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HomeMy WebLinkAbout0046 HANE ROAD - Health 46 HANE ROAD, MARSTONS MILLS - - - A obi-- 6� r if TOWN OF BARNSTA_BLE... - v%OCATION A Iq SEWAGE # -AVILLAGE Y�) Cl Y" ��_t5v. �/e'1 I Z ASSESSOR'S MAP & LOT A INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS BUMDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 — - 4 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owner's Name'�,/� ,�/� Barnstable rV All S 'V 41 IS MA 02648 2/25/13 Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector. Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone Number N B. Certification ' 4 I certify that I have personally inspected the sewage disposal system at this addr, ss and that the~ 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 orb site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section.15.30 of Title 5(310 CMR 15.000).The system: - Q ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/25/13 Insp s Signa ure 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. 46 Hane Rd•03/08 Tide 5 Official Ins f Subsurface Sewag�I I py-.M•zlofls Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 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: ® 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: Pumping suggested every 3 yrs to prolong the life of the system 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. Answer yes, no or not determined (Y, N, ND)in the ❑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. ND Explain: n/a ❑ 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 ❑ obstruction is removed 46 Hans Rd•03M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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 ❑ obstruction is removed ND Explain: n/a 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. I. 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 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. 46 Hane Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2125/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: n/a 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 day flow ❑ ® 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. 46 Hane Rd•03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 pp m, 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 fiffl. 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 11 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. 46 Hane Rd•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s� 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Cityrrown 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 (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] 46 Hans Rd•03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if 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)): Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: Last date of occupancy/use: Date Other(describe): n/a 46 Hane Rd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No recent pumping per owner 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): Approximate age of all components, date installed(if known)and source of information: Original septic tank 1988 and new d-box/SAS 2006 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 46 Hans Rd-03/08 ride 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'y 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) Caution there is an utilty line directly over the outlet cover If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g 1„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace. Distance from top of scum to top of outlet tee or baffle >2° Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured 46 Hane Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5••re 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 CitylTown 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a L4�6Hane Rd•03108 Title 5 official Insp ection form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owners Name Barnstable MA 02648 2/25/13 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level w/the bottom of the pipe 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.): D-Box in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 46 Hane Rd-03108 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 11 of 15 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 per as built ❑ 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 were robe and soils are dr y ry and compact. No indication of backup 46 Mane Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 City/rown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): n/a I 46 Hans Rd•03= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 or 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '- 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 City1rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. 