HomeMy WebLinkAbout0580 WHISTLEBERRY DRIVE - Health 580 Whistleberry Drive
Marstons Mills
A= 061 — 051
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J Yealth of Massachusetts
Official Inspection Form
ntary Assessments
Sewage Disposal System Form co Ply .
ults must be submitted on this form or on the officlai Title 5 Inspection Form dated
on forms ma not be altered in any w
A. ertification
V out I Iroperly Information: j
.only the tab key Address,
to move your
anwr-co not
use the return s a �j
key" t.-t � le 612 f- n.
AddressState
lMW
ate of Inspection:
Date
2. 1 s r
13107
me !ns
.7,1 J IL
t ( e -7 t
mpanyAddress —/
6-1
`ri — J 6 3 state Zo Code
'Fo 4ephone Number .�
Cert cation Statement:
ice that 1 have personally inspected the sewage disposal system at this address and that the
into reported below is true.accurate and complete as of the time of the inspection.The inspection
was p rformed based on my training and experience in the proper function and maintenance of on site
sewa a disposal systems-1 am a DEP approved system inspector pursuant to Section 15-W oft
Title (310 CHAR 15.000).The system:
❑ Conditionally Passes ❑ Fails
LNeIsmher try the Local Approving Authoritylre O f 3 D 7
Date
TI
e 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:
h a design flow of 10,000 gpd or greater.the Inspector and the system owner shall submit the
re rt to the appropriate regional office of the DEP_The original should be sent to the system owner
ar d copies sent to the buyer,rf 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
th same or different conditions of use.
t5fnsp"doc•11@004
We 5 OBkia1 won Form:Subsurrace Sewage Disposal System
Page 1 of 1s
Co monwealth of Massachusetts
T tie 5 Official Inspection Form
N for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Cqffcati'lop 4cont.)
V `� ' `c S �/� e- f?
AdeTess
coft
"Wo 0
Date of biw9won
nspection Summary-Check AB,C,D or E I always complete all of Section D
Sys Passes:
1 have not found any information which indicates that any of the failure criteria described
in 31 G CMR 15.303 or in 310 CIVIR 15.304 exist Any failure criteria not evaluated are
Indicated below.
Comments:
15 xl� 4P C)
11) System C Monally Passes:
One or more s . m components as described in the oConditional Pass"section need to be
replaced or repal .The system,upon completion of the replacement or repair,as approved by
the Board of Health, *11 pass.
J mswer yes,no or not determ (Y,N.ND)in the for the following statements.if"not
c letermined,"please explain.
The septic tank Is metal and over ears old*or the septic tank(whether metal or not)Is
structurally unsound,exhibits substan Infiltration or exfiftffon or tank failure is imminent
System will pass Inspection if the existing k is replaced with a complying septic tank as
approved by the Board of Health.
A metal septic tank will pass inspection if it is stru sound,not leaking and if a Cerfific,ate
of Compliance indicating that the tank Is less than 20 ye old is available.
ND Explain:
Misp.doc-1 MOW
Title 5 Mud Impectim Form:Submftce Sewage DwposW Sy-d"-
Page 2 of 18
' Commonwealth of Massachusetts
'Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
I
A. Certification ( t}
Sup)3
��
Zmers Name Date of IrmpecHonI
j System Conditionally Passes(cunt.):
Observati of sewage backup or break out or high static water level in the distribution box due
to broken or bstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspecti If(with approval of Board of Health):
❑ broken pi sj are replaced
❑ obstruction is re ved
❑ 'distribution box is leve or replace
D Explain: j
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The system required pum 'ng more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspecti (with approval of the Board of Healthy
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❑ broken pipe(s)are ced
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❑ obstruction is removed
N Explain:
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C Further Evaluation is Required by the Board of Health: A
Conditions exist which require evaluation by the Board of Health in order to determine if
the system is failing to protect pubti ealth,safety or the environment. j
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I. System will pass unless Board of ttir determines in accordance with 310 CMR
15.303(1)(b)that the system Is not functi g in a manner which will protect public health,
safety and the environment: i
❑ Cesspool or privy is within 50 feet of a surface
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❑ Cesspool or privy is within 50 feet of a bordering vege \ed wetland or a salt marsh
I
Mlsp.d=•11i2W4
We 5 Official Inwc Wn Form:Subsurface sewage Disposal System
pme 3 of 16
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Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Cer ification ( nt)
J",
!/04, -) 6 `4oP
SW
�Ocl
(Kvnees Name I oate of Inspection
Further luation is Required by the Board of Health(cont.):
1,�2 i
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2. System wl it unless the Board of Health(and Public Water Supplier,if any)
determines th system is functioning in a manner that protects the public health,+
safety and en ment:
❑ The system as a septic tank and soil absorption system(SAS)and the SAS Is within
100 feet of a water supply or tnbutary to a surface water supply.
