Loading...
HomeMy WebLinkAbout0019 FILLY WAY - Health 1+ 19 Filly Way \ ons Millst10904:AI=- l5 - ' I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sy�st/em Form -Not for Voluntary Assessments 4'M 19 Filly Way �`�J ( - V g Property Address Steven Gemborys Owner Owner's Name I information is MA 02632 7-15-11 required for every page. City/Town State Zip Code Date of Inspection 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. A. General Information ;7 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Corr pany Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was perormed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-15-11 Inspector's Signature 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface S ge Disposal System-Page 1 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 19 Filly Way j ` Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA' 02632'' '' .7-15'11'* - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ' ® 1 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: System is in good working order with no sign of failure. 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): 1 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. City/Town State Zip Code Date of Inspection 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 obstructedpipe(s) or due to a broken settled or uneven distribution box. System will Y 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 y r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. Cityrrown State Zip Code Date of Inspection 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 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 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is Centerville MA 02632 7-15-11 required for every page. CitylTown State Zip Code Date of Inspection 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. ❑ ® 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`-1WPA) 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. .5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ESWEam Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. City/Town State Zip Code Date of Inspection 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? ❑ ® 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 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 (f 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [f yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5-2011 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner—pumped 4 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is Centerville MA 02632 7-15-11 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 19 Filly Way Property Address St even Gembo rys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" 1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 9 I 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: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. CitylT'own State Zip Code Date of Inspection 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.): r 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): 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: t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number:. 2-500's ❑ 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.): Chambers in good condition and empty at inspection with stain line at 4"from bottom of chamber. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is Centerville MA 02632 7-15-11 required for every ` page. City/Town State Zip Code Date of Inspection 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 TOWN OF BARNSTABLE .00ATION 9E /I YGJ54 V SEWAGE # JII,.LAGE /!ASSESSOR'S ASAP&LOT__ NSTA.L4ER'S NAMF-&PHONE NO. 4 ;EPnC TANK CAPACITY 0 d 0 EACHING FAC:ILr.rY: (type)�!�cr•✓l PrS (size) ;O.OF BEDROOMS 3 IUILDEE OR OWNER ERMITDATLI: -�.