HomeMy WebLinkAbout0043 SAWMILL ROAD - Health 4'3 Saw
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
q3 tly
Property Address // l
Owner Owner's Narpe /j/)
information is �rS�-Di�5' llS �/¢ �O��O��
required for State Zip Code Date of Inspection
every page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector
only the tab key
to move your
cursor-do not Name of Inspector V •.
use the return ��v/O 7
key. ,
Company Name
Company Address,
City/Town State Zip Coder
' _
�- '� �•� 7��f� 7a lyo�
Telephone Z7mber'_'e.i License Number
c_t
B. Certification
LU no
I certify that.I'have-personally inspected the sewage disposal system at this address and that the
i
U") information reported below is true, accurate and complete as of the time of the inspection. The inspection
was.-performed based.on my training and experience in the proper function and maintenance of on site
ff; sewage disposal, systems. I am a DEP approved system inspector pursuant to Section 15.340 0
c`ca Title,5'.(310:CMR.15'.000)...The system:
c,C)
r Passes ❑ Conditionally Passes ❑ Fails
� ..
® e
~ ❑ Needs Further Evaluation by the Local Approving Authority
• L
Inspector's Aignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
`*This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use. n
Tale 5 officiai inspection Form:Subsurface Sewage Disposal System•Page i of 17
15ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
G ;j r-e
Owner Owner's Nam `^ /J/f�C Od 6 YT
information isC�f v•�S / J /'f//
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System sses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 17
i5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L Ald
Property Address
Owner Owner's Name 1 h
information is i�/ ��f / "�� od rr � p� �S"/y
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Tale 5 of c,al Inspection Form:Subsurface Se.age Disposal system•Page 3 of 17
Commonwealth of Massachusetts
'
Tale 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name, �n� S l o z 2 _c)j 1®
information is ,� ' �7 // � � r
required for Ci /Town State Zip Code Date of Inspection
t
every page.
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
Tate 5 Official inspection Form:subsurface Sewage Disposal System•Page a of 17
l5ms•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4
Property Address
V�
Owner Owner's Name T ��6/�
information is 7�r/�� 0,4 /l/S /,/ Y"O
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ LvJ Any portion of 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 is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Title 5 Officiat Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
t5ins•09t08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L�3
G��//% Ad
s
v
Property Address
rsI �s
Owner Owners Name
information is j�i+yf pNs �j
required for Ci /Town State Zip Code Date of Inspection
every page. H
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
�❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
El Have large volumes of water been introduced to the system recently or as part of
u this inspection?
❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
�❑ Was the facility or dwelling inspected for signs of sewage back up?
(� ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ❑ Was the facility owner (and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ❑ Existing information. For example, a plan at the Board of Health.
❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments/
Y
Property Address
�re
Owner Owner's Name
information is lv H s �j l�l A W
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information
Description:�� GO
'SO
7i
19
Number of current residents: /
Does residence have a garbage grinder? ❑ Yes 3 No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes el"No
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes �I o
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes o
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: ----
Title 5 offiaai inspection Form:Subsurface Sewage Disposal System-Gage 7 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments/
Property Address
CGt re
Owner Owner's Nameo�s /�//S
information is
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Last date of occupancy/use: Date
Other (describe below):
General Information
Pumping Records: f/ p
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval,
❑ Other (describe):
Title 5 Waal Inspection Form Subsurface Sewage Disposal Syslem-Page 8 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
��
4
Property Address
C--ar-e2
Owner Owner's Name � 0
/� � l a /a
information is i/ " ' �� oMf //' � if — ' `
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Approximate age of all components, date installed (if known)end source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer (locate on site plan): �0 //
Depth below grade: feet
Material f construction:
cast iron �40PVC ❑ other (explain):
Distance from;private water supply well or suction line: feet