❑ The system has a ptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic and SAS and the SAS is within 50 feet of a private water
supply well.
i
❑ The system has a septic tank a SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply
Method used to determine distance: i
*'This system passes if the well water analysis,performed at a DEP certified laboratory,for!
coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from
that facility and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less than 5
Win,Provided th t no other failure criteria are triggered.A copy of the analysis must be atta�'ched
to this form.
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3. Other.
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MispAoc•11i21M Tide 5 OftW Inspection Form:Subsurface Sewage Disposal System
Page 4bf16
j
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Co monwealth of Massachusetts
T tle 5 Official Inspection Form
No for Voluntary Assessments
Sul surface Sewage Disposal System Form
i
A. ertiftcation (cont.) St7v
07
s lame Date of fr n !
9
1
y System Failure Criteria Applicable to AN Systems:
You must Indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ Badwp of sewage into facility or system component due to overloaded or
dogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or dogged SAS or cesspool
❑ �( Static liquid level in the distribution box above outlet invert due to an overloaded
or dogged SAS or cesspool
Liquid depth in cesspool is less than(r below invert or available volume is less
than%day Now
El pumping more than 4 times in the last year NOT due to dogged or
obstructed p4*s).Number of times pumped:
❑ Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply,or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy,ls 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 coliform bacteria and volatile organic compounds
Indicates that the well is free from pollution from that facility and tie
presence of ammonia nitrogen and nitrate nitrogen Is equal to or less j
than 5 plan,provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form] !
Yes No
❑ The system falls.I have determined that one or more of the above failure j
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. f
E
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tS W.doc-1 W004 i
Title 5 Official impaction Form:Subsurface Sewage Disposal System-
Page 5 of 16
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For Imonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. OrHfication ( t.) r
ftAmes Name Date or heron
Large Systems: To a considered a large system the system must serve a facility with a
esign flow of 10,000 g to 15,000 gpd.
or large systems,you must icate either'res or'ne to each of the following,in addition to the
uestions in Section D.
YES NO d /�
❑ ❑ the system is in 400 feet of a surface drinking water supply
❑ ❑ the system is within feet of a tributary to a surface drinking water.suppiy
❑ ❑ the system is located in nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a ma ne 11 of a public water supply well
you have answered'yee to any question in Se E the system Is considered a significant threat,
r answered°fires'in Section D above the large system as failed.The owner or operator of any large
,ystem considered a significant threat under Section E or led under Section D shalt upgrade the
ystem in accordance with 310 CMR 15.304.The system er should contact the appropriate
ional office of the Department.