- ; CO1bL DANCE DATE: separation Distince Between the: 4aximum Adjusted Groundwater 1`4ble to the Bottom of Leaching Facility 'ivate Water Supply Well and Leaching Facility (If any wells exist an site or within 200 feet of leaching facility) Age of Wedand and Leaching Facility(If ai,y wetlands exist within 300 feet of Caching facility / sect 'W'tli.shed by c5 Q w n 5 E<r'a Iy. D Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. City/Town State Zip Code Date of Inspection 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 public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i� 6 S �t bEC ! t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Ill—._ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is required for every Centerville MA 02632 7-15-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high groundwater: 10, 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: Original design plans show no groundwater at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 19 Filly Way Property Address Steven Gemborys Owner Owner's Name information is Centerville MA 02632 7-15-11 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 - TOWN OF BARNSTABLE [LOCATION SEWAGE # VILLAGE Moe-iron s ASSESSOR'S MAP & LOT /S/ O f rJ INSTALLER'S NAME&PHONE NO. ?7-0:j 9 f y�p� Dy- SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) ?-Sep i al;=ll (size) 1 s-X i 3 NO.OF BEDROOMS -3 BUILDER OR OWNER PERMTTDATE: /0 —f COMPLIANCE DATE: I/—/2 - F17 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private,Water Supply Well and,Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Af Furnished byi � XV 6 GA .r i ��ad �•»p I a l r -sue i 3 I T TOWN OF BARNSTABLE LOCATION I SEWAGE # V LLAGE S�ISSESSOR'S1MAP & LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= LEACHING FACILITY: (type) (size) NO.OF BEDROOMS .. BUILDER OR OWNER .! 4 PERMITDATE: COiv =Ni E ATE: JC`3�t'1CxCr,4 Separation Distance Between the: '2 M q Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by s beck. TOWN OF BARNSTABLE LOCATION /9 lv �U��/ SEWAGE # _9q llG VILLAGE ASSESSOR'S MAP & LOT /S/ OQO INSTALLER'S NAME&PHONE NO. Dw. IZz,--o5 SEPTIC TANK CAPACITY 14ao , LEACHING FACII.TTY: (type) 2-500 Gal, lys=l1f (size) 1 SX i I NO.OF BEDROOMS -3 BUILDER OR OWNER PERMTTDATE: —/0 COMPLIANCE DATE:- L/—/2 ' y9 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by— 9� �1 1 r �a D,9ox N� o. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for �Bigoar *pgtem Congtruction i3ermit Application for a Permit to Construct(z/ Repair( )Upgrade( )Abandon( ) []Complete System ❑Individual Components Location Address or Lot No. /q / y � / Owner's Name,Address and Tel.No. C1C{//Ii%G 561/�s% Assessor's Map/Parcel s W, ram. Insttaller's Name,Address,and Tel.No. 4/71— 03 4!17 Designer's N' e,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 9 Lot Size sq.ft._ Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Ans/wer when applicable)�s«l/ 2 .SG® G�t� l�rti taxi=/�s �I,UGIl/ 2" Piuf� 3las� 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 issued by this Board of Health. Signed Ial.- - Date Application Approved by Date Application Disapproved for the following reason Permit No. Date Issued No. �--� Fee v ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSE�TS application f or ;Di.5pogal-*patent Con.5truction Permit Application for a Permit to Construct(6..-'Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. /9 /� Wl* Owner's Name,Address and Tel.No. ry,,jersTo0 S 04'/'3 bx/�rI Assessor's Map/Parcel Installer's Name,Address,and Tel.No. L/qr/— 03 41 f Designer's NZne,Address Ld Tel.No. Josr�l, v� l.�owrD,g Type of Building: Dwelling. No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day,.;Qalctilated daily flow, gallons. Plan Date Numberof-sheets " Revision Date Title - Size of Septic Tank r, Type of S.A.S. r Description of Soil Nature of Repairs or Alterations(Answer whenapplicable).Tjdjrr1,�/ ' 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 issued by this Board of Health. Signed fn� Date Application Approved by Date Application Disapproved for the following reason Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS 1 , ; BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(Repaired( )Upgraded( ) Abandoned( )by / /- 42 at `, h been constructed in accordance with the provisions of Title and the f r Disposal System Construction Permit No. dated Installer Lq_o L 62,s ,x„�s Designer The issuance of this permit shall of be construed as a guarantee that the sft l function a�esigned. Date I < Inspector /^n / ,/ �'1^� No. / n i I Fee THE COMMONWEALTH OF., MASSACHUSETTS/s PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ;Di5pogar pgtem Construction Permit Permission is hereby granted to Construct( epair X)Upgrade( )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:Constru ion m st be completed within three years of the date of this pe Date: Approved by � u I 10/9/97 1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systeffis Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT PLANS ENGINEERED ) i I, Jos,p� hereby certify that the application for disposal works i construction permit signed by me dated 3 /0 - ?f ; concerning the property located at /Q Frd/u W*e ,;1, /'ls' meets all of the following criteria: 1 I ere are no wetlands located within 100 feet of the proposed leaching facility 4/'-There are no private wells within 150 feet of the proposed septic system The . no increase in flow and/or change in use proposed There are no variance's requested or needed. j + If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will pQ be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. i� Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) A 1 B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: %S��urri DATE: �b—94 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted). I q:health folder:cert 1 9 P 2 5)0 r� WS115 1 I TOWN OF BARNSTABLE LOCATION � V-'.\\c- �ck4 SEWAGE # VILLAGE u- _ G C c� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,i '> a R C APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION �- 'Cp ` C`� �`l NO. TILLAGE _ DATE -, APPLICANT FEE_ 1DDRESS y t TELEPHONE NO3 ,> J�/ (Non-refundable) ENGINEER00- TELEPH NE NO. )ATE SCHEDULED ,r (Appli an 's signature) . •E S•SO o 0 0 R'0S 0biA 0 0 •PSz 0 • 0 0LOT 0 0 0 0O:0 0 0�•�• • 0 0 0 00 0J 0 0 • • • • • • o • • • 0 • • • 0 • • • • 0 0 0 0 • • • • • • • o • o • • . . . . . . . . . . 00 • o • • • • • • AS S N _. � SOIL LOG SUB-DIVISION NAME �" Ii `' DATE 0,� `jb�_ TIME f,D 45 :XPANSION A A: YES N0� � ��c-f.���N_1������� - ENGIN_EER:'?� 'OWN WATER PRIVATE WELL ` ~ BOARD OF HEALTH ����.__ ✓`F�J Ij EXCAVATOR KETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: 0 .� L9 'ERCOLATION RATE: 'EST HOLE NO: ELEVATION: TEST HOLE NO: L ELEVATION: .A_ 2 2 AND 3 '' 3 -� 4 4� - 5 5 6 6 7 T-i r►F 7 0E- 8 8 _5A0.p 9 9 10 10 r,rz 11 � it 12 14 1�� 14 15 15 16 16 !UITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD�_LEACHING PITS LEACHING TRENCF'iES INSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: TOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED :ON PERC TEST APPLICATION iRIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH :OPY: RETAINED BY APPLICANT TOWN OF BARNSTABLE LOCATIONI o SEWAGE # c5 � m -0 .D VIl[eLAGE ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) '\�lv �,� (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: G VARIANCE GRANTED: Yes No -� C�� � � i J ✓� � � � y �q ��� _ a O® O \� � ICI . � �/ r �' �� l�� � ' _� ^ `- - . �GJ � ��� �l 5 Eic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ...W.^..f----..OF....1 .......................... Appliration for Disposal Works Tonstrnr#iun Vrrmit Application is hereby made for a Permit to Construct ( k<or Repair ( ) an Individual Sewage Disposal System at: C? .f....e...............---....-----...-----------•.....................--- L cation-Address or Lot No. . s Q T.- � l..3t_..._ a cs�-- -e,f z 1f, � <.s...�.�.....---- Owner Address Installer Address Type of Building Size ..................Sq. feet UDwelling—No. of Bedrooms..................`3.....................Expansion Attic Ji-'J Garbage Grinder Other—Type of Building J....EQ^^..... No. of persons.........(................. Showers Cafeteria Q' Other fixtures -----:7�.................................................................................................................................... W Design Flow..................�3..............gallons per person per day. Total daily flow------- .................._�gallons. WSeptic Tank—Liquid capacity.l.ad.�allons Length.O...S._.._ Width.f..A°fl... Diameter._.. Depth................ x Disposal Trench—No..................... Width.................... Total Length..............0...... Total leaching area....................sq. ft. Seepage Pit No........(............ Diameter.........z_...... Depth below inlet....... Total leaching area..:�3.9...sq. ft. Z Other Distribution box ( Dosin tank„( _ _ (v78 G,�v `-' Percolation Test Results Performed by.._�_o_�vn�• e �P� Date........ -S�� �a Test Pit No. 1.. .z...minutes per inch Depth of Test Pit.....� ��r Depth to ground water..... (i Test Pit No. 2...<.z-..minutes per inch Depth of Test Pit..... . ..... Depth to ground water....1. 4-3 Description of Soil.............�p---�_. =5 !_?__...__._.4 i--It t --.. s vc'Z �1"S © Q x --------•-••......