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HomeMy WebLinkAbout0023 RUSSELLS PATH - Health 23 RUSSELLS PATH, MARSTONS MILLS A= 027 092 - - - i Fee THE COMMONWEALTH OF MAS$ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Migaal bpotem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade l Abandon( ) El Complete System El Individual Components Location Address or Lot No. , �/ � ��' f"� j j/ Owner's Name,Address and Tel.No. Assessor's Map/Parcel a Installer's Name, /Address,and Tel.No. y { Designer's Name,Address/and �Tel. /No. �"i�� G C'�'/�1��/— '�/ ✓-'�,71.E 7 ��`f/rO �y/�!�/10 nJ °�o� �v C Type of Building: Dwelling No.of Bedrooms '� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building dc'r'''�'- No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �G gallons per day. Calculated daily flow - gallons. Plan Date e<�_.4�:�/ Number of sheets Revision Date Title Size of Septic Tank c��C� T'^':4 /'� � 1 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 Certifi- cate of Compliance has been issue this Board of Health. �1 tgned Date Application Appro4d by Date 6 Application Disapproved for the following reasons Permit No. Date Issued r � No. j � �.; Fee` (✓Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZppYication for �Digaal *paem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade(/ )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. �C/,f�'�'�� ��ry Owner's Name,Address and Tel.No. Assessor's Map/Parcel :7 — 9,�_ . Installer's Name,Address,and Tel.No. Designer's Name,Address and Teel.No. 1.��� `C�OG�v� �7,5•O70� ��v/� �,fi/�v,/�O l^�j. �Pf; Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ',leo' No.of Persons Showers( ) Cafeteria( ) Other Fixtures i t Design Flow i gallons per day. Calculated daily flow gallons. 1 Plan Date Number of sheets Revision Date Title j Size of SepticTank ' � �o'o o�l 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 Certifi- cate of Compliance has bwnjssuedtVsaid of He lth. $e_��igned � Date Application Approve Date G Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertif icate of (Compliance THIS IS TO CERTIFY, that the On-site Sewa a Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )byU at oZ 3 v.f'rl' L �� has been constructed in accordance with the prov!LWtis of Title 5 anI the for Dis osal System Construction Permit No. '1 r,o��-a'11 dated Installer '' C 'Pp��r Designer v��✓ �' /J1.��o �' The issuance Q4 f 6s pe it shall not be construed as a guarantee that the sy em ill fu ction desi . Date t 9 OL Inspector o No. ��J / a�� ------------------------Fee SO 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1=i5Pogar *pgtem (Eongtrrruuction Permit Permission is hereby gra ed to Co struct( )Repair )U grade Abandon System located at Co ��� 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:Constr ctionnust be completed within three years of the date f this pe mi. Date:_ Approved by TOWN OF BARNSTABLE LOCATION ` Grf�<<s ��? SEWAGE #. �®�✓ 7.7 VILLAGE J� J' —Jr e ASSESSOR'S MAP & LOT 7—fiU INSTALLER'S NAME&PHONE NO. Z. SEPTIC TANK CAPACITY LEACHING FACILITY: (type I NO.OF BEDROOMS ` BUILDER OR OWNER { PERMITDATE: �"'�`� 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 J Feet within 300 feet of lea facility) IFurnished by i i elow,7 L 10 ,°cV �3 - � A � � A Town of Barnstable Regulatory Services Thomas F.Geiler,Director + BAMSTABLE, K&WPublic Health Division ArD ;�s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: ���� 5 Z ." Designer: D.4vlp "�1 t^-- Installer: 17, z��GZ Address: . Address: v s� On � was issued a permit to install a a T (installer) septic system at Z J ���I based on a design drawn by ,n n (address) c/ ?. Y V l LL7 dated (o b (designer) 1. V ,-certi that the septic stem referenced above was installed substantial) according to T fY eP Y Y g ythe 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 relocatidn 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 CAM staller's ignature) A. 1086 (Designer's Signature) Affix Des 'er"�"§�Stam"+Here PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND. AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form :. TOWN OF BARNSTABLE LOCATION '� �rf��l s, ��%� SEWAGE # o gs' a 7.7 VILLAGE��'4-;�'f�—J' .4P-<e S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. e e-Wa"' :7 7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER c�•�'r�' PERMITDATE: 5`22` 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 J Feet within 300 feet of leac ' - facility) Furnished by I A� �\ L / Cog o 16 ,4 ,o oz TOWN OF BARNSTABLE LOCATION c,2�'�? L-Qcrel,� al- SEWAGE # OQ 7 VILLAGE 1%-60�1 1 /9I,11S ASSESSOR'S MA & LOT6�a eO NAME & PHONE NO�rlr)IC- �J�, clot SEPTIC TANK CAPACITY OC) i c� - �LEACHING FACILITY:(type) (size) , NO. OF BEDROOMS PRIVATE WELL BUILDER R OWNER DATE PERMIT ISSUED: 17 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No F� ,.s $7.9' ASSESSOR'S MAP N0. PARCEL Of 2— L0CATION SE�yWAGE PERMIT NO. \cjci -,"* !