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t5insp.doa-1=004 Tdie 5 Dfdat Inspection Fonn:Subsurface Sewage Disposal System-
Page siof is
Co monweaith of Massachusetts
T tle 5 Official inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
5go tt)A A P-41"t"I"/" (�j Q
0 ,2 KO'
Zip code
�d r3 v7
pim&s Name I Date of Inspection
Check if the following have been done.You must indicate'fires"or"no"as to each of the following:
YES NO
❑ Pumping information was provided by the owner,occupant.or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
` ❑ Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined?(if they were not
available note as WA)
,Xfl ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
❑ Were ail 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 she 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(3)(b)l
i5uisp.doc•1 MAN Tate 5 01111dal I nspectton Form:Subsurface Sewage Dkposai System
Page 7 of 16
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Co monwealth of Massachusetts
Ti le 5 Official Inspection- Form
Not or Voluntary Assessment
Sub urface Sewage Disposal System Form
Information
C. stem of
Y �
TM
rs Name Date of inspec om
Residential Flow Conditions:
umber of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 1&203(for example:110 gpd x#of bedrooms):
umber of current residents:
Does residence have a garbage grinder? ❑ Yes &fio
I s laundry on a separate sewage system?f iif yes separate inspection required] ❑ Yes No
undry system inspected? WYes ❑ No
Seasonal use? ❑ Yes [ No
ater meter readings,if available(last 2 years usage(gpd)):
ump pump? ❑ Yes ( No
st date of occupancy:
ammerclaUindustrial Flo Conditions:
ype of Establishment:
)esign flow(based on 310 CMR 152 Gallons Per day(gpd)
sis of design flow(seatsipersonsisq.ft.,etc.
i
tease trap present? �^ J ❑ Yes ❑' No
ndustriai waste holding tank present? ❑ Yes ❑ No
on-sanitary waste discharged to the Title 5 system? ❑ Yes ❑` No
i
ater meter readings,if available:
st date of occupancyluse: pa j
Mw(describe):
t5hw.doc•1 WDW Title 5 Official Inspection Fomr.Sut=ftce Sewsp DbposW S*Wn
Page 801'16
i
Co monweaith of Massachusetts
T tie 5 Official Inspection Form
No for Voluntary Assessments
Su surface Sewage Disposal System Form
C. System Info 'on (cons)
® �.
ff state Z 27P Code
ownees[dame Date of Imp
General Information
mmmping Records: �-
W r� � ✓
ource of information:
Vas system pumped as part of the inspection? N/Yes ❑ No
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yes,volume pumped: S0ga
ow was quantity pumped determined? ll-17
A .� f
eason for pumping: Q-
_
yPe of System: zq
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)
❑ Innova&WAltemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank Attach a copy of the DEP approval.
❑ Other(describe):
14ppro)dmate age of all components,date' led(if known)and source of information:
4�S
ere sewage odors detected when arriving at the site? ❑ Yes XNo
Misp.doc•11/2004 Title 5 Official knq)ec fim Form Subsurface Sewage Dbposal System
Page 9of16
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Sub surface Sewage Disposal System Form
C. ystem Inform tion (cont)
PrIsts s ® A) ! S A-D
score /"��i L Zip Code
-EwribeiName Date of trupecHat
Building Sewer(locate on site p
epth below glade: \7evIdence
/A feet
al of construction:
cast iron ❑4o PVCn):
'stance from private water suppfit
ments(on condition of jointskage,etc.):
eptic Tank(locate on Site plan}:
epth below grade: feet
aterial o ction:
concnete [I metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age:
years
hc i age confirmed by a Certificate of Compliance?(attach a copy of
rtificate) ❑ Yes ❑ No
imensions:
lea '
Sludge depth:
sstance from top of sludge to bottom of outlet tee or baffle
Scum thickness
from top of scum to top of outlet tee or baffle 640 c 1
stance from bottom of scum to bottom of outlet tee or baffle
H ow were dimensions determined?
t
t5rn p doe 11rzm Tide 5 oftidal Inspection Form_Submface
Sewage Disposal S}rstein
Page 10 of 16
Co monwealth of Massachusetts
T tie 5 Official Inspection Form
No for Voluntary Assessments
Su surface Sewage Disposal System Form
C. System informa 'on (cont:
\J
Addre� S � �l�5 �✓SS ��� �d'
s Name f Dale of Inspection
mments(on pumping recommendations,inlet and outset tee or baffle condition,structural integrity,
squid levels as related to outlet invert, ence of leakage,a#a�
i
Grease Trap(locate on site plan):
epth below grade:
That
Material of construction:
concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions.
