—No. of Bedrooms___ _______S___________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) PA Other fixtures ................................... W Design Flow............. ......._ ..__.gallons per person per day. Total daily flow.................!;!o.--..._...------gallons. W Septic Tank—Liquid ca.pacrty 10x:, gallons Length_ 6" Width.� .t4� Diameter r ,, .. ._.-.._ •. Depth..__,`��_`f x Disposal Trench—No..................... Width.................... Total Length---------------_--- Total leaching area....................sq. ft. Seepage Pit No._---_-_---_---__-- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) { ~' Percolation Test Results Performed b - f_ - = 1,, A ` - } ^a...... Date.... jf j Test Pit No. 1...:Z.._..minutes per inch Depth of Test Pit......X)........ Depth to ground water......_.,o___--_----.- (z, \Test Pit No.2......7_-....minutes per. inch Depth of Test Pit......!` !.;,.._.. Depth to ground water......t.-_------_-. 4e ODescription of Soil-----. -- •----------••---------------Z ----------------------------- •-- ----------------•-- ----.......................... W . M. 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 TI^: " y g g p y S of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. Signed............................................................... ................................. Date � ��C, ......------ --��.el Application Approved BY Date Application Disapproved for the following reasons-.....................'........................................................................................... -------------------------•------------------------•----------•--••--•---••-----------•--...----•---••--•-----•••-------•---------•--...--------•-----•---•-•-•------•-----------•--------•--........... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............O F...�F/. '• ............................... Qwrrtifiratr of Toutpliftanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1-�or Repaired ( ) by.......C/.a O At r.5--------•Ss.A. -------------------------------------------------------------- Installer at------.. rC1 c ------- '��1�r4eA.rj4j` '��` +V/•----- -11t4•......-•----.M 5'°Cana+� L has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit N .3R. -----751V---------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....--•---•---•---•-•••-••-••--••-----.....--•.....:..............••-•-..._--•-•- Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Dispsal- orb Tnnstnutan rrmi# Permission i�/hereby granted----G' '{i f l s ..._.....57-T4',ory� to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No..,,.,0_r....Z-8......�-41eA6-_ -eZ-Z-V......4PA Ve-----------/VooRt.5;;E�/V-jV ..44.14ejr Street as shown on the application for Disposal Works Construction Permit No----_-_----------- Dated.......................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Z60 5F (Is +t 2d- 4 I,o) = _ 288 ew» A co T qlrz.h, - G..-53•Q mop =53 G LOAM T z op Et So-to x . . SJ6rSDIC �1�.AS��! PfSt' I ooa GAS IRV. wd �aM 3 I iuv- BUJ $at< 5a¢ '!�VI iG Rio 51 0 SILT' So.oQ 50• TAh1K. G+2AtJ�, BoTTo M mL'- 41 � of 'pe-op t..EtZTtt=t>=tom pL,.c`�T F�'t._.liu SLa d`L Lo CAT lo� G6S2Ttt=-.j T14A-r TNir F-ow Al7oo 5f~ta�uti,i --AQ TZ�F ctZc►•.1GE Wr-ZZot4 Ccv �pL- -G W ITN ►, Tt-!E ��IUE.t_1uE= LET tip A r> SETV3Acv- K'EQUICSMEWTS 4f= TN - -'O W U otr '#3�zAr7 rA P,Ls E�A ll'� 6o veT Rl.-A W f�0`•.�- DlaTE Il ! '►q � . BQXTCtZ �. uYF i�G_ aE�cs:rc.�z�� 1.Auo SuevcYo�s GL.AW (S WOT BASElD v�-J A�.l OSTE2Vtt,.l C o t1rCp.SS. 44S;rQ AAA- JT SUzvr--`f ¢ Tsar U��;�T; r,�doe+JtD APPt_t C.A.1,.JT D(-- r G.eM s► c- Lo-V U WE; w ' 7-9 -Dr:>Pv5A 4-1 3 Loki o— IN Sol tYI t'U 17p, +� CtjAtt,c 14814,49 43 -. 