�c) VILLAGE I N S T A LLER'S NAME A ADDRESS �cach\0� R U I L D E R� OR OWNER ® 11Jca e ev ��®t1n e S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED CN° t �s No.... Fss..........................._ THE COMMONWEALTH OF MASSACHUSETTS - �, BOARD F H TH 0 !'1-....-----•---------.OF.............. 4df'.. .................................... Appliration for Disposal Works onsUmdinn rrrmi# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Sys __ .. ..-_ -........... ...................................••....•• •......_..............................._. Location-Address or Lot No. • .. ................................................. ............................................Address •--'---------•-•••--".........."------------- - W I s Iler Address UType of Building Size Lo> V.. F- .._......Sq. feCt Dwelling—No. of Bedrooms___ ____________________________________Expansion Attic ( #15 Garbage Grinder Other—T e of Build in ------�. No. of ersons............................ Showers — Cafeteria Otherfix, urw.......................................................------...................----------------------.. W Design Flow...............- ....................gallons per person er ay. Total ily�...........:--. ......._..........-•_-- ons. WSeptic Tank—Liquid capacity/M .gallons Length- j...... Width...;r..•-•... Diameter................ Depth_.._..._.._.._- x Disposal Trench—No. .. Width. ................. Total Len Total leachingarea........... ......sq. ft. Seepage Pit No.... D' eter_.. _.___. epth b ow inlet_...__...... Total leaching area _. ..sq. ft. z Other Distribution box ( .,K Dosi t ! Percolation Test Res is Performed b ..:._ ` :.--.__---- .............. Date. ._! _. .................. Test Pit No. 1. .minutes per c epth of Test Pit.../.. Depth to ground water........................ f4 Test Pit No. 2................minutes p i Depth of Test Pit.................... Depth to ground water........................ 1:.4 .................................. -•----- ----------------------- ---------- ----•------------------------•--•------------------ •....... .-.----------------- -•-•----------- Descriptionof Soil..............................................................................----...------------------.._.......--------•------•-----------------------------------.•-- x M w VNature 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system operation until a Certificate of Compliance h be is e y the board of health. Sag ..--• .....-•••-•-••......................•- ���Y ---. . - --- ••- " ate ' Application Approved By................•--•• .... ---........... _.. ......... ...----._.__�� _�1 ..v Date Application Disapproved for the f of eas o : .... .........................................................................................................I••--•---•-•--•--•-••-••--•------•--••••-•---•---•-•-----•--•-•-•-----•---•••••......•-••••--••- �a Date PermitNo......................................................._ Issued-..........................................0............ Date � 6 rtmant of Environmental Management/Division of Wate esources r� Fe * WATER WELL COMPLETION REP GG b WELL CA/TION Address �f73< b0 Z'r ijils a h City/Town /71rz*fi 12/,#s G.S.Quadrangle Map Grid LocationOwner / Address 100 0. Om Dm� S 0 �pd/ ►�( WELL USE CONSOLIDATED WELL Domestic z Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones Method Drilled er 1) From To . 2) From-To- Date Drilled 3) From To 4) From To 'CASING ft Depth to Bedrock Length_ Diameter_ Type UNCONSOLIDATED WELL STATIC WATER LE�V/LE� Water-bearing Material Feet below land surfs a - Sand: fige[]medium/coarse❑ Date measured 3 t7 Gravel: fine❑ medium❑ coarse❑ Screen: GRAVEL PACK WELL ! Slot#length �t from to Yes ❑ No ,L—v�,/ Split Screen (or 2nd screen)' WATER ,ALITY TESTS MADE Slot V length from to Chemical L�/ Biological ❑ Depth To Bedrock PUMP TEST Drawdown feet after pumping days i hours at_gGPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) I Materials From To I o C m DRIc 4 m Firm lyl�i7/1(r,C!1.4n��ino�lC. ° p � Address � &Y 8100 City Registration No. No......................... Fx$............._............