HomeMy WebLinkAbout0063 ROSELAND TERRACE - Health 63 ROSELAND TERRACE, M.MILLS
A=
TOWN OF BARNSTABLE
LOCATION ���,�,�L Ti 9t� SEWAGE# OZO/l,-14T
VILLAGE ASSESSOR'S MAP&PARCEL I o3—/,2 7
INSTALLER'S NAME&PHONE NO. �Z?y gyc
SEPTIC TANK CAPACITY
LEACHING FACILITY.(typeV,,!2/ ,,4/, 70)6 GJ (size) /Q .iC To "C.7
NO.OF BEDROOMS
OWNER 'TG'E'e/
PERMIT DATE: 1`/S•% 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 existwithin
300 feet of leaching facility) Feet
FURNISHED BY oe
Lt
771�
No. - I j V � -/ 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye—,
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplitAtion for MisposAf bpBtem Construttion Permit
Application for a Permit to Construct( ) Repair(V� Upgrade( ) Abandon( ) ❑Complete System 211ndividual Components
Loca on Address or Lot No_117 ./ ��Jr�pl�- toA", Owner's N ,Address,and Tel.No.
Assessor's Map/Parcel j^�r s /fjJ n��
Installer's Name,Address,anyd Tel.No. Des' ner's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms _Lot Size 1014,21 sq.ft. Garbage Grinder�Z&
Other Type of Building ,5 ZDG No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.requic d) Q gpd Design flow provided 3 Yl .J; gpd
Plan Date Number of sheets Revision Date
Title leMeMov,
Size of Septic Tank_ /��91fX%5 Type of S.A.S. f
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 He th.
Signed Date / `o�
Application Approved by Datej
Application Disapproved by Date
for the following reasons
Permit No. Z/p — I Date Issued l _
lf -s,.n^^.-•-'`-w,r-..».h f�,y jl,,"'�{,,...area.-a.t.+�+�-'y,,-r^r»««..�.r..�.+�r•.--. ._ ... _ ♦ va..-+-w„K::•-�- +*+. -..._... ».
41, �tl
No. 0'
l/ 1 "1 � Fee
THE COMMONWEALTH OF MASSACHUSETTS- Entered in computer: /
'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ; Y
2pplitatlon for -Misposal 6pstem Construction permit
Application for a Permit to Construct( ) °Repair({/) Upgrade( ) Abandon( ) ❑Complete System 2 Individual Components
Location Address or Lot No./ ll��ce� � �'��'f; Owner's Nam ,Address,and Tel.No.
A�ssor'sMa/Parcel (, IE
p rlf�°�'s7��.� �ilr//� _.,..
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
7 71-
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 3�s /c9-5 sq.ft. Garbage Grinder
Other Type of BuildingP,g//? f7� No.of Persons Showers( ) Cafeteria( )
Other Fixtures r
Design Flow(min.required) 4.3/) gpd Design flow provided 3 �,3 gpd
Plan Date y/i'_/-4 Number of sheets Revision Date
Title
Size of Septic Tank lel�D ao/ I-xI5,77 Type of S.A.S. !./— 3�$� �ij}�/�}�/��®/'.S
Description of Soil A9 IV Tj�
At-
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 ; � v "''---"' Date
Application Approved by C� S Date l
,r
Application Disapproved by Date
for the following reasons
Permit No. Q6 �- J y j Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certifitate of Compliance
THIS IS TO CE TIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(1-r Upgraded( )
Abandoned( )by er „//'
at_y Zj '0 Sj='x5,->yV"0", jQ rl�Q'C has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. )U/o - r Y 3 dated t; l �'
Installer , gf/0/z7/)y �, 'f` Designer AO,/2v,# e l e
#bedrooms Approved design flow _ () gpd
The issuance of this/permit shall not be construed as a guarantee that the system will funct as design/.
Date ��•J (I Inspector_ (J�(� ✓
+No. C)" CJ� /c/.3_�___...4.._,.. .�__�._,___�--_--------------�---------__�_..._,_�.__-•----------_._-Fee
`_
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposar bpstem Construttion J)ermit
Permission is hereby granted to Construct( ) Rep it( y Upgrade( ) Abandon( )
System located at �r
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit..