1 't C � © � c" C)- � (0 48 Hane Rd•03108 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 46 Hane Rd Property Address Maher Owner's Name Barnstable MA 02648 2/25/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ii Estimated depth to high ground water: >12'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: Per elevation of home 46 Hane Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOW OF BARNSTABLE /p LOCATION ,� Ld1 SEWAGE VILLAGE 4y wASSESSOOR'S MAP P jRCEL INSTALLERS NAME&PHONE NO. Qt3a If- v SEPTIC TANK CAPACITY /ST- 61M LEACHING FACILITY:(type)3W 5o p(�J�(.� (size) ;?r 15� NO.OF BEDROOMS 3 OWNER PERMIT DATE:' ��j�D to 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 within 300 feet of leaching facility) Feet FURNISHED BY � . (A rq �i o � A 3s � ' i No. �©lVi Fees THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTIA DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rppricatiou for �Btzpozal �,_ p!gtem Cow9tructiou Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( j Abandon( ) ❑ Complete System �j Individual Components Location Address or Lot No. P / Ownnte_r's N me,Address,and Tel.No. Assessor's Map/Parcel 'I' m' -5 W j �� Ins 11 's Name,Address,and Tel.No. (568) Designer's Name,Address and Tel.No. 0 C 637, 4k a 04 6 oZ.&®i c 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(mi .req fired) 3�n gpd Design flow provided .33 1. 5 gpd Plan Date 36 Number of sheets J Revision Date Title J/ ��— Size of Septic Tank� �,g�` tW Q(Zt Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this oard o Health. gned Date V Application Approved Date c3 __ Application Disapproved by: Date for the following reasons Permit No. /0 Date Issued No. . ©�✓`+1 �t�/9 Fee — a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTF., DI ION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Di5pont 6p.5tem Con,5truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(� Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. ,),a— Owner's Name,Address,and Tel.No. �' Assessor's Map/Parcelm t 115 CoC' I b y i a6; ov Ins alle 's Name,Address,and Tel.No. �5(j��'�7��1 Designer's Name,Address and Tel.No. ' <x 65 7 a rnnl' oz(-o 1 c s Type of Building: ~- Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Design Flow(min.required) 310 gpd Design flow provided :3 �. gpd Plan Date3 b l b(o Number of sheets Revision Date Title AA Size of Septic Tank p.rX 1 5 t /(�`)Q Q Type of S.A.S. k Description of Soil v 1 _ 1 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. T Signed Date U Q -Application Approved(y Date Application Disapproved by: M Date f c.the following reasons Permit No. r �p �� L POP` Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFjY, hat th On-site,Sewa�jz Disposal System Constructed ( ) Repaired ( ) Upgraded (�) Abandoned( //)-by Y'� It �,,, G f at b ( � _�1j 6ItO I S atbeen constructed in accordance with the prov lion olf Title 5 and the for Disposal System Construction Permit No. dated_ 31J Installer / Designer -P #bedrooms 2) Approved designAloow� ,�03 0 gpd The issuance of this permit shall not(bee�co strued a 'a guarantee that the system w,li 1 function saes�ed. Date V (b Inspector ———————————f————————————————————————---——————— No. 6 �t`/ Fee /D a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS =i!5po.5ar 6pgtem Con,5truction Permit Permission is hereby granted to Constructs( Repair ( ) Upgradee () Ab j ( ) System located at `�l0 HO n oo,F1` �'�MJ k S 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 conditii ns. 