Scum thickness
'stance from top of scum to top of outlet tee Yf�
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
omments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
squid levels as related to outlet invert,evidence of leakage,etc.):
girt or Holding Tank(tank must be pumped time of inspection)(locate on site plan):
Depth below grade:
aterial of construction:
concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
t5insp doc•lirm" We 5 Official Inspection Form:Subsurface Sewage Disposal System'
Page 11 of 16
Commonwealth of Massachusetts
Title. 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System informati n (conQ I -
ftpedyJv'clv ss 0.111,�U
v (10yP
C41yin Kem ';V,:�)d
Ownees Name Date of inspecWn
Tight or Holding Tank(cons)
Dimensions:
Capacity:
s
Design Flow. inns per day -
Alarm present. ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes❑ No
Date of last plumping: Date
Comments(condition of alarm and float switches,etc.):
Distribution Box(if present must be opened)(locate on a plan):r
Depth of liquid level above outlet invert
Comments(note if box is level and distnbutieon to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,et :
u 'Lboo a
Pump Chamber(locate on site plan):
Pumps in working order.
❑ Yes ❑ No
amts in working order. ❑ Yes ❑ No
Mnsp.doc•11JAM Me 5 Offfdal Inspection Fwm:Subsurface Sewage Disposal System
Page 12 of 16
•Co monwealth of Massachusetts
T tie 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
.. A e /j e wt \Zj
ro Vddress , i
CityfT r-- State Zip Code
�S / C-1 /W� �d� l3 c7
Owners Rame Date of Inspect n
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 plain why: r--�
Type:
❑ leaching pits number.
❑ leaching chambers number.
leaching galleries number —
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number.
❑ innovative/altemative system
Type/name of technology:
omments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
egetation,etc.):
t5insp.doc•11/2004 True 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
C mmonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
S bsurface Sewage Disposal System Form
C. System Informa 'on (con )
Cilylr r. /j f t z o� p f--
t S V L�"e�1 11 , State 0y l J t� z �
owner's Name 'ld Date of Inspection
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
I
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil,signs of hydraulic failure,level ondin of
etc.): P g,condition of vegetation,
Privy(locate on site plan):
aterials of construction:
imensions
epth of solids
mments(note condition of soil,signs of hydraulic failure,ley of ponding.condition of vegetation,
e.tc.Y
t51rwp doc•I I=04 Tdle 5 Oft ial Impecbm Form:Subsurface Sewage LKsposal System-
Page 14 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Nc t for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Info ation cont)
LJ
i-->'l 7p- )j pyLtkv 'D,-, (,j(L
Property Address
�� �
n;s o� C-1 lvvS 0 ®�(3 v �
Chvner's Name of tnspec n
Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties
o at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.
Locate where public water supply enters the building.
��JSQ
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t5msp.doc•i 1i2004
Title 5 offid b orm Subsurface Sewage Disposal
Page 15 a 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Su surface Sewage Disposal System Form
C. System Informa ion (cont )
4A)D W �i S 7/� �e
rope M-7"L_5
ss I!�/� r" ti r �S
ityrro" State .Zip Code
t1vuS ✓gyp , l0-:?
Owners Name Date of Inspection
Site Exam:
Slope
Surface water
heck cellar
Shallow wells
stimated depth to ground water:
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 to a B2.a�r of H.�h-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You m s describe how you establis ed the hip ground wat r vation: —�-�
� � C LJ
t5in:p.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
Town of Barnstable
�p THE Tp�
Regulatory Services
Thomas F. Geiler,Director
• BAMSTABLE, • f
9� ' An
1639. •�� Public Health .Division
.ejE,p��A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number.of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT64 f^6
INSTALLER'S NAME & PHONE NC�) /,0�Y,_
SEPTIC TANK CAPACITY 16-00 g0116n
LEACHING FACILITY:(typejZ �)��i^d 1 I-S (Q-) (size)/o?i,Y 7c l
NO. OF BEDROOMS PRIVATE WELL O PUBLIC W TA ER
CBU:lL:D]EZ3R OWNER &'l
DATE PERMIT ISSUED: Q A2Y-
�
DATE COMPLIANCE ISSUED: t"l
VARIANCE GRANTED: Yes C:No:5-'
�� -' -
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No.- 'Y '•.6•----- FEB.....d 0-.Q.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
. pplirativit for Uhipatial Work.5 Cnowitrurtion Prrini#
Application-As hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.................................................