Date � //� Approved by
FROM :down cape engineering inc FAX NO. 2Speo Jun. 09 2010 01:17PM P1
Town
k� } fu(arv��ns 91'. Geffer. Ph-e.00r
k RWRN9'PARTd�,J�
nears// 13'A1��R1ltG �a,'.�tll��7 �};n�n�flQ1IIn
Thmn as Mn!.11 emn,Dilre doir
200 Maine SO.rP0,Hyisuluui`i,MA.WWI
Office,; 508-862-4644 Fix.: SOS-i90-b30
�nn.s�t�llle>< 1[DesiF r.�>p>s catoa>na Form
Date.: � ./ ./� �e�v:t�;e.�erum�id� �� �f�� la.suess�lr's T��o Il'�n ea l< IZ
Tesigner, v4 v� ,
{ � /1�1►'1 11151.1flea•: 130 0�
.Address: ��� �OLi r. � l Address: -0- 40)6
4q V/
C)n. 1r���� �
� was i sti ued a j?e1l'rl7it to iris
(date) (1flSt7Q,(.GA'�r
septic system at 3 koSe�CLyIGC
based oil a design drawn by
(,address) -dated Ll—2-1—IV
(cicsi. lcr) -
-- 1 certify that the scpti.c system referenced, above w;-is installed su.bstanti (fly according to
the design, which may include rninor approved changes sraell as late,-, 'I rclocati.or,. of the
distribution box and/or septic,1111c.
T Certify 111.9t the scptie systrmi referenced above was installed m1h iiiiijor changes (i,e.,
t;,re7.teF. t11,9.J1 10' lateral relocuLion of the SAS or any vertical of a.(ay C0111-9o]:1Cnt
of the septic sy5ti.rri) brit ill a.coardanc;e Zvi tb. State Local Regulations. Plan .r(,visi()n.va'
certified its-built by designer to lullow.
;': fir+� , qs
{: QANIELA, tip
S�
rlrlst� s�iignature.) r rA i
_ 46502
, w
(Desig,nefs Sigrlaturc,)l� (Affix Desigml rls S({.nip 1je.r6)
)d t,. ,.A6P 1CaT��i'CnM TO B AY�NS.i:,1_IL :_ i`i!:aJGnT' HEALTH i),i_VINJ.UN.�EIItTWICATdt, QDF
1 .1111A :la LI, WILL N011 im SSPED 1J,�.g-`D., .30'1;ia. THIS FORM' AND tlS_13UILT CARD 0RT,
DB�C'T�T�&T?1R4�TpTlf H�1t1�4�:t'rAaJA.,1L 1"�,&;�i�i 'Y_i ,.AeD.:A'1A IlDHY➢ Jd�11T. if h?f�AllTlf 9i'6�t .
0:11ea111i/SejAic/rletiijper(',erliFiUA i0Tj T'orm a-)(i-04,i1oo
fit'® o Barns
P#
1Depactinpiat of Regulatory Services ) /®
L BARNT MIL.F 4 IP1_bfic Health DiAsion Date
200 Main Street,Hyannis MA 02601
• �PEp MA'S P � .
Date Scheduled
Time Fee Pd. Q�• l/!�
Soil Suitability Assessnienrt for Sewage
n ,
Pcrfonned By: �Cc, Witnessed By.; t 1ni
LO CA'PION GEA NT'M4 IL INF ORIVdA'1 ION • u
!� /J�e /� i Owner's �j
Location Address Name
lJ �\ ( / -
M - �1 P Address
Assessor's Map/Parceh /c� Cugiueer's Naiue ( `F�d 0) �1
NEW CONSTRUCTION REPAIR Telephone If 'J G a 15
Land Use. D,A �vQ Slopes(%) y—,�—�70 Surface Stones
Distances from: Open Water Body fl Possible Wet.Arep N/ — ft Drinking Water Well ft
Drainage Way M _ ,_ft Property Line �Z fl Otlter
SliiETCHG (Street name,dimensions 0f lo(,exact locations of test holes 8c pert rests,locate wetlands h 6 n proxinuSy to holes)
�v5,e
Co
7 r5 �
CQ
ti
50
'a ( 00
Parent material(geologic) Depth to Bedrock, JVO�
Depth to Groundwater: Standing Water in H01e; NO /'V� k.. Weeplhg I'miil Pit PANe IVU
Estimated Seasonal High Groundwater- /" "9 UJ!R
DETE 1�iA7CION FOR SEASONAL 111011 WATER TABLE
Method Used: —
Depili Observed standing in obs.hole: In, Depth to 5911 Moltlisl h),
Depth to weeping from side of obs.hole: _ in, Grtlulidwuter AdJUSIMent.e
Index Well f# Reading Dale: Index Well level ALL1,faethr_y �_ Aeil.Crtaundwater UYLI
PERCOLAT10i ,Irs".r -- irate. 'role
Observation
Holt## Time.at 4°
Depth of Perc Time at 6"
Start Pre-soak Time @ � _ Time(9"-6'7
End Prc-soak �U
Rate Min./Inca
Site Suitability Assessment: Site Passed_X Sit.,,Failed: Additional Testing Needed(YIN)
Original; Public Health Division Observation Hole Data To Be Completed on Back------Y__
**q`If percolation test is to be conducted tivitiiiil 100' of wetland, you njutsit first Uotify tine_
Barnstable Conservation Division at least one (1) vvee➢c prior to begin hilig.
