Loading...
HomeMy WebLinkAbout0072 HARTFORD AVENUE - Health r -- - - 72 Hartfordw*Ave-n v e-. Marstons Mills,, A= 1_Q3-W Commonwealth of Massachusetts V Title 5 Official Inspection Form -�,V,, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: l v key to move your cursor-do not Carmen.E. Shay use the return Name of Inspector key., Shay Environmental Services, Inc. Company Name 111 Thornberry Circle Company Address er, Mashpee MA 02649' City/Town State Zip Code • 508-539-7966 3080 Telephone Number License Number g 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 performed 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 WQ&2 7/19/10 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 4 report to the appropriate regional office of the DEP. The original should be sent to the system owner f 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposa System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mt g Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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: No evidencew of any carryover noted in D-Box. No evidence of current or past hydraulic failure noted. Zabel filter present in outlet tee of tank. 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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 obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town 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 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 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town 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— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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 N ❑ 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)] 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,000 gallon tank with 15' x 30' Leaching field - 3 Laterals Number of current residents: None 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 ears usage d Municipal Water 9 ( Y 9 (gP ))� Detail: Not available Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town 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: No pumping info available 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7-11-2005 per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.75 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 25 feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of cracked or broken piping Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) No evidence of cracks or leaking, tank appears to be structurally sound, inlet baffle and outlet tees in good condition. zabel filter present in outlet tee If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 5 x8 x 5 Sludge depth: 48" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town 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 28 Scum thickness no scum layer Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): inlet baffle and outlet tee in good condition. no evidence of carryover. Zabel filter noted 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town 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.): 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•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town 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 D-box present 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.): liquid level equal with inverts. three outlets present. no evidence of solids carryover. D-box in good condition. 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: I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-15'x20'x1' ❑ 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.): augered test hole to top of pea stone. Stone is dry with no evidence of ponding. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f New Page 1 Page 1 of 1 IUWNUrbA JNJIA-bLr, LOCATION -7o2�a�>�('� Aj e SEWAGE# 2 `-3e'4. VILLAGE 404t A00b t�L.I)S ASSESSOR'S MAP&LOT/" CXSI INS MLLER'S_NAMt&PHONE NO. A 13fcxo►J SOC�=H�o-�/S4y SEPTIC TANK CAPACITY LEACHING FACILITY: (type) A (size) 1 SX 3(7 NO.OF BEDROOMS BUILDER OR OWNER —RsioL PERMITDATE:7 �f/'OS COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5=EL& Feet - Private Water Supply Well and Leaching Facility (If.any wells exist on site or within 200 feet of leaching facility) SCc p.6-) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) _ Feet Furnished by ..? J ah-4tQm 44-- GVG'/ Z,4- 3157 co c-Z- r � 33 � ~S ry e r http://www.town.barnstable.Ina.us/assessing/2010/HMdisplay.asp?mappar=103045&seq=1 7/20/2010 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r — Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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 ground water: no groundwater encountered in test hole on file @ 10 feet below grade 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 (abuttingproperty/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: TOPO Map You must describe how you established the high ground water elevation: Refer to soil log and plans on file at Barnstable Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 72 Hartford Avenue Property Address Federal National Mtg Association Owner Owner's Name information is required for every Marstons Mills MA 02632 7/19/10 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 Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 } /dc) No.C)QrJ 5— 3c� �THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTI- - OF A f -'o"*-3S e L4-S APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( Abandon ( ) - ❑Complete System Individual Components Location _ / Ow is Name Map/Parcel# dress Lot# Telephone# taller's Name Desi ner's Name / ,D ✓�O/\ ���dresC �'�P Ai��1 T \ ���� ��7Addressa.0C19 T � Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms 1 X tJi Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required).330 gpd Calculated design flow gpd Design flow provided 33 gpd Plan: Date �S` Number of sheets Revision Date Title Description ofSoil(s) G�-�vc-y L"`t"�Y ors 7-U vim, ,rq,J0 Soil Evaluator Form No. Name of Soil Evaluator d JG1y"" Date of Evaluation f) Ds' DESCRIPTION OF REPAIRS OR ALTERATIONS "34'cw/vn 4e51 1Z-Z-r> The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu grees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signe Date Inspectio FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO.(!��" THEJCOMMONWEALTH OF MASSACHUSETTS FEE OARD OF HEALTH! t vs-fit-t t'k 0F /1�I"d m APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT j�kpplication for a Permit to Construct ( )-Repair ( ) Upgrade (x) Abandon ( ) - ❑Complete System Individual Components 7� n.7r?i*0J1Lo �) e Tc.vLec-L Pr,vA Location Or's Name M,4P / 3 Car 4S' �S�_w e� Map/Parcel# Ajddress f2 o — U ZI 3 Lot# Teleph #one I I>AIV c�- 13. J o#^'s ,1:2 -"i?wler's Name Designer's Name �D X i I/Iddress d) Address Qp O o 5o;6--L!co -frsp- e# Telephone# Type of Building: C Lot Size Sq.feet Dwelling—No.of Bedrooms e yfr Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures I1eo-ign Flow(min.re�wired) 33 gpd Calculated design flow gpd Design flow provided 333 gpd Plan: Date ��'� .�S : _,. Number of sheets 1✓ Revision Date Title Description of Soil(s) �4 t/4�� G c'°f'4 Y f�"`4 7-� r�C4i""'' J,4-A✓O Soil Evaluator Form No. Name of Soil Evaluator JP(r j Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Lam/ e l-Ur iIV G l 0 a 3 6-4C,C o i" k?7+.( 7A-^-K- .4-^sty AL/C+C.G, /G rcEo f J .4 3a "—lr iS �+✓ LCa9-�h/r•�`G �/�`�-d The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further-agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signe, �� Date Inspectiofl FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 s NO. �� 5 f �` THE COMMONWEALTH OF MASSACHUSETTS FEE �&,C,�Aow V BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: ,4ks g h ( ? at `7:L has been installed in accordance with the provisions of 310 MR)5.00 (Title 5) and the approved desi n lans/as-built plans relating to application Nor�C�i.S.3;I,(.jdated �_ �� Approved Design Flow s (gpd) Installer JC tv A 0 N Designer: Inspectors .Y... �D to The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 ..--------,--_ ---.--.__-__.--_--_---_-_. --_,_,----.------1--.------_ - ,_--�.