��rrrrLL Lo ou; address or Lot No.
................._[6S V �tP ._, Y1 s ---------------------------------. `:?... �/¢/y1,C3,iQ/IIG
O��ner Address
`� ' ...✓lit r Ot t
Installer Address ®
UType of Building Size Lot-_S�---3H1__....Sq. feet
Dwelling— No. of Bedrooms_________ __________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter................ Depth----------------
I� Disposal Trench—No. .................... Width----_-_--_-_-_---- Total Length.................--- Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-------------....... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit_................. Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
------- --------------------- ---------•------- ----------
0 Description of Soil.............................................................................................. .................. ......
U --- -- -- •......
Z -••-- --•---•--------------- --------------•---------------...----------------------------•-----••--•-- - ----
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 Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of-Compliance h ee issue b e o d of health.
� �- y �
Application Approved By ----------------_. ....... -
...- - --..---- .. - ----- - -- ------- --- '......................._ ----- -- -
.....-- ---- ..-- ...... ........................................
Dare
Application Disapproved for the _lowing rear n : .............. ... -- ................ .. . . . . . . . ............................
......... . .................................... - ------------------------------------------------------..............................------------------------------- ................................
PermitNo. ......6---------------------------------------- Issued ..................-------------------------------------- e
Dace
s� 4
No-7_y. �..... Fs$..../ ?..........
THE COMMONWEALTH OF MASSACHUSETTS `
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphratiuu for Uiipuial Worlw4amitrurtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: "11P
----------------�.=�—#�G�----w�r.,rfl�-6Pvv.. �.. /VF.r (... .....S•/yJ.`l/s
ress
or
�,S..a�f.Pr..o�.o,3f'P�a3�s- J•-•--- -•----------------- ��..�/......',NI�C•t..- /�?lL1E,....................................................,. 1S .. o
Owner Address
a c✓�?vvT'7 GUJ',-j ."7�nT" C,v�-rL Q`� , ✓L.. , �'Lr UZ_ .......
Installer AddressSo? Q
Type of Building Size Lot_...... ....1 t.....Sq. feet
Dwelling— No. of Bedrooms_________ __________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _
W Design Flow--------------------------------------------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 below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.----...._.__.__-___ Depth to ground water_.--_-----_______-_-_-.
fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_--_------..__...___--.
a --------•--------------------------••---•••••---•--•-----•••---•----••-••--••••••-••........--------•--------•-- ..........................................
DDescription of Soil....................................................................................................................... �-
x �}•-......................................', -- /
U �� ,,
W -------------------------------------------•--------------------------------------------------------. - �=--�----��-'--......--..-..v-------•---------------
UNature of Repairs or Alterations—Answer when applicable.----.-__-.--�f_________________ f._._......_.._................._._._.....________.____...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system`in operation until'a Certificate of Compliance'has'bee issued,by^ e board of health. -
-_
SI ned - n . ----
.�---
------
g
Dare
.Application Approved By ---------------- -.....------- fl._l>. . /W........._.. ...
Dare
Application Disapproved for the following reafVs- --- -------------- --------- ----------------------------------------------------------------------------------------------------
. .................. .............................................................................
............... . . ..... -------
------------ ........ -----------------------------------*................ -------------------------------
Permit No. .. — ................... Issued ................ . . . ... ... ..Date.....
-------- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
V1 erti irate of Tomplt2 are
v
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by -----------------------------------------------------------------......--------------...... ---- ---- --------------------------- --------------------------------------------------------------------------------
? 2 � � 1 1nsr.J ler
at ------------� '(....-. ----7!2----- N, w,._ ------- --------M----,V 1---------------------------------------------------------........-----------------------------
has been installed in accordance with the provis.Os of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ---------------------------------------------- dated ...._-.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT�THE'_
SYSTEM WILL FUNCTION SATISFACTORY.