QASEPTf0PERCF0RM.DOC
ON
TI—OLE LOG
Depth from Soil lfarizon
Surface(in.) Soil Texture 5di1 Color
(USDA), ' Soil Other
(Munsell) Mottling (Stricture,Stones;Boulders,
— --- S,/ 'Z/ Con istenc % ravel) _
L_-.
CU
I
AG ro
S Z S
y
w
R��ip �T,p ray
RR
Depth N I p from soil Horizon ®g'� �'®dryer Role# 7j
Surface(in.) Soil Texture Soil Color
(USDA) Soil Other
(Mansell) Mpttling (Structure,Stones,Boulders.
Cons! enc %Gravel
�G Y/LW
Depth from Lvc .
)DEE1 P OBSE V-ATTON HOLE, LO Soil Horizon �j[®]�#
Surface(in.) Soil Texture Sail Color
(USDA) Sail 1 Other
(Mansell) Mottling (Structure,Stones,Boulders.
Cc si tc c O vel
a
DREPOESERVATIONTIOLE
Depth from Soil Horizon �'®�'! Hole#
Surface(in.) Soil Texture Soil Color
(USDA) Soil Other
(Munsell) Mottling (Structure '
Stones; Boulders,
Cons' ten o
a I
I
1190 l InSUrance)fate Maw
Above 500 year flood boundary No Yes
Within 500 year boundary No
- Yes
Within 100 year flood boundary No y65 T^
Deitatfm ®� t'P+t—oteurulPV 0c_ C!1—r r1l ]EnOviousMMaterial
Does at least four fe0t of naturally occurring pervious material exist in all areas observed throughout the
al,ea proposed for the soil absorption system? :Lam'
1`l'not, what is the depth of naturally occurring pervious material?
tC'e�te—�c1921on
I certify that on .
cf( ate)I have passe
d
1 the sal evaluator examination approved by the
Department.ofEnvlronmental.PrOtectiOl7'and that the above analysjs,was performed by me consistent with
the recloired training, expertise and experience described in CIO CMR 15.017.
Signature
Date
"w. Q;\SBPTfC\PERCEORM.DOC
TOWN OF BARNSTABLE
LOCATION � ���—��� �� SEWAGE #
VILLAGE d2h&i�= /2Z& ASSESS?� R''S-�MAP & LOT
NAME&PHONE N i
SEPTIC TANK CAPACITY I6019 lne —
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER O OWNER
PERMITDATE: COMPLIANCE DA :
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
o�5
I .Q
r_
.,, - .• ... _ of � �\
E
iJI AY 9 2000
+ iBi.L
HEALTH
NEPPT
{; BORTOLOTTI CONSTRUCTION, INC.
45 INDUSTRY ROAD, M ARSTONS MILLS, MA 02648�
508-711-9399 508-428-8926 FAX: 508-428-9399 -•''
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: CJ/
Date Of Inspection s Inspecto 'ti N e:
Owner's Name andAddress:
CERTIFICATION STATEM .NT•
I Certify that I.have personally Inspected the Sewage Disposal System at this address and that the Informa-
tion reported belowls true,accurate and complete as of the time of Inspection. The Inspectioln 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
Passes
Conditional) asses
Needs Fur Evalu o By.the Local Approving Authority
Failure
Inspector's-Signature Date:
TheSystem Inspector.,shall submit a copy of this,Inspr etion 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 000,000 gpd
or greater,the•Inspectonand,the System,Owner shail,submit.the Report to.the appropriate Regional Offie of
the Department of Environmental Protection. The Original should be sent to the System,Owner and copies
sent to the Buyer,if applicable and the Approving Autlliority.