•-----•--••--- V ------------------- -............. ------------------------------------------------------------ ....... ----------------------------------------------------------- •--------- .....----------------- •---------------........................................................................................................................................................................................ V Nature of Repairs or Alterations—A er when applicable- ................................................... Agreement: The undersigned agrees ttall the aforedescribed Indivi al Sewage Disposal System in accordance with the provisions of iITI4 5 of the tate Sanitary Co Th u ers' further agrees not to p/etystem in operation until a Certificate of pliance has bee s bo f health. ` Signed ------.-•--- . . ApplicationApproved y---••--•---•• •-----•--_.._................ .............................................. ......... - Date Application Disapproved for the following asons:-••••-••------•---•-•---••--.........•-••••-------••-•--------••--.---•--•-••••--••.................•--•--...---- ----•-...--•--••--•.............•-•---....••......--••-••-------•-•---•---•.........•----•--•----•----•---•-•-••-••-•--••-•----•--•-•••-•--••--••-•-••---•-•-----•--••••••--••-••----•--•-•-•----------- Date PermitNo......................................................... Issued.....-----•----•---------------•----•---•-------•---•--- Date Noh.--j-U-) .......:..SJ ... -' THE COMMONWEALTH OF MASSACHUSETTS w BOARD OF HEALTH .T J. V.V..e!,�......OF.....i7�..... •,T , �S j.-�7.? !_ i Appli.ration for Disposal Works Tonstrn.r#inn Prrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Location•Address J or Lot No. r..!............»................r ._!'.:::.._... ._..._..� F.... .: ... f_.�..... l 7....- ........ �...._._...:. ....... ...... r. . . . ! / Owner 1 ^/f Address a ~_f. �' r� -...........- ---- `-.................................� .. t�•" ..--.... ._•.................... ......................................•............... Installer Address Q Type of Building Size Lot..!__` .... .....Sq. feet U Dwelling—No. of Bedrooms..................�_�__.........._..__..Expansion Attic Garbage Grinder_(---) Other—Type T e of Building -^.___. No. of ersons.._._.._�._._.__.__�_.____ Showers .-� — Cafeteria �= a YP g •• •--....::• P ( ) ( ) Otherfixtures `= ----------------•------------------•--._-.-........_.._------•------......__..._ W Design Flow...................-,i......�..............gallons per person per day. Total daily flow...... ��__�...._......._.........gallonss. Septic Tank—Liquid capacity_-!_-._.__..gallons Lengthen?'._.�...... Width-:!:.'.!b.'._ Diameter-------=--- Depth-:;.......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------I------------ Diameter......!...�._...._. Depth below inlet..................... Total leaching area..............L...sq. ft. Z Other Distribution box ( )' Dosing tank_(,....) 7 c,,t, '-' Percolation Test Results Performed by.... --a _......I...__..... .! ..: �!-� {--•------------------ Date.----- -- --... ........ Test Y ,.a Test Pit No. L.Z-...?....minutes per inch Depth of Test Pit.. .!._-.x__!'_`�Depth to ground water.. �.._ .... �r 44 Test Pit No. 2--- '___Z.....minutes per inch Depth of Test Pit.....{ _..6 Depth to ground water----I.. P4 ............................................ .................................................. J -----• ....fa.--..i_....... D Description of Soil.............r t _ —. , I. _. ..c __________________ _.........................................................._._._..._._.... r C... Z',+''1!. Q x w UNature of Repairs or Alterations— wer when applicable..................................:............................................................ ........................................................... --------------.-_•----------•-•--•----•-----...------------------------------•------=-------.......................................... Agreement: The undersigned agrees `install the aforedescribed Indivi ual Sewage Disposal System in accordance with the provisions of TITS: 5 of State Sanitary Cod —Th. u ers' further agrees not to place the ystem in operation until a Certificate mpliance has been is bo f health. Signed......� :' .. . I/ Da •- Application Approved By._ �11_� ................(4. - r z � ------------------------ Application Disapproved for the f ollowi g reasons:------•--------•----•--•----•-------•------------------•-----------------------••-----------------•------ ----- ..