'Provided: Constructio must b /completed within three years of the dat• of this pe it. Date 1!J Approved b Town of Barnstable Regulatory Services I Af I Thomas F.Geiler,Director "e"AK Public Health Division Thomas McKean,Director 200 Mala Street,HYanmb,MA 02601 Office: 508-862-4644 Fax: 508•790-6304 Installer do Des'mer Certification Form Date: 9-22-06 Designer: Sbav&QZMpMgg4L$erv'r, ,s Inc. Yostaller: Robert Septic Smice& Addrew: P.O.aq&§27.Fjglmnuth Addrem: Street _MA 02536 Yarmou . tuts On—IM 6 __ b=S ne�Servi'ce was kssued a permit to install a (date) " (installer) septic system at MA based on a design drawn by (address) ShX-v_ironmental Services Inc dated !} (designer) _XX_ 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateW relocation of the distribution box and/or septic tank. T certify that the septic system referenced above was installed with greater than 10 lateral relocation of the SAS or any vertical reluuuuun of an corn neat of the septic y p� stern but in accordance with system) th State &Local Regulations. Flan revision or ceri built by designer to follow. OFF CARMEN (IMtaer's Si ) E. SHAY N No. 1181 Te s4 Brier S ig A iX Des VT.R A..QIW 194i IPI r®AT 'iPFi ��r a�►it, r yr, r,.,,... �.. ..�- ,b _,,.., — --•... - - y'° 1,Ji.a D lJil1, rAND .' Q:H9WWSVdc/DiAper C&nMMft Form 100/100 r 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM L hereby certify that the engineered plan signed by me dated ,5 30 No, concerning the property located at 4t—, WS meets. all of the following criteria: • This failed system is connected to a residential dwelling only...There are no.commercial or business uses.associated with the.dwelling. 0 The,soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests,at the site without a health agent present. • There is no.increase in flow and/or change in use proposed ' • There are no variances requested or needed. • The.bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) O B) G.W. Elevation 40 +adjustment for high G.W. DIFFERENCE BETWEEN A and � " SIGNED : DATE: 54 lAo,—C)� NOTICE Based upon the above information;a repair permit will be issued for bedrooms s maximum.. No additional bedroom are authorized in the future without engineered septic system plans. V•` qASeptic\percexemp.doc + lQ� Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Wald Trudy Coxe Governor 880"q Argeo Paul Celluccl David B.Struhs u.Governor canmwloner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 46 Hane CERTIFICATION M Property Address 'MirLs Address of Owner. Dave Ham Date of Inspection: 3—3 0—9 6 (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site eew disposal systems. The system: Zs — Conditionally Passes — Needs Further Evaluation By the Local Approving Authority — Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A) SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. J EM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. es,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. 11/03/95) 1 One Winter Street * Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292.5500 i,Printed on Recycled Paper ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PeopertyAddrem 46 Hane Rd W.Barnstable Owner. 3-30-96 Date of Inspeotion: Dave Ham B)SYS. CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,uuuless a well water analysis 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 ppm. 9) O ER (revised 11/03/95) 2 1 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Hane Rd W.Barnstable Owner. Dave Ham Date of Inspection: 3—3 0—9 6 D] STEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMIt 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to the failure. _ Backup of sewage into facility or system component due to an 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 boa 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 1/2 day flow. Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for cohform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARG SYSTEM FAILS: Th following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into Hill compliance with the groundwater treatment program requirements�f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for fluther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46. Hane Rd W.Barnstable Owner. Dave Ham Date of Inspection: 3-3 0-9 6 Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �As built plans have been obtained and examined. Note if they are not available with N/A. v The facility or dwelling was inspected for signs of sewage back-up. _1/4'he system does not receive non-sanitary or industrial waste flow VThe site was inspected for signs of breakout. system components,excluding the Soil Absorption System, have been located on the site. v1le septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or ' tam,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. _YThe size and location of the Soil Absorption System on the site has been determined based on existing information or //approximated by non-intrusive methods. vThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 46 Hane Rd W.Barnstable Property Address: Dave Ham Owner. 