00 f I�i 1 ryo� 6�2� BORTOLOTTI CONSTRUCTION, INC. 6 Z0130 45 INDUSTRY ROAD,.MARSTONS MILLS, MA 02648 .�til ., 508-771-9399 508-428-8926.- FAX: 508-428-93.99 �S`,UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION Property Address: 73 Date Of Inspection 7 Ins ector's Name: Owner's Name and Address. CERTIFICATION STATEMENT: I Certify that I have personally.Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate`and complete as of the time of Inspection.' The Inspection was perform- ed based on my Training and Experience in the Proper Function.and Maintenance of On-Site Sewage Dis- posal Systems.T e system: i Passes Conditio' Al ses Needs Fu _er valu 'o the Local Approving Authority Failur Inspector's Signature Date: Gd� The System Inspector shall,submit a copy of this Inspection Report to the Approving Authority,with 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.Sy stem Owner and copies sent to the Buyer,if applicable and the Approving Authority, INSPECTION SUMMARY: A) SYST�1 PASSES. W I have not found any Information which.indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES;: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection.` Indicate yes,nor,or not determined.(Y,N,OR ND). Describe bases of determination in all.instances. If"not ,determined",explam'why not: The Septic Tank is..Metal,Cracked,Structurally Unsound,shows Substantial.Infiltration or exfil- tration,or Tank Failure is imminent. The System, will Pass Inspection if Existing Septic Tank is Replaced with.a,conforming Septic Tank.as Approved by the Board Of Health. Sewage Backup or Breakout or High Static VVa.ter Level observed m the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): -1 _ 1 t `. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION (continued) - Broken pipe(s)replaced Obstruction is removed -Distribution Box is leveled or replaced The System required pumping more than four times a year due-to,broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): Broken pipe(s) are replaced Obstruction is removed. C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board.Of Health in order to determine if . the System is failing to protect the Public Health,Safety and the Environment. 1.)SYSTEM WILL PASS UNLESS BOARD OF HELATH.DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy U within 50 Feet of a Surface Water Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a Septic Tank and Soil Absorption System.and is within 100 Feet to a Surface Water.Supply.,or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil.Absorption System and is with a Zone 1 of a Public Water SupplyWell. The System-has.a Septic Tank and Soil Absorption System and is within 50 Feet of a.Private Water Supply Well: The System has a Septic Tank and Soil Absorption System and is less than 100 Feet.but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for colifo.rm bacteria and volatile organic compounds indicates that the Well is from pollution from the facility.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 0)SYSTEM FAILS: I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified .below. The Board of Health should.be contacted to determine what will be necessary to correct the failure. , Backup of sewage into facility or system component due to an overload 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 clog- ged SAS or.cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day now.,. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion.of a.cesspool or privy is within 100,Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a Public Well. Any portion of a.cesspool or privy i.s within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 1.00 Feet but greater than 50 Feet from a private water supply well:with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria.,volatile organic compounds,ammonia nitrogen and nitrate .nitrogen. E) LARGE SYSTEM FAILS; The following criteria.apply to a large system.in addition to the criteria above: The design flow of a system is 10,000 ggd or-greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface.drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen.sensitive area.Interim Wellhead Protection Area .(IWPA)or a.mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check ifthe following have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health. ✓None of the system components haye:been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been. introduced into the system recent or as part of this inspection. ��As-built plans have been obtained anal examined. Note if they are not available with N/A. j. The facility or dwelling was inspected for signs of sewage back-up. =The system does;not receive non-sanitary or industrial waste flow. _JzfThe site.was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid; depth of sludge,depth of scum. /The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - • s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: ,� 99 Design Flow gallons Number of Bedrooms:_Number of Current.Residents: 2)gza JL)41 Garbage Grinder: Atir' - .Laundry Connected To System:oz,,L Seasonal Use: Water Meter Readings,if a ailable: Last.Date of Occupancy. fh4npJ7l P C � COMMERCIALZINDUSTRIAi •�� Type of Establishment: Design Flow: gallons/day .Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: c� System Pumped as part of inspections/ If yes,volume pum ed: gallons Reason for Pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow.Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APPRO M TE AGE of all componen ,date installed if known) and source of information: Sewage odors detected _hen arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: / Depth below graded Material of Construction: +� concrete metal FRP Other (explain) Dimensions:5,,,5"X&ry V Sludge Depth: Scum Thickness: " Distance from,top of sludge to bottom of outlet tee or baffle: Z� Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,conditi -in of inlet.and outlet tees or baffles,depth of liquid level in relation to out t invert,strucntegrity,evid nce of lea age,et .) AAr / Z2o' GREASE TRAP Depth Below.Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation.for pumping,condition of inletand outlet tees or baffles,depth of liquid level in relation to outlet invert,structural,integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete . metal - FRP Other P (explain): Dimensions: Capacity: gallons Design Flow. gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: >/ _ Depth of liquid level above outlet invert: &L4 L-1 Comments: (no f level and distribution is equal,evidence of solids carryover,evidence of 1� .akage i to or out of box,etc PUMP CHAMBER:ZAQ�_ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive methods) If not determined_to be present,explain: Type. Leaching pits,number: Leaching chambers,number:__6?_Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: C mments: (note conidtion of soil signs of hydraulic failure levej of ponding,condition of vegetation etc.) CESSPOOLS: /6 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; Materials of construction: Dimensions: Depth of Solids:. Comments: (note condition.of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) :. . I - 6 - cw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH Of SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. i 5 3f DEPTH TO GROUNDWATER: Depth to groundwater: Feet © Method of Determination or Ap roxi ation: 10X)m-,?S�d �® ��✓� � �? 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I • ,. - -,.: .._._, , r ,. �._. � , ; �s: ..• .« v!A1:L.S.r.wlNcoJ72,tteTL}L D RAWIN6 NUMBER . � - .� 1:_ .-'. 1 :. ^ . - ° "' ;: - - ;i.,Fc-. --— -�b.E51 tiC,.._�:_��:_ .�Y.AINN tS �i�b• • .gym • 3�.1 ! t f6 '' � ��' � tvKf1 WA�J,• R_4tsT. ov • - r r'w N r f•r lor�4 SCALE: ILO APPRDVEO GATE: •.. '.;b, �. ,.,' s -:' :,- ...... a... ,_ -_' .,. .,.. -:. ., r ..�« a--ri ,.. .. .. '.r ..,. rc -� :;;5 DRAWING NVMBER�,. a n . - - _. _ , .I, '�j.I...._.__I#�,,a�j I III.t e.j.I�I....oA�1'�W.I.' TYPICAL 1000 GALLON SEPTIC TANK �I i./1Ii o.�IL"A.IInI I I-I'-T I IT II I IIlA eI I..sI...j,I\I�I)t L1I�:.-,I'L--..I,�I,I,''.�..J.�I--_I I I�1 I��I_N.I,.I,,:,'j.�0 IA I.-r.�(R1-I�-II.\Y�8I .�.�.!',5_.I,_I..-� . c II-,I AFjjI.p... 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I�I I , I I I,�jIr1.-..�I q 1-,II I�.I,.�.1IIi:I�I�-_�I.:I,,I.' . SECTION A A , rI.I I1 I;.L�',,..I .�.1I�p,I,.11I-�I.jI�.�I:.I�.II�:�'j�,�..-,I11 j,.1I.j' j,�I..--..,:I,I1�4�I�-I.1�j'.��jI- I�.�iI I�I-I I�.I ��, I.J.,j�I_-,.,.1 1,,;'�,�II q. .j,II 1.�-;1IjI,1I �I , a- ,w�,,„ NOT TO SCALE .c-. .. ', l R C SYSTEM " OF ADDITION TO LEACHIN . e VENT PIPE O Least 24 Inches tall PROFILE VIEW I NOTE. ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. (( ) Schedule 40 PVC w/Chorcoai Odor Filter " 2-18" DIAM. ACCESS MANHOLES : m - r. , ;,, J% 10 min. from " Wit' , ��" '"' '.: 7 r, •S ., yin+-'"RIP i �.- house to septic tank 3" of 8• - 1 2" Washed Peaston B' „ ,_ ,, Existing Foundation 1/ / »z, �*:,'_ - �4 _1 �."�,. -- ,•r : t:. Septk tank coven must be iq»o , . .....t. »r __. s ,. T.O.F. slev. - 100.00 hin 8 n. of finished rode over SA3- 100.00 3/4 to 1 1/2 Washed Crushed Stone „• r. •,, a:..,, +_,: .-�h•.. r, : . -I ` •, ,: :+'.•'j< .:.: r, - wit i 9 Crode oNer D-Box - 10000 b•.(• .• ••t_�'.v..ri.9_a:`'. `•.r.i. v c. -K.. � .d .rode over Septic Tank- 99.00 < .x. c •ri ,,r>.' �I - \mil-Grade ' _. ., , +i..«.'ayWy -.:.::... _,.. ., __I'an, - `-ti/""I � .j _ - ` 4 PVC CAPPED INSPEC110N PORT TO BE o AN WITHIN 6. OF GRADE y I r{ t� '7 > 4• Viz, .. "'r G :,O"' piSTA11 rn D TD 4,1 iR A M �. �d -i.{t�� r . Top Load- Elw. -96..75 1 -11 t . �`'' s ao2 6 HaIE T of SAS- Eiw. �06.60 o y (H-20) DIST. sox pJLET - 4 4 .:, :- L r -. i s=o.o .� . .,; . .�, t 1 or Greater oU r5l� w.::,-x �, :,,.i3�"e_„.z c' `' r ,,_ - EXIST, PIPE V) '7 EXIST.11,000 GA 0" EHectM Depth . s .w �t •ry "-. ` FROM FOUNDATION 5R _ ( 1p__, .. a,;, i I U. K SEPTIC TANK O rA 20 7 Unita t? 5.25' _ 44.00 THE ACCESS COVERS FOR THE SEPTIC TANK, , ,,, :-1c • ' 5 .. , H 10 V11 r o o ON aX AND ACHING COMPONENT -14 - 9i -.`f � � . q ,q a.D.M. p DI$TRIBUTI B LE 5 :.to s a iti�t . , rsn. ,: • r 0.83 10 Inches +-.•R- r- tl I ) ,r;,+-c ^� T"•I--•R-" .,� ti , SET DEEPER THAN B INgiES eF1ow FINISHED g ,..,.., r . CONCRETE FULL FOUNDATION o I r 0) Q5 ( 4' 6 _,," ,4 'y r,''• r GRADE SHALL BE RAISED TO WITHIN 8 OF, ,.'-^ �9" 'Y +�. y�N_ v u °' tl o' Fl►NSNED GRADE ♦t rwa'. 'K � ` j j II 0 STEEL REIINFORCED PRECASt CONCRETE m ws�w+ <, eltrs *r«e. �.., SYSTEM PROFILE d z o A o' EFfecttve Length INSTALL TUF-TiTE GAS BAFFLES OR EQUALS . a IPLAN VIEW . II-III:1- � A . NOTES , :I""-�.II- .GENER L _ Not to Scale i '. ,J > j t 4' 4' li SOIL ABSORPTION SYSTEM (SAS) .