.^.-�........-- .... or ------ --DATE...... ---------------- ------ Inspect
- -...Z./-
l-----�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
[� TOWN OF BARNSTABLE �
..............
.. FEE.. d c.�.
Bispusttt Vorkii �unu#rr#iunrrnti�
Permissionis hereby granted---------------------------------------------------------------------------------------------------------------------------••----------•-
to Construct ) or Repair ( ) an Individual Sewage Disposal System
atNo....... '� t1J.2r Q � '� ---------------------------------------------------•-----•---•--.--•--_
Street as shown on the application for Disposal Works Construction Permit No/y/_.1 \_\6�........ Dated-----
........................... ..,'...:___-;_ .__. ......................................................
L r
DATE........... �-----'�`--•------•----•r------------------------------------- of Health
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
YMl.tGw.Ib.MWI.WNM.inY'.rwYr.+.YRM vAYr_•w..<+a"a+•Mn.MM'.t.ua�lVlr[J.vV.►MM•rttiWwVrwIMN•ww1:' ..ar•w.c..•MT.+MTWM•.wM l4M1MT'1.eM.t .MYT/f.wr"!•M. YltlrMwbMVM./.NWdtiMa++.aY.MYMnMAw+nrl WwMw+.wa.!'wlDvww.blwMMarnrrR avwwYl•wYwx)k.«ti ww•Iw.•NrwYMWAMMaM1uRMT.sII.'.ivMiMJYYNMnK..tns•.wi'rs.r,+1lr4a 'J'eNNRAMAwIH.W!rtRxalMaHMWwstw.ilWn•NTii'IWrtwMMrYMM.1fM•nM-.'IYh'9ClMFwrVM•/}+,w.tf]11MflALL•+{.YII!!/YI1wW.+mnv.I.nNkt.M.M1.Nme..af.'.uY -
• 5)/fi EM PROFILE'
NOT TO SCALE
TOP FNDN FINISH GRADE
EL . 7-�. O FINISH GRADE OVER OVER TRENCHES G 610
FINISH GRADE 73.0 FINISH GRADE OVER DIST. BOX 9,O
:.o,4 o SEPTIC TANK
.d e:
7Tfi" i .
12" MAX. ;
s 4•..o b'
a:o D� +o'::Q•o 60 'v Oo4.y6dp'��.ad•, a• A'ti 0 .d w b '
e.•* , e TOTAL .LENGTH OF TRENCH -J6'' 1 ,
OUTLET PIPE LEVEL
Io, max ( 3
FOR 2 FT. MIN.
.e•.4o0 ;p ;e 00 IN`
.d6qt:AP END8C. I. OR PVC TEES b$ �¢93 ��� �. )C1 o /Zas E .' C� 7 n C_I .
J.
bsM r FL . I / mo
o o GALLON D D.IS TPIBU i`.ION BOX
cos .o Y po _
f-/6'f7 7 P F 7+0 INS TA L ON L _VEL BASE
EL . 6�.�- .;o•a o < � fl� FLOW DIFFUSORS ,
�4 sa a PRECAST CONCRETE a
•a
H-- /D REINFORCED o
AI ao.
w 'e• o v;'°moo•o d0 y o v:to �� ° v.a �•D4�r :b�'Q �4'd '4b�0'
:moo o a TRENCH SECTION:
SEP TIC TA NK
INSTALL ON LEVEL BASE NOTE:' EXCAVATE TO ELEV. --V&..0 OR
LOWER- TO REMOVE ALL IMPERVIOUS �
90.00 a9. 73 MA TERIA L BENEA TH THE L EA CHING AREA 4" DrAM. -� t 2" MIN.