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® F` H A TH ---.: ...... ,r,,, ��. ... Appliratinn for Disposal Works Tonstrnr#inn "rrmi# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal SyV77- ... . .:................ .. . •-•--•_.. ...- --•--•--•••-•--••----•--......... ..... .---• . .Location-Add:ess - - --- or Lot No. It .. . t.�?:t:�_.... C —Address W ! � - -•--•.........................•- -•..._......-•----•----••-••--•--•-- ....--..Q•-••••��...................... Ins ller Address d Type of Building Size Lot2...,_...1_V.......... Sq. f t V Dwelling—No. of Bedrooms.._ ...._ .....Expansion Attic ( � Garbage Grinder (4�I� ....._...---•--••----------- — '� Other—Type e of Buildin :__. ___.... No. of persons............................ Showers Cafeteria P-I YP g ----- P ( ) ( ) Other fix urns WDesign Flow.:............ ..�......................gallons per person ner day. Total daily....... 0...._..........__..__..` Ions. WSeptic Tank—Liquid capacity�ln%a__gallons Length.....��..... Width.. -._.._..... Diameter................ Depth ....... x Disposal Trench—No. .;,_.............. Width ........_.._...... Total Length.......___._...___. Total leaching area.._....._____.......sq. ft. Seepage Pit No...�� L�.__.. D' eter... b ow inlet___..__...---. Total leaching area.. 3.sq. ft. Z Other Distribution box (l Dosir� to '-' Percolation Test Results Performed bVIII. l' v -E�ai.J.......... -- -------- Date 5 l .................- ,� Test Pit No. l,l__.._......minutes per nc epth of Test Pit___r.............. Depth to ground water........................ �14 Test Pit No. 2................minutes p i Depth of Test Pit.................... Depth to ground water........................ 04 ---------------------------------------------------------•------•-------•---------------------------.------------.---------------........ "------------------ ® Description of Soil---------------------•-•--------........................---•-----...-----------•---------------------------•------•-------------•-----------...............-•----•---•-- x U ----••-•--•-•---•............................•--•---••-•-•-•---------------•-----•••-----•--.._......--•••-------•---•-----•--•-•-••----••-•----•---••........._..................----•-•--••-••........ W -----------------------------------------------•- ---------------------------------•--•-------------------------------------------------------•---•----------------••----------------------------••-•-- U 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to ;acetem 'n operation until a Certificate of Compliance h bej is u by the board of health. !� Sorea'son2 44` .... !� �f Application Approved By.................... -- -------�::-�-- -�'�=-- - ---.....---- ....-....... '-� ' � Date � Application Disapproved for the f of ------------------------------------------- •------------------------------- ----------•-------............ ---------------------------------------------•----------------•--------•-••----------------•---••---------•---••---------•--•---------•-•-••••-•...---•--•--•-----------••----•----•-•-•............. Date PermitNo...................................................---.. Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H T� is�?'f.........................OF ....../r 1 1r........ .:. ................................................. (9rdifiratr of Tnntplianrr S I?r!9 RrIF Individual Sewage Disposal System constructed ( or Repaired ( ) stall;; ._ -- haF been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code s described in the application for Disposal Works Construction Permit No.___•---�...�__. T... dated---------cr .�{_ ----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANI THAT THE SYSTEM WILL FUN TION SATISFACTORY. DATE.................. .Z ................................ Inspector--------------....------------------•---••---•----•-•-------------.............--- A �Z- TH COMMONWEALTH OF MASSACHUSETTS BOARDOF..........................OF... /1!/1.. ..r..<....::............. ............---...........---•- No.9 '_. ( FE ....... iI fin. n tr to anti Permission is eb granted..R=_ ..............�T _ . !..._ _ to Construct epay,,(, ) arti t�ividual S gage ystem at No........ ... ` .1/,il� ---•-- i Street as shown on the application for Disposal Works Construction Permit No..