3-30-96 Date of Inspection: FLOW CONDITIONS RESIDENTIAL• Design flow: 33 Q gsllons Number of bedrooms:-3— Number of current residents: Garbage grinder(yes or no):_L/ - Laundry connected to system(yes or no):� Seasonal use(yes or no): Y Water meter readings, if available: icy Cl 7 4 Zo, a ��ct'A Last date of occupancy: 3 •-30 - 1 4 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 6 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: A,, A System pumped as part of inspection: (yes or no)_L-o�0 If yes,volume pumped: ¢allons Reason for pumping: TYPE OYSYSTEM Septic tank/distribution box/soil absorption system Sin&cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) A/'e) (revised 11/03/95) S 4 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oondnued) Property Address: 46 Hane Rd W.Barnstable owner. Dave Ham Date of Inspection: 3—3 0—9 6 SEPTIC TANK:_ (locate on site plan) Depth below grader / _ Material of construction:_✓concrete_metal_FRP_other(ysplain) / z . /0S C Dimensions: 4 ` 7 y- T to Sludgey depth: �" Distance from top of sludge to bottom of outlet tee or baffle: 1/d' Scum thickness:' Distance from top of scum to top of outlet tee or baffle: g Distance from bottom of scum to bottom of outlet tee or baffle: // Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural into"' , evidence of leakage,etc.) .5.,-s zgj, 6�a a. n �$/� _ /V c) Lt..,c�&t j iy y'�,i t G TRAP_ (locate o site plan) Depth belo grade: Material of nstnwtion:_concrete_metal_FRP_other(e:plain) Dimensions: Scum thicla Distance fro top of scum to top of outlet tee or baffle: Distance m bottom of scum to bottom of outlet tee or baffle: Comments: (recomman tion for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of ,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddeeaw 46 Hane Rd W.Barnstable Owner. Dave Ham Date of Inspection: 3—3 0—9 6 TIGHT H K:HOLDING TAN _ (locate on plan) Depth below Material of n•_concrete_metal_FRP_other(e:plain) Dimensions: Capacity: one Design flow: gallons/day Alarm level: Comments: (condition of' et tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of bog,etc.) /--y PUMP C BER:_ (locate on si plan) Pumps in wo order:(yes or no) Comments: (note condi ' n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Hane Rd W.Barnstable Owner. Dave Ham Date of Inspection: 3—3 0—9 6 / SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits,number: leaching chambers,number:_ leaching galleries,number leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: Comments: note condition ot��Gsi n hydraulic s of hydrau Mue,level of ponding,condition of vegetation etc.) 6 6 0 Cad �/z ��eb a LS CESS _ (locate on si .plan) Number and on: Depth top of I 'd to islet invert: Depth of solids yer: Depth of scum r: Dimensions of pooh Materials of co on: Indication of dwater: inflow cesspool must be pumped as part of inspection) Comments:(nnte condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site p Materials of co coon: Dimensions: Depth of solids: Comments: (note ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddeesw 46 Hane Rd W.Barnstable Owner. 3-30-96 Date of inspection: Dave Ham SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' f DEPTH TO GROUNDWATER Depth to groundwater• j 5`+ feet II _ method of determination or approximation: (revised 11/03/95) 9 r r . THE COMMONWEALTH OF MASSACHUSET7S BOAR® OF HEALTH AVV iration for Disposal Works Tongtrurtinn Prrutit Application is hereby made for a Permit to Construct (,,-<Or Repair ( ) an Individual Sewage Disposal System at: Locatio - ddress or LoT --- f ...Owner ^._ _ .... re f__....Y_-`. .e.................... Installer /�`/ Address , Type of Building - Size Lot______.