INSPECTION SUMMARY•
A) SYSTE PASSES;
I have not found any Information, !rich indicates that the System violates any of the fail-
ure criteria as defined in 310 CMI' 15.303. Any Failure Criteria not evaluated,are indi-
cated below. -
B) SYSTEM CONDITIONALLY PASSES
One or more System Components ue-ed to be Replaced oriRepaired. The System,upon
completion of the Replacement or Repair,Passes Inspection.
Indicate yes,'nor,'ornot determined(Y,N,OR ND). Describe bases of determination in all instances. If"not
determined",explain why not.
"'The Septic Tank is Metal,Cracked,Strut,turally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is iburninent. The System will Pass Inspection if Existing Septic Tank
Is Replaced with a conforming Septic`l imk..1s Approved by the Board Of Health.
Sewage Backup or Breakout or High Staiac ter Level observed in the Distribution Box is due to
" ' broken or obstructed pipe(s)or due to,a broten,settled or uneven Distribution Box. The System
will pass Inspection if(With Approval of the Board Of Health): `
-1 -
�r k7xy �el i rk : ¥ ;t`tt 44t�is;{lSy`? 7?r5, jsa ' rac;tiF
"€ b� "i AL
r r A, I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A'
CERTIFICATION(continued)
Broken pipes)replaced,:
Obstruction is"removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)-are_replaced
Obstruction is removed
C)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 BOARDt OF HEALTH,DETERMINES THAT THE'
�11;;SYSTEM",LS,NOT FUNCTIONING IN,A.MANNER,WHICH WILL PROTECT THE.
PUBLIC HEALTH AND SAFETY.AND,THE.ENVIRONMENT: ,.
. Cesspool or n is within SO.Feet of a surface water.
Cesspool or privy is within 50 Fee
privy' t,of a bordering vegetated,.wetlandjor ksalt marsh.
2)SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC'WATER
SUPPLIER,IF APPROPRIATE).DETERMINES THAT THE SYSTEM IS`FUNCTION-
ING IN A MANNER THAT PROTECT: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 I of a public
a ? water supply well.
The system has,a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has aseptic tank and soil absorption system and is less than"100 Feet but:30
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and_volatile;arganic compounds indicates that the well is free from pollution from r
the facility.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or,less'a'
than:5 ppm•
D)SYSTEM FAE S:,
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 overloaded or clogged SAS
or cesspool.
4 Discharge.ouponding of.efluent to:the surface of the ground or surface waters,due,to an ,rc°
- overloaded or clogged AS or cesspool
:'.Static liquid4evel,in the distribution-box above outlet invert due to,an overloaded or clog
gj � , 1;: .ged SAS or'cesspool a' r.1 1 ,! r r •.f 4 -
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
Required pumping more than 4 timed to the last year NOT`due to'cloggedor obstructed
pipe(s). Number of times pumped. ,
2
i
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 I-of a public well.
Any portion of a cesspool,or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
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 gpd or greater(Large System)and the system is a significant
"threat'to public1liealWand safety and the environment because one or more of the following
conditions iexist: .:, .
The system is within 400,freet 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 1I of a public water,supply well '
The owner or operator of any such system shall bring the system and facility into full compliancemith the
groundwater treatment program requirements of 314 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'!f!e following have been done:
V Pumping information was requested of the owner,occupant,and Board of Health..
=None of the system components have been pumped for.atleast two,weeks and the system,has,,
been receiving normal flow rates during that period. iarge'volumes of water have not been
introduced into the system recently or as part of this inspection.
T/ As-built plans have been obtained and examined. Note if they are not available with N/A.
V 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:
system components,excluding the Soil Absorption,Systetn,Mve been located on site.
The septic tank tt►anholes were'uncovered,opened and the interior of the septic tank was in-
spected for eonditioti of baffles or tees,matnrial of construction,dimensions;depth of Uquid,
e
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-
X i
•s �a � r i '�t ik�4;�. i'
L ,.