Comments (or, condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction: L
❑ polyethylene ❑ other(explain)
concrete ❑ metal fiberglass
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
6 )<
Dimensions:
Sludge depth:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
t5ins•09108
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L�3
Property Address
C�YQ
Owner Owners Name 1�' 1 A�1/ � �-
information is rs/�� �1�� /� !�� dL
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Septic Tank (cont.) 31'
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness i
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? o
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
uP-0 i h ✓►d� �e d cr �i v�� ,
Tti �✓ GNC S It'1 �i0o� �Ghd �7i0
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Da►e
Title 5 official Inspection form:Subsurface Sewage Oisposal System•Page 10 of 17
15ins•09108
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Titre 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
t5ins•09t08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's
information is
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Ap
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins.09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
--
Owner owners Name
information is / `rs T(J✓lf r' '��15 Da6u a -aS=l D
required for State Zip Code Date of Inspection
every page. City/Town
D. System 111formation (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
�O
/,4 �jlt4
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
(Sins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner owner's Name
information is / r��✓1 /' //j od 6`>�'� 02 o?S
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official inspection Form:Subsurface Sewage Disposal system•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
• Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r
Property Address
CG✓e
Owner Owner's Name �1
information is �G,��,y s ��l/SQp2 �l 42
required for State Zip Code Date of Inspection
every page. CitylTown
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where lic water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
Q �
C h�
II
C
Cover
I-1��
3 1�j- 6/
[Sins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PC)
Property Address
Crymer Owner's Name ^�information is A /
/ •S I � S � �� a —d /D
required for State Zip Code Date of Inspection
every page. Cityfrown
D. System Information (cont.)
Site Exam:
❑ Check Slope (O o /
I � � 1
❑ Surface water C.
❑ Check cellar
❑ Shallow wells / /
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Toy, ' 91
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15rns•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4
Property Address
CG,e
Owner Owner's Name A� �S jv
information is S�o� 141 1 S
required for State Zip Code Date of Inspection
every page. City/Town
E. Report Completeness Checklist
inspection Summary: A, B, C, D, or E checked
ETZInspection Summary D (System Failure Criteria Applicable to All Systems) completed
�y tem Information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
t5ins•09/08
TOWN OF BARNSTABLE
LOCATIONS. SEWAGE #
VILLAGE A ILLS ASSESSOR'S MAP 6 LOT gZ3-04/
INSTALLER'S NAME & PHONE NO. Co`T slay 90 "coO
SEPTIC TANK CAPACITY 1-dO0 460&
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS_3PRI OR PUBLIC WATER '
BUILDER OR OWNER loin/ Z&VO/ou
DATE PERMIT I&SUED:oO�&h
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�j
i
Town of Barnstable P# 11 0_q
Department of Regulatory Services
„AM Public Health Division Date I 1
659,a�� 200 Main Street,Hyannis MA 02601
Date Scheduled Time Fee Pd. ` 00
Soil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By: �C
LOCATION& GENERAL INFORMATION
Location Address.�' 2 SSW 'p�11 (fin` `. Owner's Name 1'
\`�`�.�✓(J/ Address
Assessor's Map/Parcel: 6t(,J �e7 Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use-,.. {�QS1�fl Slopes:(%) 2 076 Surface Stones P4 JA9
Distances from: Open Water Body ft' Possible Wet Area ft Drinking Water Well —N46—ft
i �I
Drainage Way ft Property Line ft Other Al /3 ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands inn proximity to holes)
MP?
Parent material(geologic) O*tA C4jr, Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Aarje Weeping from Pit Face aft. _'a
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLEFQ
Method Used: fz�KCe[4r CRIS-
Depth Observed standing in obs.hole: Nf� _ 1n. Depth to loll mottles: a in. -
Depth to weeping from side of obs.hole: '- — in. Groundwater Adjustment -- f�•
Index Well# Reading Date: Index Well level Adl,factor,,m Adj.Groundwater Level.@ a
PERCOLATION TEST Bate_ %X5TlMe 1 o..��
Observation w
Hole# 1 Time at 9"
Depth of Perc
''__--��_1 "
� Time at 6"
Start Pre-soak Time @ Time(9"-6") �h
End Pre-soak 1 Ct
Rate MinJlnch ZM PSI
Site Suitability Assessments Site Passed _ Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to by conducted within 100' of wetland,you must first notify the.