RE:PL A CC- EXCA VA TED MA TERIA L WI TH ' 3" OF 1/Ei"-1/2"
CLEAN, CLAY FEE SAND a ,:e.:o,.04 o.44.p, b;e ,b a ,..m`;��
�`�tea: ..'e. , °• e$�� WASHED PEA STONE
/ 3/4 1-1/2" WAS!?ED :N
Q • .. O,e
CRUSHED S TON f_" • �
-" _a • 4
TRENCH WID TH
GENERAL NO T�=S
-� 1. ALL EL EVATION.� SHOWN ARE BASED ONALL CAPE NUMBER OF TRENCHES 'I �
2. ALL PIPES IN THE SYSTEM MU,a T BE CAST IRON NUMBER OF DIFiFUSORS ' .�
�I OR SCHEDULE 40 PVC. '
0�..�SER►�A-T.Id"ON PI T
1
T.HF Bt']AAl� AL TH MUST B. NO _— _
.,
WHEN_ CONS TRUC IO,N IS CUM�PL I�TE PRE OR
w P RCOLA TION PA TE.•
•:: f., ,? 9 .5. F.' / 'f �8 TO BACKFIL L INb E
ry � �
S'� \ 4. ANY CHANGES IN THIS PLAN MIDST BE APPROVED 2 MIN./IN.,
Ti
~ � rp� BY THE BOARD OF HEAL TH AND CAPE 6 ISLANDS h'ITNESSED BY. -
SURVEYING CO. INC. ' T.McKEON
5. MATERIALS AND INS TALLA �WN SHALL BE IN _
COMPLIANCE WITH THE STATE ANI TARP BARNS. BRO. OF HtAL TH DESIIGN L7A T
CODE - TI TL F_ V - AND LOCAL APPLICABLE E
, DA TE:• ✓AN. 14.1986
RULES AND REGUL A TIONS
-� NUMBER OF BEDROOMS d
4. 6. NORTH ARROW IS FROM RECORD PLANS AND e a NO
ro so i� .�.�ors GA RBA GE DI SPIOSA L
., •- .__. .... ..._ .-.._._._._.._. ..._.-- ••• �.g , / IS NOT 70 BE .USED FOR SOLA.I� _PURPOSES 4' � i
7. FLOOD HAZARD ZONEC [NON—HA,?AF)OJ DA IL Y f�L ON
440 GAL .
--- -- TOWN WA TER - �- 1500 GAL .
-- _ 8. WA TER SUPPL Y_ TO SEPTIC TA NK )PEG D.
6e -- SEPTIC TANK IPROV.IDED 1500 GAL .
%' cK \ _ •^fEIU/u�A ;<,�w LEACHII�IG 'REQIUIl7ED 440 GPD.
poop•0 \ AOP'e�A•
P
aPBo �•Nou •o AA REO 'D �+ 440 GPD/0. 75 SF/GPD 587 SF.
�o� / MsvruM
•,r
v a
637 SF.
\ t' AA PROVIDED .�3 X 49
LEGEND r
7 \ 00
_ 2i •.• ti0 0• �
i I \ T w e POS D EL EVA ION
\ � h FRO E
70 -- EXISTING CON TOUR REVISED SEPTIC DESIGN
OBSERVA TION PI T
�'� �• (C, 0 DISTRIBUTION BOX
�5� PPOPO SED S�E'WA G� DISPOSAL S YS TEM
I (D� o f L ON DIFFUSOPS
_ C, r ► ., : ;r: PREPARED FOR
o o :y'EP TIC TANK ''� �:�' A BBO T T CONSTRUCTION CO.
L O T _63 WHIS TL EBEPR Y DPI VE
i�EsEkvE AREAof- , MARS TONS MIL L S — MASS.
PIPE INVERT ELEVATION <' �AV!ARLES
SANicki DA TE.•����Y��,, /9 9,3 CAPS 1C ISLANDS ENGINEERING
28065
PLOT PLAN o a, SCALE A S NO TED 133 FA L MOUTH ROAD - SUI TE PE
SCALE.. 1 ,n' Co/ S/ art ►�� kt:
-,, .
PLAN/V NO, r 3MA SHPEE MASS.
to h h •�L�««i� K l ,