;`SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
k "YPART 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 C
SYSTEM INFORMATION
/ FLOW CONDITIONS
BE5 ✓ `
Design Flow: ,3�gailons Number of Bedrooms: Number of Current Residents
Garbage Grinder:,/ !?' Laundry Connected To System:(dQa Seasonal Use:
Water Meter Readings,,if Table:
Last Date of Occu RCIAIANDITSTRIFALo
Type ofFstabhshment }. �{
Design Flow sallons/day,'Grease Trap.Present:(yes or`no)' ' '
Industrial Waste Holding Tank Present
Non„Sanitary Waste,Discharged To The Title V System:
WaterMeterReadings,If Available: Last Date of Occupancy:
OTHER Describe)
Last Date of Occupancy:
GENERAL' FORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection• If yes,vol me pum onsx
Reason for:pumping
TYPE F SYSTEM-
,Septtc_Tank/D�istri ution Box/Soil Absorption System
$ingle'Cesspool",t
,Overflow Cesspool,
Privy t
Shared System(If yes,attach previous,inspection records,if any) :.
Other(explain)
AP PRO E. f al.,comn(wents date'nstalled- if known and source of tnformatto�t
y , -09
Sewage odors`detect ' when arriving"at'the sit
-4-
l`
Rx # -r v
SUBSURFACE SEWAGE.DISPO.SAL'SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: t/
Depth below grade: ��9 Material of Construction: 0 Concrete metal FRP Other
min
Dimisions: Sludge Depth: Scum Thiness: ALM
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet fee or baffle:
Comments: (recommendation for pumping,.conditic,n of inlet and outlet tees or baffles,
,depth of liquid
level inr tion to et Inv rt;structural itegrity,evjd n of i akage,etc.) r1ol.
17.
CX
GREASE TRAP:
Depth Below Grad 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 inlet and outlet tees or:baffles,-depth o£liquid
level in'relation to outlet tnyert,'structural integrity evidence ofleakage, etc.'
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Constructiun:_concrete metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flonv: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alariu and float switclies° etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet inverq�
Comments: (note if lwmkand distrib tion is equal, evi�of solids ca rryo er, evidence f leakage into
o ut of box,etc.)
PUMP CHAMBER:
-.Pump is in working order: x,
Comments: (note'condition of pointy chainber,'condfuor ff pumps and appurtenances,etc.) '
_5_
�} „' : .nF,tGR µ "¢hnn''Y'. t•" aT�.+ ° i 1 ,kixr.
I..`
' f 4''4:�1'7,.?iya7'i'•:vy�}Y�Ye�1�y "'�'�{> �z r.,. : �i � :P, ` �
SUBSURFACE'SEWAGE DISPOS&SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOLI.ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated non-intrusive
e9 Y PP by
methods) If not determined to be present,explain:
Type
Leaching pits,.number: Leaching chambers,number: Leaching galleries,number
Leaching trenches,number,length:
Leachingfields,number,dimensions:
,
Overflow cesspool,number:
Comm :(n ndition of 'l�signs of h raulic failure lev�ofndi ,condi ' n o vegetation,
eA
t
CESSPOOIS. /A/, ..
Number and nfi 0o tion: D e th=to of liquid t inlet in
P P
o et vent: �
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
____.Materials f to also n•constructio . Indication of groundwater:
Inflow(cesspool mu
st be um as of
( IM! pumped tart• inspection)
Comments: (note condition of soilk,signs of hydraulic failure,level of ponding,condition of vegetation, ,
etc.) `
PRIVL., `
MateofC0?n-6trnUcfion:r Dimensions:
Depth of Solids:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
- - '�. ..e''S ...-'•� __ . :.~ R _. ..__ ._1„t'+.. ._..,._. ', • .., _. _.,..._ � L ..t k ter i: _._ ..,.._�
r y,
-6-
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.
f
DEPTH TO GROUNDWATER:
Depth to groundwater:_ 19 Feet ,
Method of Determination or Approxi atio : /� I'�iY�/lrl�' /TjI�J $► ,dam f
eig
� .
7-
�J
LO-CAT ION SEWAGE PERMIT NO. t/
/-Or1l A
VILLAGE
Zo fta
I N S T LLER'S NAME & ADDRESS
o
B U I L D E R OR OWNER
rA �. �Af 4- !P j /yAl/y �pl%
DATE PERMIT ISSUED fy 071
DAT E COMPLIANCE ISSUED
Y
•� ( - ,.