Barnstable Conseirvatiori Division at least one(1)week prior to beginning.
QASEPTICVERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture a Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
ConsistencL 96(Iravel)
L, 23 1A.
t3� ,
C -S t v s`-i- w Leeg /OCFo cdw
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon, Soil Texture Soil Color Soil , Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
nsi en %
(o- ch SE s)1-
CL, M- .6 f t 00u- 10 d
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture, R' Soil Color, Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Con i toGravel)
r
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency.
Flood Insurance Rate Man:
• ' Above 500 yearflood boundary No_ Yes_V
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturallv Occurrins Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Pr tion and that the above analysis was performed by me consistent with .
the required train' g, x se nd fence described in 310 CMR 15.017.
Signature Date"
Q:\SEVnCVERCFORM.DOC
TOWN IrSTABLE /
LOCATION L.7� I6LJ F SEWAGE#2d -100
ILLAGE ASSESSOR'S `MAP&PARCEL14
INSTALLERS NAME&PHONE NO. �
SEPTIC TANK CAPACITY (, S e t [ i►�•(� CU
LEACHING FACILITY:(type) t N (size)
NO.OF BEDROOMS 73
OWNER
PERMIT DATE:
�(��'ol� 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 1
within 300 feet of leaching facility)• Feet
FURNISHED BY
i � . _
�v �L-d��� � /' � p
� �� . �
�- �o�
— �� �,
� �, � �
3a
����-
No. r_ Fee
THE COMMONWEALTH OF MASSACHUSETTS49 Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS WY
Application for �Dizpozal .p9tem Con.5trUCtion permit
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) LComplete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
IV�a►rS-�o�'►5 IM.i 11S t��vvU�--..
Assessor's Map/Parcel 3 _05 rri an -
Installer's Name,Address,and Tel.No. ��IRS—.I E�9 Designer's Name,Address and Tel.No. —"39
D S a nt5 (2-E• fla 021 �-�aIm .
Type of Building: 2 4
Dwelling No.of Bedrooms v Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2 i
Design Flow min.required) 3 30 gpd Desi n flow provided �J 1. gpd
Plan Date O ZO6 Number of sheets Revision Date
Title on
Size of Septic Tank Type of S.A.S.
Description of Soil U
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 Ti le 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this oar ealth.
Sig Date
Application Approved by Date
Application Disapproved Iy: Date
for the following reasons
Permit No. ! Date Issued
t��n/��` /t r
No. ' ... Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Y
I I, At phration for &5 bga[ �§p$tem CongtrUctiott permit
Application for a Permit to Construct O Repair O Upgradey) Abandon( EYcomplete System ❑Individual Components
Location Address or Lot No.45 lj fyl I l) Owner's Name,Address,and Tel.No. '
Assessor's Map/Parcel ub-3 _.05 rS. T t IQ.
��77g- ►
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
a.
lit 6S,PD• r5c�-15S ,�kjannrj (?.CE-S PC-) &1,4 (an 'TAU r1r1 ,fi
type of Building: 10
Dwelling No.of Bedrooms Lot Size `T-/,6W sq.ft. Garbage Grinder ( )
Other Type of Building s No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2 !
Design Flow(mein.. +required) / �• gpd Desi n flow provided ��I, O gpd
Plan Date tT ' tJ f 6 4 1 Number of sheets Revision Date ,
Title . T
f 'Size of Septic Tank D Type of S.A.S. � 6
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
a accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate f
Compliance has been issued by this Board f,Health.