____________________Sq. feet Dwelling—No. of Bedrooms_____________ _____._____________.__._.Expansion Attic.�-T--- Garbge-Grindef ( ) Other—Type of Building l F__tk^'*J No. of persons........j(e�............... Showers — Qaf *eri �" P4Other fixtures --- �--.-------- --------------------------------------------•---••------------------•--------••-•----------- W Design Flow___________________ ------__ gallons per person per day. Total l-da ily�flow.._.. _ ._______.___._____._ fons.I WSeptic Tank—Liquid capacity�_.________gallons Length_e�_____.4_____ Widthll'___l______ Diameter________________ Depth___:_____.t. x Disposal Trench—No_____________________ Width_._..___7.__._._._ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........I---------- Diameter_.____._�_`�_. ._ Depth below inlet..... Total leaching area___®$.sq. ft. Z Other Distribution box ( �� Dosing tauk-—j-- L '-' Percolation Test Result Z Performed by_____` _� _Cz� .Sie Kk j... Date...4__ .Q ��� `3 3 a Test Pit No. 1....____________minutes per inch Depth of Test Pit.........____....... Depth to groun water_._._._____.. 44 Test Pit No. 2___L..:?-minutes per inch Depth of Test Pit.....t..gt°___ Depth to ground water____ '! r L Zp o Description of Soil.. t'°'l_.e-wc- A-" x •----------•-----•-----------•-----...-•-----._.-•----------------•--•---•---•--•-••-------------------------•------------------....------•-------...-----•---•----------------------------------•_--••- U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ Agreement The undersigned agrees to install the aforedescribed Individual age Disposal System in accordance with the provisions of iITI�i, 5 of the State Sanitary Wee Thed further agrees not to place the s stem in operation until a Certificate of Compliance has be e lth. igned_/--'� --- � ) a Application Approved By..................... ----•----- Date Application Disapproved for the following red s--------------------------------------------•-----------------•---------------...•--•--••-----•-._.........---- ---••--•--•-----•----•--•-•---•••-------•-•-----•------•--•--•---•--•.................•-••--•-•----•....-•----•-•...._...•••-•••-•--••-•-•------•----•---•-••••---•--------------••-•--•••-----._....... Date irPermit No.. - --------------------- Issued....................................................... Date _ 1 THE COMMONWEALTH OF MASSACHUSETFS 4 BOARD OF HEALTH ................ a._,.../, OF..... , c .� i............................................�.. Appl r ation for Disposal Works Tonstrn.rtion ermit Application is hereby made for a Permit to Construct (,-'`)or Repair ( ) an Individual Sewage Disposal System at: / ---� .. --•- .---- Location-Address or LDt ......�� � --•-�_..!:o-�'7 •............................. ...........�`..,1 1:1'� 'l..l_.... ......... --------................. Owner dress �.. .�. c- %1.. ..................... Installer Address Z dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............�`-�.........................Expansion Attic_(—)- Garbage-Grinder ( ) Other—Type of Building No. of persons...._..(-(:n............... Showers-(—) — Cafeteria fll Other fixtures --------•- - --------------- . W Design Flow..................*-=_!-�............•__gallons per person per day. Total daily flow.-_-- _`�...__.._.............._gallons. WSeptic Tank—Liquid capacityl.�%- .gallons Length'��__-!...... Widths._!.4.... Diameter................ Depth._... x Disposal Trench—No..................... Width._.............. Total Length___..........._. . Total leaching area....................sq. ft. Seepage Pit No........I----------- Diameter_._..__�___T_._._. Depth below inlet....3.:. ....... Total leaching area...:.1 9�3..sq. ft. Z Other Distribution box (�)-r Dosing tank.(--) e l/ 1 �y� 4/ `"' Percolation Test Results Performed b 63 %' a_�. �...:. ........'---•------- Date_.__ .,_....._ .-.�____.-__....... y ------------ . , as Test Pit No. 1... z•...minutes per inch Depth of Test Pit.____�_.1-_....... Depth to grounewater._ �_Z..... `.__. (i, Test Pit No. 2---�-...._'_....minutes per inch Depth of Test Pit___L.Z_°...... Depth to ground water---... ...... ...... 3 z. z / -2 " ' - I i '-1 r ----------------------------------------------------------------•----•----•--••-•------•••-;-•-....._.......--•-•-----•....._........