. e
.��
,�
��
f
No........... FEE...IAI)..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... /7c -. of .. ./ 245 -....................................................
Apphratiun -fur Di,ipuutti Worko Tonutrurtiun Vrrntit
Application is hereby-made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal
S stem at
................... -----7z�76&4cC-------------------------- L,o-/-----/? -- A ��1T )A..............................................." r �-V' -...73A XA� -!_Y__�_'•"-•---•-•-------•---.._...._...---..
aJ__ "-'-•• ----- /T •I Installer.............................•-•--...... W.4.��.'y, !Z!:.... . Gs�........... ..........---
W .-
Q Type of Building Size Lot_. . _P �,.l.__.--_Sq. feet
U Dwelling—No. of Bedrooms--------A..............................Expansion Attic Wes& Garbage Grinder ()VC�iU,t
Other—Type T e of Building No. of persons
p., yp g p - - �_________________ Showers (:) — Cafeteria
----------------------------
a' Other fixtures
W Design Flow.....................s ._.__._____.__..gallons per person per day. Total daily flow.......... ___--_____-----......gallons.
WSeptic Tank—Liquid capacity -gallons Length---------------- Width....... Diameter------- Depth.--.-.-----.._-
x Disposal Trench—No_ ____________________ Width.................... Total Length-------------------- Total leaching area.._----.__-_-...__-_sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth belo inlet._.__ -----------
Total leaching area------- ..........sq. ft.
z Other Distribution box ( ) Dosing tank ( ) D /02 - �-. / 5 ® n
Percolation Test Results Performed by--------- -------- ------------------------------------------------•- Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit--.________________- Depth to ground water.-..----.--_--.-----.--
�14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground
x I
r ! '
water ter.-.--._.---._----_------
`...rG , ••Descpti f Soi ---•--------
U -------------- 44t-,4:.of---- . . `---------------------------------------------------------------------------------------------•------------------
W
---------- -------------------------------------------------------------------------------------------------------------------------------------- ..........................-........................
..
V Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------_.--..-_--_---. -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further,agrees not to place the system in
operation until a Certificate of Compliance has beeissued by the boai f health.
SiA... ®`
-------------- ------
Date
Application Approved By._.. = ~ =D7 6----------
ate
Application Disapproved for the following reasons--------------------`--------------------------------------------------------__.------------------------•----
--•-•-•-•••------•---•-•---•-...•--•-•--•--•-•..._.._•--------•--••••--------•---•---•---.•-•-----•-----••--••--•••------------•-••------------------------•••----•----•••-••--------------••--•••.....
Permit No.
Date --
Issued.....1...............................................to 7 7
Date
No........... Fss...f.J................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
iv 4/ ........... ..........................
Appiiration -fur Uhipoutti Worko Tonotrurtiun Vrrntit
Application is hereby made for a Permit to Construct X or Repair ( } an Individual Sewage Disposal
stem at: _11 r /
. d3 I1/„ 7_....t *4Q.7. f 7 11. 1� --JAL.._ .. '{
d ss
Installer Address .{,,
U Type of Building AA Size Lot-.�0.45Y9_ .Sq. feet
Dwelling—No. of Bedrooms--------6�4..............................Expansion Attic WW/V& Garbage Grinder (At/6*4_
per, Other—Type of Building ............................ No. of persons...... Showers ( .) — Cafeteria
al Other fixtures --------------------•-__-__-___-__
W Design Flow....................a'Z----___.__-__--gallons per person per day. Total daily flow......... "6--_.__-____------.-..gallons.
WSeptic Tank—Liquid capacity`40_gallons Length---------------- Width................ Diameter................ Depth-.---------.----
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet_.--____-______-__.. Total leaching area---_--.___----__--sq. ft.
z Other Distribution box ( ) Dosing tank ( ) D�_�C�h, - t•'- /�,;_ - 76
Percolation Test Results Performed by--------------------- ................................................... Date----------------------------------------
Test Pit No. I----------------minutes per inch Depth of "Pest Pit.................... De.th to *round water------------------------
G14 Test Pit No. 2......•---------minutes per inch Depth of Test Pit------------------:- Depth to ground water......•-----------------
--------. f r------•-i------.---`-_-•-•----------•------------------•-•----
O Descriptio f Soi l- ,.�'''1 ...V -tr!k �-..-�..__'.5-.....`......5 •-----L Le-------------------------------
------------ -
W
UNaturetof Repairs or Alterations—Answer when applicable-------------------------------------------------------__--.--.-_.--..-.._-.---------_------.....