Y
Sig / �����/ Date
Application Approved by / �/ �d5A IIIX ,'!/(/X Date
Application Disapproved by: 0 �`. Date
for the following reasons �� 4
Permit No. Date Issued ! t/
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
r THIS IS TO CERTY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (,V)
Abandoned( )by 86b�r6 l �-
at M t m r 15 L3 �)o w m 4 has been constructed'n ac ordance
with the provS ions f Title 5 aqo the for Disposal System Construction Permit No. Ot%" � dated
Installer _ aiT/U�t`/L�I Designer C
#bedrooms 3 Approved design flow gpd
The issuance of this permit shall not be onstrued as a guarantee that the system will fu"nc ibn as designed.
r �
Date M � / /�.(n Inspect
__ .
No. J-- --------------------------- Fee -----=--
✓� 'u F✓ ��--21)rJ�
THE COMMONWEALTH OF MASSACHUSETTS
�YOPUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Migponl �§pgterrt Con!5trUCtion Permit
` Permission is hereby granted to Construct ( ) Repair ( ) pgrade ( N) Abandon ( )
System located at �
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction dust be omp ted within three years of the date of this •�rq�Z /���
Date -% aI Approved by / ���-,
Town of Barnstable
°��"E' •� Regulatory Services
Thomas F. Geiler,Director
• snxivsresit,
NAM Public Health Division
A'f�► `'� Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:
Designer: Shay Environmental Services, Inc. Installer: t � �
m C=
Address: P.O. Box 627 Address: \ ate° , isA
East Falmouth, MA 02536 oA-it, , F�
On was issued a permit to install a
( ate) (installer)
septic system at (�t�7(mil �` based on a design drawn by
(address)
Shay Environmental Services, Inc. dated _ L (a
(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.
f 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 Mqs�p�
CARMEN
(In er's Si ature) o E.
SHAY co
No. 1181
.p o
l �Q►s7E��G
(Designer's Signature) (Affix Des p 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
a d i
3-24'DIAM. ACCESS MANHOLES 1 �� ;
Bedroom Bath Bath 1a' �• s�v 9 3. ;
Kitchen
Dining ."•("�
Bedroom Schedule 4 PVC w Charcoal Odor Fllter �� `
VENT PIPE (O Least 24 inches tall)
10' min. from in
NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. D SECTION A -A INLET
�ss�N10i a r
Existing Foundation House to septic tank PROFILE t'IE1P OF ADDITION TO LEACHING SYSTEM INLET ":, `�. `� '. 011 '
Uc tank oovers must be D-BOX cover must be
Levin Room TOP OF FOUNDATION ELEV. 100.00 (Assumed) 9 witMn a In. of finkrhed rode �J THE ACCESS COVERS FOR THE SEPTIC TANK, v
Bedroom g GARAGE wtthln a In. of finished rods 9
` Grade over Septic Tank- 9e.00 Grade over D-Box- 97.50 over SAS- 97.50 3" of 1/8" - 1/2" Washed P•aston �ti DISTRIBUTION BOX AND LEACHING COMPONENT >z v; z
-T ,,.r•T, SHALL BE RAISED TO WITHIN 6" OF
3/4' to 1 1/2 Washed Crushed Stone ^,r.77171 T, 1 E +' ••' r• FINISHED GRADE.
S 002 STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TiTE GAS BAFFLES OR EQUALS +
3 HOLE H-10 4'PVC(CAPPED)INSPECTION PORT TO eE
8 12 NEW S.0.01 or Greater
ST. BOX 3' Maximum Cover Top OF System- Elev. • 9375 INSTALLED AND TO BE IMTHMi 6'OF GRADE PLAN VIEW ON ALL OUTLET TEE ENDS
3 BR HOUSE FLOOR SCHEMATIC EXIST. PIPE 1,500 GAL. 2S. s. 0.01' pef f , 3-24'REMOVAOE covets
FROM EXIST. FWNDATION (a SEPTIC TANK a oot 0-Effective Depth f I V.►e+.n.v.ee.wury A
11 e.soft in
in s' .