_.... D Description of Soil-•---- T =::�..:1.:. .: = == ' '.._..._. ..- `�' ` r 7 ' ` p j} ��`'�/ 1 - ` 3 x C- - - -------------:�-----•----------- ----- -- - - ------ - <<, W -----•--------••------------------------------•--------------------------•---------------------------------------------------------------••---•------------••-••-...-•----•-------•---••-•--•....•---- V Nature of Repairs or Alterations—Answer when applicable................................................................................................ •--- --------------------•-'" ----------lc->-------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: fig The undersigned agrees to install the aforedescribed Individual wage Disposal System in accordance with the provisions of TITI 5 of the State Sanitary C�de�The unders' e further agrees not to place the s stem in operation until a Certificate of Compliance has bee ' sued th �bo lth. Signed_! - - =f ' f rJ"' `3"/ O / `� f' 7' D Je Application Approved By--•----•-•..... -n=`- � -P` ' `' �j'�- •- --•------ ate Application Disapproved for the following ref ns:------•-------------•-------••------•----------------------------•-------------------------•----------•--.._.._ -------------------------------•-•---------------------•-------•-•----...--••------------...--•-------------...----•----•--------•----------------------•------•---------------•-•---.................. Date Y _��► Permit No......................................................... Issued................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ti/t.�+^, OF..."'.'.�. ...2/Y� / L �.-........... ................. .. ........................................................ (Intifiratr of TompliFanrr THIS IS T�)fBRTIF ,-That the Individ"uh,l ew. e D• sal System constructed ( Z-)or Repaired ( ) bf.....t-C • -....._. v-.. - 1 Installer. ��I�� at . -------•-.....---•----------------•-. --------------- has been installed in accordance with the provisions of TITI:E j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... ......................... Inspector.................... �----------------...---------•-----••-....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ......... .------••---.._........-•-•-----•-•--...... ..- No......................... FEE........................ Disposal Works Tonstrurttion _permit Permission is hereby granted.................. _to Construct ( � ) or=,Repair ( ) an Individual wage Disposal System s ----- .............................-4:L----------•--•--------------•----•---•-------------- =-------------••--......_...... Street d as shown on the application for Disposal Works Construction PvImit No.i4!..}> ' ____ Dated.......................................... ��G�1 Board of Health DATE--------•-------------------------�----...�.�..f-----...................... FORM 1255 A. M. SULKIN, INC.. BOSTON TOWN OF BARNSTABLE 1<O_CATION ' , ��SEWAGE Pie M VILLAGE ASSESSOR'S MAP & LOT i 'M INSTALLER'S NAME & PHONE NO. Ict H 1 c. Ic 9- SEPTIC TANK CAPACITY OD LEACHING FACILITY:(type) �, f (size) a NO. OF BEDROOMS PRIVATE WELL OR WAT BUILDER OR OWNER l_eb- \ S 0\\ 0(-- DATE PERMIT ISSUED: - / L DATE COMPLIANCE ISSUED: 7 VARIANCE GRANTED: Yes No 1 � 4 ol ' S\ 6 0 G . g I �6 SECTION A -A 2-16• DIAM, ACCESS MANHOLES ,PR *NOTE: ALL PIPES ARE TO BE 4• SCHEDULE 40 P.V.C. IV min. from PROFILE VIEW OF LEACHING SYSTEM " °• 4 .� $paal�tLn Existing Foundation house to septic tank p_Box cover mud b• Not to Scale +••;• •' " ' rM va �' Septic tank covers must be e._'.!.'>!�'t�;s•�:�L.••..� «, r. ofi TOP OF FOUNDATION 6 ELEV. 100.00 (Assumed) within 6 in, of finished grade wthin 6 In. of finished grade -• !� Ir �. a /+• /+ Grade over Septic Tank- 99.00 Grade over 0-8oz- g0.00 ode over SAT - 9000 s• to t t/Y • Ts%W Cru.Md star.• b PVC(CAPPED) BE S . I►STALLED AND TONBEE WI HIN 0 OF GRADE �� / /^ ~ 1A•r»0.02 PORT TO BE 3 HOLE H-10 / ` OU T M Rd i�`'`''•-s-n-n-� ' 10• EXIST. sate IST. 80X 3' Maximum Corer '. '1 �'i 5�0.01 or Cr Tap OF System-Elev.� 95.73 •I' EXIST. PIPE �' '�. v7 1,000 GAL. s. 0.01• I s �J �:, THE ACCESS COVERS FOR THE SEPTIC TANK, FROM EXITT. FOUNDATION rn SEPTIC TANK $ 60 Per toot / " r p �4 Effective DISTRIBU110N BOX AND LEACHING COMPONENT :? v,„e„f-'T;:'�•�'r;^r^�kT.:,:'+ SET DEEPER THAN 0 INCHES BELOW FINISHED 1 Ii A H-10 rn N S. Effective Depth' Sidewall h GRADE SHALL BE RAISED TO WITHIN 6. OF CONCRETE FULL FOUNMT�N-� 0 11 ui � 3 Units Q 7' 21, STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE 6 o i rn 6 11 3/4•-1 1/2• Ii i 4. 