-----------------------•----------•-----------------------------------------------------•-•----------------------.----.----.------------------------•-------------------------•-------------•----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued b the bo of health.
�1F Date
Application Approved By--- ---- -------Erg- - -- ------------------------------- - ? -----------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------•••-•••-•-••••-••-•--•----•----•--•-------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
PermitNo.......................................................... Issued.......-t - 7... ...... ................................. ,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ...........0 R.O.tj.. t.V.571 . r$4Z..............................
Tprtifiratr of 01komViiaurr
T 1 TO C RTIFY That the Individual- Sewage Disposal System constructed 0() or Repaired ( )
by......e._�__ �----- Ak7. ...........
Inst ]erg
has been installed in accordance with the provision� } .5._-•- 1 ......................
s of : tie e XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit Nod;,%._�._ �`__________________ dated---- _=__-_7_-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
c-��DATE. ...'I..... ..' ---------------------------•-- Inspector------- ......---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. . .. ......oF.. , . :"...........................
N o. .. T FEE-� ----•-. ....
R.1i ial Morkq TTomitrurtion Vrrmit
Permission is hereby granted-_X-OH U..--•- .A-Z ------------------------------------------------------------------------------------•.-
to Con truct Repair ( ) an Indivi 1 Sewage Disposal stem
at Nol� l) r•-- a .! _ 1 /�Q! - Street' �` ,.ir... `!41,., .�
as shown on the application for Disposal Works Construction P it N .:.. • � Dated-::_ �.7_�_ �...............
---.----------------------------_
q_ _ Board of Healt:V
DATE----------9-----�----------------------------------------------------------• (/�/
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
t
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40t !$
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D % f'L 1-2 /4/
IOCA7/6nt : MARS7-ONS M141-S r
S C A ,t E J `= 60 A A TE' -ell-2 5,
f oR: 4VER E 7T W. P�M NANEN
Y HFh'ERY C-R7-IFY 7h'A7- ?'JJE EXiSr-
i/YC- f ouND A 7•%oV .40CA-r14N /S CORRECT
C AS S1101 lV AND DOES CONFORM W iTH
7Nk fiwil-DING S478.ACK REOUIRMEN7'S
I Q f THE %D w N of D+4 R/t1 TA LE i
2
ALL
SHALL
OMPONENTS
SYSTEM PROFILE MARKED WITHCMAGNETIC TAPE OR BE NOTES
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION.
1. DATUM IS APPROX. NGVD ,Q o
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE
2. MUNICIPAL WATER IS EXISTING oe
\ TOP FOUND. EL 88.5'
MINIMUM .75' OF COVER OVER PRECAST 2% SLOP REQUIRED OVER SYSTEM 87 2' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ocu a
Oc I
PRECAST H-10 4. DESIGN LOADING FOR ALL PROPOSED PRECAST
RISERS (TYP.) 85 5' - 4"0SCH40 PVC 2" DOUBLE 1ryASHED PEASTONE UNITS TO BE AASHO H-�
' PIPES LEVEL 1ST 2 OR GEOTEXTI E� FABRIC 5. PIPE JOINTS TO BE MADE WATERTIGHT. �o
' 84.2' tome r°
10" EXISTING 14" 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Shubael
TEE SEPTIC TANK** TEE 84.1�t*� o00 0 amp::,
WITH 310 CMR 15.000 (TITLE 5.)
83.65 PO'�
0 0 0 0 0 o 6" MIN SUMP o
GAS BAFFLE::; °00000?00.00 12" MIN. INT. DIM. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND
83.83 83.66 NOT TO BE USED FOR LOT LINE STAKING OR ANY
4' LIQ. LEVEL (ACME OR EQUAL)
' 0 0O 2 00�0 81.65' OTHER PURPOSE.
i;...r...,_•:..:, r.- H-20 3050 INFILTRATORS " O
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC.
3/4" TO 1 1/2" DOUBLE WASHED STONE 9. COMPONENTS NOT TO BE BACKFILLED OR
6" CRUSHED STONE OR MECHANICAL CONCEALED WITHOUT INSPECTION BY BOARD OF w�
COMPACTION. (15.221 [21) OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30.4' X 10.25' HEALTH AND PERMISSION OBTAINED FROM BOARD
5.15' OF HEALTH.