• _ 0-I c c « 1`7•� i ' 3-•24 REMOVABLE COVERS { 91 a 10 u 11 0 # 1. Contractor Js responsible for Digsafe notification r fin` 6 In.of 3/4"-1 1/2" Effective Width (S �' »j • : , 4' •� '' • ' • %.;. and protection of all underground :utilities ,and pipes.II^- o Ve compacted stone O .1' • :.. p Y! Cf O m INFILTATROR HIGH CAPACITY (H 20 LOADING)/'GEORGE O BRIEN • ?' ,r I 2. The''septic„tank one:distri Lion box shall, be-set 4 I/" - Q Bottom of Test Hole 1 Elev,-89.00 3 imtn. dearmu c, I ,, '� OR EQUIVALENT) Not to Scale IN,E s• miT. 2• min. Inlet to cutlet e.m,� .i level on 6 ,of 3/4 -1 l 2 ,stone. `ti S In v Obs. Groundwater - Test Hole 1 Elev.- NONE OBSERVED otLTLEr ' ^ " i taf�dre,,r- 3. 8ackfill•'shouldwbe clean sand or grovel with`no' Y I ( � ,U,U NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18 /EFFECTIVE HEIGHT IS 10 ,o•min. ,�. stonts over 3 Itl site, er- �� VJ& ,Q s' -7• .11 is s' -T 4. This system is subject to inspection during installation _ Vej '' Ef ",• 4'-0• min. by Carmen E. Shay - Environmental Servlces,;lnc. w Oa j• Uquid depth bo 5. The contractor shall Install this system in accordance , A COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE °"F . ~ with Title V of the Massachusetts state calla, the approved plan NOTE tl , J and Local Regulations. ' " �•f i•M•I '•L.♦N�L 1",t.. .•%J\ : ., .fir . , . .. •, FOUNDATION 1' --� SEPTIC TANK ----48' D-BOX ° .* 20 - LEACHING FACIUTY e'-o• +'-10• 6. 1f, during Installation.the contractor encounters any • CROSS SECTION END--SECTION soil conditions or-site conditions that are different -�- from those shown:on the'soil `log or in our 'design ., installation must halt & immediate `notification be . made to Carmen E. Shay -, Environmental .Services, Inc. ,�.,1- 7. No vehicle_ or heavy machinery shall drive over. the I septic system unless noted os H-20_septic components. I 1j1 8. Install Tuf--Tits gas baffles or 'equals on'oll.outlet tee ends. I 9. All Distribution Lines shoil.be 4" diameter Sch. 46 NSF PVC pipes. i 10. Ail'solid piping, tees & fittings shall be 4" diameter �� PERCOLATION TEST Schedule a0 NSF:PVC pipes with water tight`taints. '�� 11. MUNICIPAL WATER NOT AVAILABLE AT SITE and Surrounding Properties �) 3�, - DTest Performed tBly CARMEN AE.USHAY 2004 EXISTING WELLS WITHIN'150 FEET OF SAS AS'SHOWN ON PLAN. R,S. C.S.E. OF 3�P �� `\ Results Witnessedl By. WAIVER per BARNSTABLE BOH .'� �� Excavator. Robertts Septic Service FIG 1a '' �\ Percolation Rate: Less Than 5 min./inch ® 63" BELOW GRADE. - I /% z O FOOD ,'� O� \' -100 ____ -� TH PROPERTY LINES & WELTANDS ARE APPROXIMATE AND - !,1�',�II l7 CB D.H. Test Hole COMPILED FROM THE SURVEY PLAN,GENERATED BY ,� �i, ` 102 185� FND �,I' No. 1 BAXTER & NYE OFOSTERVILLE, MA,' DATED 11/1/79 Y �, /, _DEPTH SOILS -ELEV. ENTITLED " CERTIFIED PLOT,PLAN OF LOT 28 EVERGREEN .DRIVE, �Ie . , , / 0 101.00 BARNSTABLE, MA; AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN ,�'' j % Loamy Sand THE SEPTIC SYSTEM INSTALLATiONRPOSE OTHER THAN .. I... j�j I I I,I..II I�I-I I��"-.,.j I.,.�-�I.�I�I j III,I.I-I�-j j��..I. I'�I I jj�j II I 1��I,..�I_�.II�I91I��k 6.1 1�1-�I�0 N�I-�I1l,1tjI�I�I l\�zII p�j�\�I 1t�.I 11f 4\6\-'\t.-i,l/IiI 1 I II\-V I\I j\.�.I II�..j 1 1 IIr I I.I I 1I 1 j I..,.\..I."If,.I,I.Ij I.-j..I I,'IzII..��,j�1-I�1�III I_II.I 1I j47_,./.1 I�I�_�II�-I.I.�1b I-.I-I./,i/.I-I 1...1.-f I,,f.-I1-., , d / / ,,v /,r // Loamy San .. 41. 