4. PLAN VIEW INSTALL 1UF-TITS GAS BAFFLES OR EQUALS ���•} SYSTEM PROFILE i compacted *ton* i u • ,q , 3-24• REMOVABLE COVERS 6m Not to Scale u i II t2, 1 5 02400K 1tc5t�lyi 0204 rF1AnRL■a c Effective Length - Effective Vldth i 611131e-11/2• u SOIL ABSORPTION SYSTEM (SAS) . . :. 4• compacted *tan. Effective Vidth 3'min. clearance • .. GENERAL NOTES 8 min. Y min. inlet to outlet �+ ,r P NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6• BELOW GRADE o INFILTRATOR MODEL 3050 (H-20 LOADING)/ SUMNER L DUNBAR INLET 11r_ s•mh. NOT TO SCALE m i Lw�T.ar- ounEr 1. Contractor is responsible for Digsafe notification (OR EQUIVALENT) ,o•min „• a and protection of all underground utilities and pipes. Bottom of T••t Md• 1 Elw.�eaoo 5• -7• af Groundwater Observed - NONE OBSERVED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 30• /EFFECTIVE HEIGHT IS 24' �S ', a•-7• 2. The septic / distri¢u$ion box shall be set '-'---"---" 4•-0• min. level on 6 of 3 4 -1 1 2 stone. e uquld depth 3. Backfill should be clean sand or gravel with no stones over 3" in size. �4 4. This system is subject to inspection during installation •"• •� 'R• '.M. ..,f,. - .•.. .;•.•! by Carmen E. Shay - Environmental Services, Inc. °•_0• 4' -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 and Local Regulations. 6. If, during installation the contractor encounters any TYPICAL 1000 GALLON SEPTIC TANK soil conditions or site conditions that are different NOT TO SCALE from those shown on the soil log or in our design installation must halt & immediate notification be made to Carmen E. Shay - Environmental Services, Inc. 98-- 7. No vehicle or heavy machinery shall drive over the PERCOLATION TEST 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: MAY 25,`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. WAIVER (Per Barnstable B.O.H.) EXCAVATOR: Roberts Septic Services Schedule 40 NSF PVC pipes with water tight joints. Percolation Rate: ., Less Than 2 MPI ® 36 11. MUNICIPAL WATER IS AVAILABLE TO THE SITE and Surrounding Test Hole Test Hole Properties. No. 1 No. 2 LOT #9 - ~-- ----- -•',9a DEPTH SOILS ELEV. DEPTH SOILS ELEV. 25,272 Square Feet t/- p 96.00 0 96.00 �L42E: THE PROPERTY LINES ARE APPROXIMATE AND Sandy loam Sandy Loom COMPILED FROM THE PLAN BY CRAIG T. SHORT, P.E. O 10 YR 3/2 10 YR 3/2 ENTITLED "CERTIFIED PLOT PLAN OF LOT #9 'HANE ROAD, M. MILLS, MA," 0•-6• As 97.50 0•-6• As 97.50 1DATED AUGUST 7. 1986 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN LSOoanm oamy IT SHOULD BE USED FOR NO PURPOSE OTHER THAN j 10 YR ts/e 10 YR s/e THE SEPTIC SYSTEM INSTALLATION. 6•- 30•1 B 95.50 6•- 36-1 Be95.00 Mm. MED. GARAGE �� �� Sand Sand NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 2.5 Y 6/6 2.5 Y 6/6 FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED EXIST. \ �`� 30"- 120 C, 36'- 120 C, B= OF AS PER BOARD OF HEALTH SPECIFICATIONS. DRIVEWAY �'`. #46 \ \ 2 EXISTING LEACH PIT_TO BE PUMPED DRY & OPEN SPACE 'mte u �tS FILLED IN PLACE co `� EXISTING e! \ \ 56• ` • `�\ 3 BEDROOMwefB'` Lifer �\ HOUSE \ ASSESSORS MAP 151 PARCEL - 008/009 ZONING - RESIDENTIAL 8'ogjj�. . . FLOOD ZONE C �� • � EXIST. 1,000 GAL. .' '� ��,-_- Perc �11 » » DECK . TEST HOLE #2 `\ \ too Depth to Perc: 36 to 54 EPTIC TANK �. ELEV.- 98.00 �\ . Perc Rate= <2 MPI ` Groundwater Not Observed ' � � THERE ARE NO WETLANDS LOCATED WITHIN A 200 RADIUS " No Observed ESHWT OF THE PROPERTY III88' ti` '� ADJUSTED H2O Elev. None \ O 11 1 PROJECT BENCH MARK --'�� , TOP OF FOUNDATION • P°.h:••,�'• '�• cb 0 ELEV. - 100.00 Assumed •J ALL OUTLET PIPES FROM THE Nam•' 1,. ,. f / Failed "`AWL .i I DISTRIBUTION BOX SHALL BE LEGEND � \ -6,4S-t}NE,._, . .S•.�,•'rF,. I I Leach Plt �� ti / SET LEVEL FOR AT LEAST 2 FT: 1�• CONCRETE COVER 3- 0•u OUTLET v •. 2 M'. -GAS- KNOCKOUTSs DENOTES PROPOSED 1� • NE- •- -. . _ -TEST HOLE #1 H,4 NE'ASr RI, . ounET t2• r,�T SPOT GRADE ELEv. sa.oD DENOTES EXISTING ` (40 FOOT RIGHT OF WAY) X. • ' ,. », ' 104.46 `� �� I ,01• SPOT GRADE ` ' \ 1.76 PLAN SECTION CROSS-SECTION PL PROPERTY LINE 3 !HOLE DISTRIBUTION BOX - H-10 LOADING PROPOSED CONTOUR / O NOT TO SCALE 6 10 97- - -- - -97 EXISTING CONTOUR LOT #f 0 ® DEEP TEST HOLE & Cb Design Calculations PERCOLATION TEST LOCATION Number of Bedrooms: 3 Bedroom EXISTING Garbage Grinder: No FENCE Leaching Capacity Required: 330 Gal./Day (MIN. PER TITLE V) Septic Tank - 2 x 330 Gal./Day = 660 ;USE EXIST. 