( 1 X SLOPE) ( 1 X SLOPE) 10. CONTRACTOR CALLING DIGSAFE (1 A8886344-72 3)LL BE BANDLE FOR LOCUS MAP
FOUNDATION EXIST. SEPTIC TANK 27' D' BOX 3' LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND &
FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT WORK.
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE BOTTOM TH-1 & TH-2 765'
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE. NO GROUNDWATER FOUND . 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 103 PARCEL 127
SHALL BE REMOVED 5' BENEATH AND AROUND THE
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
LEGEND SAND.
z..
99- EXISTING CONTOUR
X 99. EXIST. SPOT ELEV. Os
99 PROPOSED CONTOUR
�4C SYSTEM DESIGN:
198•41 PROPOSED SPOT EL. +O
�►� GARBAGE DISPOSER IS NOT ALLOWED
TH 1
YqH1 TEST HOLE DESIGN FLOW. 3 BEDROOMS ® 110 GPD = 330 GPD
Y BENCH MARK - CORNER OF A (� C� USE A 330 GPD DESIGN FLOW
DECK ELEVATION = 88. �' >>
2' SLOPE OF GROUND 3' c� 6Sp.
UTILITY POLE <v� 9tio SEPTIC TANK: 330-GPD (2) = 660
RE-USE EXISTING SEPTIC TANK**
FIRE HYDRANT -
NOTE NOT ALL SYMBOLS MAY APPEAR IN DRAWING
LEACHING:
x 88.45 GARAGE SIDES:2(30.4 +10.25) 1.8'5 (.74) = 111.3 GPD
TEST HOLE LOGS BOTTOM 30.4 x 10.25 (.74) = 230 GPD
EXIST. DWELL. 14 w TOTAL: 461 S.F. 341.3 GPD
ENGINEER: ARNE H. OJALA, PE, SE �87.95 TOP FNDN = 88.5'
x
DAVID W. STANTON, IRS \ USE (4) H-20 3050 INFILTRATORS,
WITNESS: �, 87.a WITH 1' STONE AT ENDS AND 3' AT SIDES
79 �
DATE: 4/16/10 x 88. DECK x g 86.66
x 88.30 87.54 w`°/ / / x 82.17
PERC. RATE _ < 2 MIN/INCH o �8 �� j, �, /
8 .54 O
CLASS I SOILS P# 12889 x x '1' 0 (j 5.51 LOT 18
20 908t SF
L 8 - 6.74 / MA
x 86.57 66 x 83.18 APPROVED DATE BOARD OF HEALTH
x 88.79 -�
ELEV. ELEV. 86.50' 86-20
00
" 87.9' " 87.5' x 87. 7 6. 2 x 85.35 1cn
0 .53 J
89 TH 6 a6 a
A A 16 Ln
SL SIL 26. \ t O
cn o
x a7 93 x 86 ao
10YR 2/1 10YR 2/1 � TITLE 5 SITE PLAN
6" 6 o coo
OF
B B 91 77' x 86.53
SL SL x 87.55 63 ROSELAND TERRACE
10YR 5/6 10YR 5/6 x88 1
24" 85.9' 24" 85.5' 91.66' MARSTONS MILLS
PREPARED FOR
PERC c c _ BORTOLOTTI CONSTRUCTION/
SCIUTO
k . ��HOFMAS �`��j"OF4fq
MCS MCS DANIELA.9c��N �� DAAIEL oyG APRIL 21, 2010
2.5Y 6/6 2.5Y 6/6 IVIL
0 4 so
N6.46502 off 508-362-4541
F a, gt99 I fax 508-362-9880
o�. E Al G downcope.com
10 down cape engineerinOJALA g, inc.
120 77:9 132 76.5 CIVIL N No. 9 civil engineers
'P P
Scale: 1 20' o.46502 o a`� land surveyors
NO GROUNDWATER ENCOUNTERED �j 1-I�zow P sTE� �� �a ss� o y
939 Main Street ( Rte 6A)
O_O�U p 0 10 20 30 40 50 FEET DATE OJALA, P.E., .L.S. YARMOUTHPORT MA 02675
10-068.DWG(SBO)