-•-••-------•--••--•-•-•...............•...._.....-•••----•............--••-•-••----•-•-....•••---•----••-•--•••-•-•-••---••••--•-•••------•-•------------•-••••••--••-----•----•-••••-••--......--•-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................!7..:: et/.....OF... _ .r... ,? ✓..= .!... �? ,................................. T rtifirate of TontpliFatirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V)or Repaired ( ) 1_� / r / t` f- ---=),' /-'S i •..... - !`' -, .-----, /f by- -----------------•--....----------•-•.................. Installer has been installed in accordance with th provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit Up _ ................... dated------------------- THE. ISSUANCE OF THIS CERTIFICATE S ALL NOT�E�CONSTRUE® AS A GUA�d�VT�E�IAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. ,__'..._X.- .................................. Inspector......0\. - - - --- ........................... ✓� THE COMMONWEALTH OF MASSACHUSETTS J BOARD OF HEALTH C - Dinposal Workii Tonntrudion Vprrmit Permission is hereby granted----,�=� = .............. t.` - ='t/--` •-•'........- ........................................................ to Construct (j�)'or-Repair ( ) an Individual Sewage Disposal System at No......''` -- f G - -- 1.� -•--------•-..._ ...._....._ Street as show,on-th application for Disposal `'��orks Constru Ii p Pe ��5 .__._______ Dated.____.....__�........................ `!�._ f Board of Health DATE- ....... - = == -.... FORM 1255 A. M. SULKIN, INC., BOSTON „ BENCH MARK : " °` TEST HOLE RESULTS *. P { (C � Q „ • 1 ,,-1 1 DATE WITNESSED BY 7n"C1 j JN4 TEST H0LE't / TEST HOLE 2 7” F, ti =- a a s 4 '3 ..._.,..__�....._ �✓tom � r r s WOGROUND WATER � GROUND WATER �, � �: ENCOUNTERED ENCOUNTERED } S A R fi0 I TO JT �r ; i ' ELEY. TOP OF AND� MANHOLES !2 OF VFiNI BE BUILT GRAD _ FOUNDATION SHED E � - & �— E�, N ADE I 2 /o SLOPE -1rt " ,',� �; _.—� DIA. -- - 4 G• DIA. PIPE FIRS 2"MI ,�.. _ MIN. PITCH i FT. 2� LEVE j_ f N . LAYER OF MIN . 2 - - r _ 41 • 1/ 8- V2 PEASTONE d MIN. C H M� ' QWg"i., ; r' , ' INVERT �. / GALL/F T. ON INVERT 6"swHP I'NVEPT . :Q ? ED r L S !� H E a FOOTING TO 9E PLACED E P T I C TANK 0lST W 2 . ; 1 N•VE R T INVERT BOX INVERT ERT `• cr WASHED STONE ON A MINIMUM OF 18' OF N %� w ° � ALL AROUNo _- x ,, I PLACE ON � �, ( ± �i �•«• BOTTOM AT ELEV. /� . .-� ---►� ` -f t 7 = Y VIRGIN OR COMPAGTED ' ' IO�MIN. FIRM BASE 1 ? '� ��: E SAND ` -C7_ °` r.-.` � i GARBAGE t; 20' MIN.} , r GRINDER ^' a � 4" OIA. PERFORATED DRAIN PIPE WITH 3/4 t P R O F I L E OF G R O U N D WATER TABLE 1 TO I/2 DIA , STONES7 AC. rl SANITARY DISPOSAL SYSTEMf ( NOT TO SCALE )► ra D E S I G N D A T A w _.. # CONSTRUCTION OF SANITARY DISPOSAL BEDROOMS SYSTEM SHALL CONFORM TO THE MASS. 33a _.• " DESIGN FLOW GAL /DAY ENVIRONMENTAL CODE TITLE 3t LEACH RATE MIN./INCH (REVISED 7-' 1-77 ) AND THE TOWN / 5 1 HEALTH DEPARTMENT REGULATIONS REQUIRED LEACHING CAPACITY ?' 0 SEPTIC TANK, DISTRIBUTION BOX AND LEACH- PROPOSED G�L,/`DAY ,v 1a — /, cJi� rc , G ING UNIT TO BE OF REINFORCED CONCRETE : `�� C ,, 4-/ MIN. CONCRETE STRENGTH 3000PSA REQUIRED SEPTI� TANK : /000 GAL, MIN, STEEL STRENGTH = 20,000 PS. I. � r' `4 's MIN. DESIGN LOAD I N 0 : f PROPOSED SEPTIC TANK -' /000GAL, 1 DRIVEWAYS NOT TO BE LOCATED OVER SYSTEM z. UNLESS H2O DESIGN LOADING IS USED s ALL PIPES AND FITTINGS TO BE WATERTIGHT - AND TO BE OF CAST IRON OR APPROVED P.V.C. HEALTH AGENT APPROVAL DATE ISI ,TE PLAN SHOWING PROPOSED CONSTRUCTION ZONING DATA LEG EN D LOCATION : BARNSTABLE . � �. FOR : LE 8 El.— S 0 LLOWS O EV. CORP- DATE : � ��� ZONE ©�'&'/V SPACi ant Ttf =atiE �`� TEST HOLE LOCATION � LOT � AS SHOWN ON RE _ ' � ) � � REFERENCE VISIONS • REQUIRED AREA .�_ 14SGo� /099►4" EXISTING SPOT ELEVATION 17.6 �PL�H °FMB PLAN BOOK 420, PAGE 1 �� ( 134 37,5 ' EXISTING CONTOUR — 16 cAi REQUIRED FRONTAGE •.._. � � s�0T REQUIRED FRONT SETBACK . ,�3 7,4 PROPOSED CONTOUR —"""' 0�24 SCALE '- 1 "=40t REQUIRED SIDE SETBACK �� � 7S` PROPOSED WATER SERVICE W—•--- r, GISTENAt �°��ti�� REQUIRED REAR SETBACK I ,��` 7S ' PROPOSED GAS SERVICE G PROPOSED ELEC. & TELE E 8 T CRAIG R . SHORT , P. E . PROFESSIONAL CIVIL. EN Q 1 N E E R BUILDING INSPECTOR APPROVAL DATE 131 OLD ROUTE 132 , HYANNIS , MA. 02601 FILE NO. t ( TELE. (617 ) 362 - 9 �411 SHEET 0 / "ill i W