�d_.�'._6�---- Dated--__---_6 T® .......... ---•-------- = DATE........ ' l� ��'��-----------------•... soar' a1th FORM 1255 At MM. SU. KIN, INC., BOSTON r i • .T # O T/f �/6 0 jtqA c A 0 S z7 Su -- _ — -- — _ v /� eo - 8 10L , AC©a1 NO. 814. UPPERCAPE—ENGINEERI I ° = P.O. BOX 616 E E: SANDWICH, MA 02537 362-6281 r - L. . s�3:s 3 cP�sFe f � ti TOP OF FOUNDATION , CONCRETE COVER CONCRETE COVERS EC -S"Zx/ 4'•CAST IRON 12"MAX ��r (2 MAX. r OR SCHEDULE 404"SCHEDULE 40 P.V.C.(ONLY) PITC PIPE PIPE- MIN. ' LEAC PITCH I/4"PER.FT PITCH 1/4"PER•FT. PIT TINVERT NG�INVERT INVERTSEPTIC TANK EL.ycr bIS7: ELY. �:�. •: > V.INVERT BO. . . .... GAL. INV RT EL.�9::�. INVERT �W w I/Dw l ' •;�!.., . . I _ - /� DIA. 5/ PROR LE OF WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED BY: DATE ��,/•��£��.•.... 71ME...... .. ... � l�I�kE�a!•. . . . . BOARD OF HEALTH j TEST HOLE I TEST HOLE 2 (� fr� ��.•�it1�, / 44Z' ENGINEER ECE.Y...$: %OP/GOAiy TU PI LGA/+l su,2 so/Z- 1 DESIGN DATA : NUMBER OF BEDROOMS . . .. . 3. . . . . . . . . . TOTAL ESTIMATED FLOW • 13.5.Q . . . GALLONS/DAY meb •�/3 . . . . r✓�E>7 SAN BOTTOM LEACHING AREA SQ.FT./PIT AwA SIDE LEACHING AREA SO.FT./PIT GARBAGE DISPOSAL . . A.1o.'. (50% AREA INCREASE) TOTAL LEACHING AREA • a:G . . . . . SQ.FT PERCOLATION RATE -5 . . . . 'MIN/INCH 0) LEACHING AREA PER PERCOLATION RATE .. SQ.FT. 1.:WATER ENCOUNTERED /' • NUMBER OF LEACHING P17S . .O�Y�`�. . . . . . . . . . APPROVED . .. . . . . . V2: ..3�iYG�,= /�3 •�i rJ' •//3 ,/gTlOdl, . . BOARD OF HEALTH . 6)(51) DATE. . . . . . . .'. . . . . TO7_, ,l • •AGENT---OR INSPECTOR d1ar '•' e .J J COBy �`�� '8G• � � � r` UPPERCAPE ENGINEERING R ,� ��: . . . . . . a 814 P.O. BOX 616 9 u .o • it?.�'�/. /YUi`? .S• • E. SANDWICH, MA 02537 s PETITIONERS: ' • • ' 362-6281 �.pp�NATAC `.;:. g BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 _ 6' 508-771-9399 508-428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w ` PART A CERTIFICATION Property Address: h ce QS'eI&Ir a VI; Date of Inspection: — G Ins c or's Name- Q'­ Ow er's Name and Address: CERTIFICATION STAT .M .NT• 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 per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further Rvaluation B th ocal Aproving Authority Fails Inspector's Signature: Date: �9fp 'The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY- A)SYS M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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 health,safety and the environment. protect the public he , the system is failing top p y 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS"NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feel 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 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 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of aiuinonia nitrogen and nitrate nitrogen is equ al to or less than 5 ppm. D)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 overloaded or clogged SAS or cesspool. Discharge.or ponding of eflueut 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 loan overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below.invert or available volume is less than 1/2 day flow. Required primping more than 4 times in the last year NOT due to clogged or 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 public health and safety and the enviro►unent because one or more of the following conditions exist: The system is within 400 Feet of a surface drinkling 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 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 if a following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _�one of the system components have 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 recently or as part of this inspection. _ZAs-built plans.have been obtained and examined. Note if they are not available with N/A. 'I he facility or dwelling was inspected for signs,of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ✓The site was inspected.for signs of breakout. //All system components,excluding the Soil Absorption System, have been located on 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- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART' B CHECKLIST.(continued) _L'-"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 RESIDENTIAL: Design Flow: gallons Number of Bedr000is: 3 Number of Current Residents: Garbage Grinder:Altj Laundry Connected To System: YtS Seasonal Use: AA Water Meter Readings,if Aa actable: Last Date of Occupancy:4y t jnC CO RCLALAND ST IAL! 