CONCRETE FULL FOUNDA u h H-10 ri 5 Units ! •� A ": 4' IT
u r7 ae3' (10 inches) 6.25' ' ao' min. a.ara,n - „• .m Ir ' GENERAL NOTES j
' ' 8'min+L_min. hest to outlet s'mh
3L 3 INLET _
SYSTEM PROFILE a In.of 3/4•-1 1/2" i e > ,; 31.25' w ; Lrgol�Twel I—OUTLET 1. Contractor is responsible for Di safe notification
compacted •ton• > rn o•mM. µ• ) P 9
Not to stole ` � -is � N • rn 37.25' a'_7• >;� I ,'a• _r and protection of all underground utilities and pipes. 'I
c 3.5' 3.5' U Effective Length e 4'-0'min. 2. The septic tank / distrit�W{jion box shall be Get
c - 3' an soft Lkluld depth level on 6 of 3 4 -1 1 2 stone.
SOIL ABSORPTION SYSTEM (SAS) ?
3. Backfill should be clean sand or gravel with no
a In.ot 3/4•-1 1/2' .
composted stone < Effective Vern INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN stones over 3 in size.
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 8" BELOW GRADE y;.,,, r .t., , .; , '., •) 4. This system is subject to inspection during installation
m° (OR EQUIVALENT) Not to Scale •70•_0. a'-e• by Carmen E. Shay - Environmental Services, inc.
Bottom of Test HoleAElsv.-$=M NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 5. The contractor shall install this system in accordance
CROSS SECTION END-SECTION with Title V of the Massachusetts state code, the approved plan
Groundwater Observed - NONE OBSERVED
and Local Regulations.
TYPICAL (H-10 LOADING 1500 GALLON SEPTIC TANK 6. If, during installation the contractor encounters any
NOT TO'SCALE soil conditions or site conditions that are different
from those shown on the soil log or in our design
IMaV Substitute with 1500 gallon H-E0 Polyethylene Tank-George O'Brien Co. installation must halt & immediate notification be
mode to Carmen E. Shay - Environmental Services, Inc.
7. No vehicle or heavy machinery shall drive over the
PERCOLATION TEST P 1 142 4 septic system unless noted as H-20 septic components.
8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
Date of Percolation Test- SEPTEMBER 15, 2006 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes.
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter
Results Witnessed By. DONALD DESMARAiS ( Barnstable B.O.H.)
EXCAVATOR: Shay Env. Svcs. Schedule 40 NSF PVC pipes with water tight joints.
Percolation Rate: Less Than 2 MPI ® 60" 11. MUNICIPAL WATER IS AVAILABLE TO THE SITE and Surrounding
--- Properties.
Test Hole Test Hole
No. 1 No. 2
DEPTH SOILS ELEV. DEPTH SOILS ELEV.
0 98A0 O 48.00 ��
THE PROPERTY LINES ARE APPROXIMATE AND
Loamy Sand Loamy Sand COMPILED FROM THE PLAN BY BAXTER & NYE, INC.
LOT #385 10 YR 3/2 10 YR 3/2 NTITLED " CERTIFIED PLOT PLAN OF LOT #384 SAWMILL RD, M.MILLS., MA
o'-s• Ae 97.50 0•-6- As 97.50 DATED MAY 07. 1982
AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
Loam =my IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
10 YR 5/6 10 YR 5/6
� 6"- 30" SILTS LOAM 95.50 6•- 30" SILT ROAM 95.50
00 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
/r s.5 Y 5/0 2.5 Ya/4 FROM THE EXISTING CESSPOOLS TO BE DISPOSED
30"- 6o G 93•0 30"- 0+ 93.0o OF AS PER BOARD OF HEALTH SPECIFICATIONS.