5' , LOT #27 - / WETLANDS LOCATED WITHIN A 200' RADIUS OF.THF.,SAS ARE AS SHOWN. I �' , , a"- 38• 8,i 8.00 L. 1 " / SILT LOAM I 4 PVC / i,1. 1 i : NOTE: ANY``STRIPPED OUT SOIL CONTAINING LEACHATE . .', \ Vent Pip / 1 PROJECT BENCH MARK , /Ix\ 4 ,, 10 36"-60, C, 96.001 ;FROM THE, EXISTING SEPTIC :SYSTEM :TO BE. DISPOSED \ , 0 - / TOP OF FOUNDATION �� `. \ %. , -�" `j = 0.00 Assumed Med OF AS PER BOARD OF HEALTH SPECIFICATIONS. �,, . \ o ; ' r ELEV. 10 ( ) Sand 1, % / TEST HOLE 1 �,,,,, , o / +'"i r EXISTING SAS TO BE;PUMPED: DRY & " `� � / ELEV.= 101.00 • \i''tt>k , _- ° , -,.,, , REMOVED TO FACILITATE INSTALATION OF NEW SAS '' �" \ 'j a d ti e -144 C: 89.00 60' �' h +'�4 .L dui' _ ,�.. _ :-. - .. • 1\\ \\ < _ \ \ 'r'j�.a ' r '' ASSESSORS MAP _ :125 PARCEL.- 066 \ \ I ��_- -,- "-.`�J11" S,�,j+1 r r, \ i th \ � ♦ . , O t \ .- I ----- \ _� i ZONING, RESIDENTIAL - . \ N Perc #1 . •O \ / I \ -•<-_ ram` ----------�-~' I \ _ _ • De tli to Perc: 62" tto 80" O. / . I \ N > P ,, . ; 1 _._ in imch ,» , - - - - - - t \ Perc Rate <5 m --- - __ CB D.H. : 1 f s. -- - - _ - _. - __ __�_. 4 �_ '--: _. Groundwater Not Obsierved , ;.. I_._-_-- _.__ _i_.- _ --- _ -. �-.__=FND_ -----_ __.�. .__-- _ _. / i >: . _ . i + \ \ , r'' 144 WETLANDS LOCATED WITHIN A 200 RADIUS`Oi THE SAS ARE AS SHOWN. 1 I 1 BOTTOM OF TEST HOLE Elev .1 { k 1 r 0 1 c> \ I i I 1 � ,o ADJUSTED'H2O Elev. No Adjustment Required O, - U, i I I i I Lealch\TRENCH \\ (� 1 \ o D I \ ,, \, \ DISTRIBuTTnON BOX SHALL. BE le CONCRETE COVER L E G E N , I ALL OUTLIET PIPES FROM THEE 1 i I 1 �' I �1ST. 1000 qaL \ SET LEVELL.FOR AT LEAST 2 FT. I - I I / I `^ •. . I. e - S"OUTLET " .v', .a,.+. y 1 I i i i septic Tank \ KNOCKOUTS 8X0 DENOTES PROPOSED f I I i / \ I 1 16s• OUTLET '4 (-' I 12• INLET SPOT GRADE ( , ( , I \ / DENOTES (EXISTING O I \ , ( \ :. ,- �: s' �.� . ' 2 X 104.46 1 \ , , . \ I / \ / I HOUSE #17s \\ 1a5• i.7 - SPOT :GRADE ( \\ (i / `' ; l( `:. ) i •c!\ PLAN-SECTION CROSS SECTION PL PROPERTY LINE I � I / � . / EXISTING I / s :` I f i / 2 BEDROOM \ \ (( J,r // - /► -- �? HOLE H--2O DISTRIBUTION BOX PROPOSED CONTOUR f \� r ,/ % HOUSE ( ' NOT TO SCALE f / \ % / <i / / 1t / -CT, ( ( , / % / / / -97- -- - -----97 EXISTING CONTOUR , r � /' // /i i cfl6,\/ � * cfl DEEP TEST HOLE & / • ; /' � / / `� °' i n Calculations CATION :. / , _'_-_ /, / / Des q PERCOLATION TEST LO / -.1 / / \ ,. / _ C-1 NCE . / / 1 Number of Bedrooms. 2 , Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V) ! ----r FE . q . O , �,� i .1' \ Garbage Grinder: No ( n , i ,!MU c t� -r^ M�XrMvM F \ / -- ( � Leaching Capacity Proposed. 440 'Gal,/Day Minimum 0,V* f^ �1 7 y - / I N WAT R :_WELL -,. / LOT #28 .• _ PRNATE DRINK( G E / �' / / 1 / Septic Tank . 3 x 4410 Gal. ay= $80 USE EXIST. 1,000 GAL. Septic Tank. p :- -- cP P B���OtlM S on� - 0 - , y •o / 53,320 Square Feet +/- I / SOIL ABSORPTION AREA: Using percolation rate of <'2 min./inch / O 0 I Bottom Area: 0.74 al s . ft. x 500 s . ft. = 370 gallons ,, PORCH Gj , C9 / q q REVISIONS O 1 , ►% /'O Sidewall Area: 0.74 (gol./sq. ft. -`x ` 99.6 sq. ft. 73.7 gallons . . I / Providing: = 443.70 gallons - y DATE: . i , I4� O N0. DEFINITION ,, r A i / / I AP CITY H-20 UNITS HAVING A b.83' 10 INCHES EFFECTIVE DEPTH /, - i B D.H. / / Use. (7) INFILTRATOR IH GH C A ( ) r 1 <: / TH 4.0' 0 WASHED STONE ON THE SIDES AND 3' OF WASHED STONE O , / r , r TO BE USED WI OF WASHED �, / , r / / , ON THE ENDS. NO STONE 'UNDER. st Caw i / l r 1 9Q+ , I i i / I / / I c3` , , , . S, / 0 1 / / / d / 0 I �O I i / ,� x .,, ' 04 . ( 4 1 / / _ , _ , / \ �� I / /r LOT #29 i � 4 i / r / r / 1 /'�,� . 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