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: GENET NFORMATION PUMPING RECORDS and source of iuformat'oii: E /U System Pumped as part of inspection:_if y volume pumped: gallons Reason for pumping: TYPE 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): APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odor$detected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: " Material of Construction: concrete metal FRP Other (explain) Dimisions: ',� Sludge Depth: cP '' Scum Thickness: / Distance from top of sludge to bottom of outlet tee or baffle: ?,4 1/ 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.)��S Cp_ Ao Za11�, P e-1 �Zi1 G / '" Gam/ /0/,,AAvJJ__ /�" p P 22 IV GREASE TRAP: Depth Below Grade: Material of ConstrucLion:_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 of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDINGT -(ANK.�_CJ Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: allons/day Alarm Level: Comments: (condition-of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: � Depth of liquid level above outlet invert:AID/'kiA Comments: note�evel id distribution i e ual, evidence of olids car��evr nce of leakage i t or t of box,etcrzpJ� &�bn I�l C 1�4 �t C(rGr C �� Q PUMP CHAMBER- 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 approximated by non-intrusive methods) If not determined to be present,explain: Type: ' Leaching pits, number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments: (note condition of soil,si us of I!ydraulic fail a level of pondin&gondition o vegetation, etc. S C� I' Gvi a �/ ii �• Q_t4 V::4;77t�L CESSPOOLS: ' Number and co gumtion: 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 soilk, signs of hydraulic.failure, level of ponding,condition of vegetation, etc.) PRIVY4of Materiastruction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -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. c rJ i 16-V 7 r� f i, 2 ' i DEPTH TO GROUNDWATER: 1 Depth to groundwater: Z S Feet , Me dDetermination or Approx}'oration: ,f'�,fi/s9G1�Ci� 7`1D11 Z11", �'f �!® c� •�' 41 -7- 41 -- i ASSESSORS MAP: � 2 w� - TEST HOLE OGS �Oqd PARCEL: - ---- _.- -- _ FLOOD ZONE: � PL�Lu J _ SOIL EVALUATOR h mo( NOTES. REFERENCE: --.�----- � l qbb (P�t�i� Z�bZ WI TNESS : IBC' f�`�L� i � ._.__�'���---- -�.-�-- � DATE: -� ',! � C7 ' i 1) The installation shall comply with Title V and Town of 1ZS . P Y Barnstable Board of y� L1Da..• __ book,*. � � Z PERCOLAT I O RAT : � '�i � Health Regulations. 45 ►' ill ! 2) The installer shall verify the location of utilities, sewer inverts and septic N TH- I TH-2 components prior to installation. Alr 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. i 4) This plan is not to be utilized for property line determination nor any other ' 1 purpose other than the proposed system installation. ,n�1, -ss�— 5) All septic components must meet Title V specifications. c 6) Parking shall not be constructed over H10 septic components. LOCATION MAP �r�TS, _.�._.� / -� 6 (" MCC> �f f�t j _ 7) The property is bounded by property corners and property lines as depicted. / 64412 8) The property owner shall review design considerations to approve of total number of bedrooms to be considered for design. Receipt of payment for the U L0�7 plan and installation based on the plan shall be deemed approval of the K number of bedrooms. � 9) The existing leach it shall be um� S g P pumped and backfilled per Title V Q Abandonment Procedures. 1 10 )Proposed p ed leaching is to be wrtlun 36 inches of grade or provide venting or cut grade as permitted by the Board of Health. /\ �y 11)System components to be 10 feet from water line. SEPTIC -.SYSTEM DESIGN .; FLOW EST I MATE ... .-.er Y•XA.' 1 F_ l 4 �BEDROOMS AT I Id GA!/DAY/BEDROOM - GAL/DAY / <SEPT IC TANK` \ ' SAL/DAY x 2 DAYS - (LQ GAL U 5 E r GALLON SEPTIC TANK iP.IL-�l1L�C. t P ` fPa$��c a L ►mil Wd' l� J A{ . ab SOIL ABSORPTION SYSTEM - "p4Q ul)/ a a M ��. ti /6 �Q G-)1 ,1-(_„ 0, `(�0 SIDE AREA: � /I d?, + BOTTOM AREA: NJ SEPT" IC SYSTEM SECT I ON IAA91 loll14 W iU 1# O D-BOX °u �"�1 ���` .. OOC� GAL 67bD --S ,i ti SEPT I C T NK Ufalh ' � t �S S1, TE AND SEWAGE PLAN LOCAT I ON : l ► rl v PREPARED FOR : a o - SCALE: I 0 W *: DAV I D B . MASON '01- DATE: bI I b o DBC ENVIRONMENWL DESIGNS EAST SANDWICH . MA DATE T ( 508 ) 833- 2177