odium -Coe s M dium -Coon
' Sand Sand EXISTING CESSPOOLS TO BE PUMPED DRY &
LOT #384 ,\ 2.5 Y 7/4 2.5 Y 7/4 FILLED IN PLACE
49,600 Square Feet +/- \ - 8R "- 1 4 Ca mom
I
48.6'
/
ASSESSORS MAP - 063 PARCEL - 056
SHED /
Vent ZONING - RESIDENTIAL
µ. k LOT #360 y�' Pipe -- i Pert #1 FLOOD ZONE C F
Depth to Pere: 60" to 78"
TEST HOLE 2 / Pert Rate= 2 MPI
�' i Groundwater Not Observed NO WETLANDS ARE LOCATED WITHIN A 200' RADIUS
ELEV. 98.00 i� Failed/ /- �__ - I / No Observed ESHWT r
( x�•... __ t OF THE PPO`r>'R1Y
.� Cesspool
_ ' ADJUSTED H2O Elev. s None
Ile
TEST HOLE #1 37 5' �%`r • ;��r I / -
;48y / EXIST.
s ELEV.= 98.00 .��' • .` / C DRIVEWAY
i .x {• ; �__` ,-' ����. ; ; ALL OUTLET PIPES FROM ,HE LEGEND
• Failed f __ _ ` wsTRlsunoN Box,HALL BE COVER
\ �� �\ / / / SET LEVEL FOR AT LEAST 2 FT. 12' CONCRETE
Cesspool 2
'' ;`F •X h, ; ) ; �\ �\ ��\ _-- xNocxouTs 8X0 DENOTES PROPOSED
v;•w O % % �\ .` ��\ / , - - s5' OUTLET tr INLET SPOT GRADE
' O - .c ___� .., •;;1 DENOTES EXISTING
D-Box ` % "' X 104.46
�O
EXISTING \�\ ��� ,'' 1aa• 1a5• SPOT GRADE
' - ; PLAN SECTION GROSS-SECTION PL
I NEW GARAGE PROPERTY LINE
1500 gal.
Septic Tank �- -----' T
3 HOLE DISTRIBUTION BOX - H-10 LOADING -- -- PROPOSED CONTOUR
NOT TO SCALE I
97- - ----97 EXISTING CONTOUR
#43
Design Calculations ® DEEP TEST HOLE &
EXISTING
o� , / PERCOLATION TEST LOCATION
PROJECT BENCH MARK ,-''- 3 ,BEDROOMA/�'''se.
/ TOP OF FOUNDATION HOUSE
' ' � Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) � -� FENCE
i ELEV. = 100.00 (Assumed) Garbage Grinder: No
Leaching Capacity Proposed: 330 Gal./Day MWmum (Min. Per Title V)
Septic Tank - 2 x 330 Gal./Day - 660 USE NEW 1,500 GAL. Septic Tank. PRIVATE DRINKING WATER WELL
SOIL ABSORPTION AREA: Using percolation ra1'.e of <2 min.�nch TT
Bottom, Area: 0.74 gal/sq. ft. x 370 sq. ft. 273.8 gallons REVISIONS
I I / Sidewall' Area: 0.74 gal./sq. ft. x 78 sq. ft. 58 gallons
Providing: 331.80 gallons
NO. DATE: DEFINITION
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH,
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
94 ON THE ENDS. NO STONE UNDER.
----------------
---------------------------------
PROPOSED
/
t5'
y
PREPARED FO R :
SUBSURFACE SEWAGE DISPOSAL SYSTEM
OF
0
MS. MARY- BERRIAN
94 - ---------- #43-' /;' /; �,, #43 SAWMILL ROAD
46 C00LOIDGE PLACE
MARSTONS MILLS, MA
LOT #36 f
W. LONG BRANCH, �JJ , 07764
/ tN OF Mq PREPARED BY:
A N �G�� CARHEY E. SHAY
0 20 40 50 NS EAWROXNEWTAL SERVICES, INC.
,sTE P.O. BOX 627
f SgNITAR`P`' EAST FALMOUTH, MA 02536
i f
SCALE: 1"=20' TEL/FAX : 508-539-7966
SCALE: 1 "=20' DRAWN BY: CES DATE: SEPT 18, 2006
PROJECT#SD-967 FILENAME: SD967PP.DWG SHEET 1 OF 1
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