1,000 GAL. Septic Tank. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch PRIVATE- DRINKING WATER WELL Bottom Area: 0.74 gal/sq. ft. x 300sq. ft. - 222.00 gallons Sidewoll Area: 0.74 gal./sq. ft. x 148 sq, ft. 109.50 gallons REVISIONS Providing: - 331.50 gallons Use: (3) 3050 H-20 INFILTRATOR CHAMBERS, HAVING A 2' EFFECTIVE DEPTH, NO. DATE: DEFINITION (4' W x 7' L) TO BE USED WITH 4' OF WASHED STONE ON THE SIDES AND 2' OF WASHED STONE ON°THE ENDS. PREPARED FO R : PROPOSED SUBSURFACE SEWAGE DISPOSAL SYSTEM OF GORDON &- MARYLIN COLBY #46 HANE ROAD Living r 46 HAN E ROAD MARSTONS MILLS, MA FAMILY Room c Kitchen v p$ ROOM J DD Bedroom Bedroom MARSTO N S MILLS MA� � � , PREPARED BY: Bedroom Dining 02648 �N of s q , Storage Storage R "RHEN E. SHA Y 0 20 40 50 0 ENVIRONMENTAL SERVICES, INC. N . 11 �a P.O. BOX 627 2nd Floor .per �� 3 BE HOUSE FLOOR SCHEMATIC 1st Floor s sT EAST FALMOUTH, MA 02536 ANITAR\ SCALE: 1"=20' (Description Provided By Owner) I TEL/FAX : 508-539-7966 SCALE: 1 =20 C DRAWN Y•B CES DATE: MAY 30, 2006 PROJECT#SD-923 FILENAME: SD923PP.DWG SHEET 1 OF 1 .. ,# BENCH MARK : ope /V 5p14c IFF t33; z N, c,.1131 TEST HOLE RESULTS P , 2 9 .,,�. DATE •, -` WITNESSED BY r JZ ,gr.J VDGXF`y LmrS r►)e .c)rtf _ ` _ rr p E' 2 © T•d c L �i 9,7 20 0 J7 xf L- G?T- / � T O p : / 2S" 2 7 2 s ?` 1 t 77 s uC•3 s©� o�cx n .. f I C LA y' r ?3 r r (0 �,. to _ L / 7, L \\ l L t 1 Cl.7 3 Cn / /a• /2 a ! !1 _1.�__._. -_.. -_„. ..,..,_ ai��• •"> 04 ` 4 I AA04 7-0 0 ,2 19 P rJY ,./ ;. . o C S f �' uT r � �L. ,c.. Y MANHOLES AND COVER TO BE BUILT` ,T0 z ; ELEV• TOP OF 4 t r c WITHIN ' 12 OF FINISHED GRADE ., FOUNDATION FINI . SHE M 2 /o' j " 713 0 8 S a GRADE LN, SLOPE • . ;` e '•+ a . , >, - • - A o I a '. 4 . DI _ 2 t r .•:• - •• _. ,PIPE FIRS tt ` . t MoN. P1 P E 1N. 2 LAYER OF' �: ,w�„v. (N.P!"TCH , EVE • I ,. FT_ l - f t, -- 1 .«I E T,x �'`�.., P AS ONE tMIN, PITCH 141 .r , .: �. 1 GiOa ,. t iS, • 4 ....-... ,, _ r X / INVERT G !1 r INVERT _ s_aw�o: JNVERT GALLON _ to i�..7": ® . a. D I A; I E TIIC TAN4,_ 2.: . t 1 S: Z4 ,. , . INVERT 3 v • INVERT ,• BOX p._.• A E0 . STONE WAS _ AR'ROUND'. A Lt 0 PLACE ON � � ;I .� WTOM AT ELEV. k FI R'M BASE` $' -0 _ . . �- • N. � GARBAGE 2 N.) 4G - .�- ( # y i / ELEV. / 07 ,t3`o r- c r N 7 ,PROFILE OF , GROUND WATER TABLE �a ISPOSAL SYST•EA S A N I TA.R Y D . .' t NOT TO SCALE DESIGN _ DATA _ CONSTRUCTION OF SANITARY DISPOSAL _ �^ BEDROOMS ,5p SYSTEM SHALL CONFORM TO THE MASS. DESIGN. FLOW 3 GAL. DAY aveN/7_ t o D E _ ENVIRONMENTAL CO.DE TITLE � �.- l 2 LEACH A -- C .., 5v� H RATE MIN. IN H (REVISED'. 7`I'-7 7 D E 0 W N F , � t R I S E D ) AND T ti T 0 REQUIRED LEACHING CAPACITY • 33 rev s r'44 a 4HEALTH G U L A T 10 N -- -- T•, �- R E 8 , • SEPTIC TANK, DISTR18UTiQN 80X AND LEACH PROP SED � � y © _GAL DAY, . ING UNIT : ' TO BE OF REIN F©`RCED CON CRETE r MiN. CONCRETE STRENGTH 3000PS.i, foao REQUIRED R.ED SEPTIC TANK R MIN. STEEL STRENGTH 20 000 PS. 1. . <1 1-4E r u �•�"" ' . .. MIN. DESf ON LOAD J1WG , N2 © PROPOSED SEPTIC TANK• r DRIVEWAYS NOT TO �3E , LOCATED OVER gYS<;N T TEM U 0 UNLESS . : H2 , DESIGN ,LOADING 1S USED • ALL PIPES AND * FITTINGS - TO BE : WAT.ERTIGH"T HEALTH -AND To BE , Of c�►sT �R01N oR aPPRovED P.v.C. AGENT APPROVAL - DATE , [TE P SLAN_ SHOWING PROPOSED CONSTRUCTION ZONING DATA LEGEND LOCATION OF FOR 4 � jpATE 4 r , P S s�/ e/, ' Q Pam" .,... ��'� , �' TC :•. � TEST HOLE LOCATION cAIG REFERENCE REVISIONS e . .. SHORT REQUIRED ��C EXiSTING SPOT ELEVATION 176• nj� . _ E 0 R D U1 E FRONTAGE (/�` '- E 1STING CONTOUR 1 �; A •. 4C461.., 3PROPOSED ' . C REQUIRED FRONT SETBACK �-, ../ l 4 - PROPOSED' WATER ` -SERVICE W � -REQUIRED SIDE SETBACK . z GAS SERVICE GREQU1RED REAR SETBACK . PROPOSED PjUn. Bj rdv ca, I /1 � 7PROPOSED ELEC. TLLE E T _q BRA R S,,-H2O R T P. E . E PRO FESSiONAL C IY i L .� _ N 01 V E E R 1 ., 3 _ 3FILE t Ot0 R 0 T 2_ �A,N:M 1 S - ` : .. TE U E t _ H U+I A, ::a 2 6 a 1 ... U L D G N.S ECTO`R -APPROVAL DA _ , 8 t �.N :INSPECTOR _ .. EET4Zf , • ks 4 , , y a: _