-�-- - No. PCO -5 3(; THE COMMONWEALTH OF MASSACHUSETTS FEE 00 r.a��a`aI ro BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( --<Upgrade ( ) Abandon ( ) an individual sewage disposal system at s c rk r�) firo e- as described in the application for Disposal System Construction Permit No. 53 C dated )1 t -.5 Provided: Consttrrjuctj"o/n`shill be completed within three years of the dat,of tern his perthi 1`,,c a, cond�ilions must be met. Date f ! ! f, Board of H ait.h___A�14 "'�"" FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON rt ; Town of Barnstable Regulatory Services 9 �scE; Thomas F.Geiler,Director Eo r °i1� Public Health Division b°r Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form i 1 i Date: t Designer: Address: On l was issued a permit to install a (date) (installer) septic system at 7-2 1"/LrI:*M elVe based on a design I drew, (address) 1VWji47-msl n�cc,t dated I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. Vr 40 T 1 t A • ( esign s Signature) (Affix p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 5M/01 NOTICE: This Forru B-TO"Be Used For the Repair Of Failed peptic Systems Ohl Y- i F PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM i L .c 6. J ° 'S°^' hereby certify that the engineered plan`signed by me dated_ 7 oS" concerning the prop Prope located at 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. . l • Tne soil is classified as CLASS I and.the percolation race is less than or ecual,co minutes per inch. The applicant„ay use historical data to conclude this foci: or r::av conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed t • There are no variances requested or needed. £' si • The bottom of the proposed leaching facility will not be located less than foureen 4 (14) feet above the maximum adjusted groundwater table elevation. (A dust the groundwater table using the rnmptor method when applicable]' } Please complete the following: A) Top of Ground Surface Tlevation (using GIS information) G i B) G.W. Elevation 4 _adiustment for high G.W. S© DIFrz�tCE BETWEEN-A and B 6 1 SIGNED : DATE: S` NOTICE Based upon the above information, a repair permit will be issued for bedrooms i maximum. No additional bedrooms are authorized in the future without engineered seodc system plans. a q:health folder:perte�ttp a ---------- --------------- Now wqlmm� mm 140.OF ACf(jAL DISTR" ION, 19L A or LINES�3 LEACH114G FIELD LENGTH OF LEACHING UNE;'v LEACHING FIELD'DIMENSIONS-. .4 L "END"CROSS SECTION TEST PIT DATA 3(7LX1FWX06H SCALE- NONE FINAL GRADE TO BE STABILIZED A` FINISHED GR*E`(SLOPE 021 EL,-100.9 Perrformed, Sy- Da n 4 ­' 7,A jr-,h n s o n P.. C.S . ;7 Dal-: June 1 29 0 S 4"SCH 40 P,/C PIPE, 2"(M IN) Z'LAYER 1/8"-112*DOUBLE TP-1 (EL. 100.9) EL-S7.10 WASHED STONE� (BREAKOUT) Lca.11y ca tt 10 Y 4 EL. 45(END) 3 P T oamy sand -1 1/Z'DOUBLEWASHE _, 7 1211 3 OIIIF.AC:l D 3�4" STONE 3 3 2 -,Yr, 12 e r, 1::.ne a�a_ L 6 c'-,4/LD&V 4�" �.':rave­ oam-Y Earna; EL 95.95 r�v ,V Z1,o CL-,servc_,d LEACHING FIELD To MEET (A c 0 b s 17 c i Gro-u1ndw;:i-ar J PEOIJ18EMENTS OF 31LI CM A 1525Z 6 r PERCOTATION TEST DATA END OF DISTRIBUTIMI LINES TO BE BOTTOM OF TP-1 (EL. -`694) Irl-i 6 hw 14 A-K N 0 0 6 S.Gl,�/E S 14\0 VENTED(SEE PLAN A14D PROFILE) Date: �,r­nx- 17, Yg Jf 2,")0% A�S 4 DISTRIBUTION BOX t J H-20 P e_­ 4 REMOVABLE CDYTP, 4"SCH 40 OUTLET LATERALS 'EL FOP.A SCRED=- OF E:Lzv.,%TIONS DISTRIBUT-ION BOX TO MEET SHALL BE SE T LEV 3D REQUIREMENTS OF 310 CMR MINIMUM OFTHE FIRST,TWO rt,- 0 0�-x 15,232 WATER TIGHT NESS, FEETAND CONNECTED TO 4 ? EACH DISTRIBUTION LINE 0 T n-7. T n 4 CONSTRUCTION,ETICt re an k i \AATH SOLID SCH 40 P.rl_PIPE 4"SCH i 1 Ou, s e p -i ,: 07 a- 40 NO�OF OUTLETS:S T(E T n T-n i S!�­ 'r, - ­r�, EL e 9G,80 E L, 913,62 r MFCHA!TCALLYCRUSHEI IS VV -f 0,5"H v 1NE j< jiV DW) A, T p m lop%I Iq of LeachJnq F'4eld C"ttom 0 L 1,h 4 ng 7� 4ed Z-C �,T-7�I woo 'A (A PNt' 17- t4 0 LEC-F-ND 11��er I D I NOTES I-,r 7L I "'V6, 9 4,1 x > /000 &At-4-014 t"7 t All -ruction r 0,F 0(0 0 const rinn t o t h e �v T methods sha L1 confo Prcrosed �-nn-cur YeTrIlc CMS, ' 15� and the Sa, rnstable of Healtt; Req-UiatlorIs . T 'here are no knbwn priv U iate o- p b14c we feet/400 . feet, respect- ive, Of the proposed leachin" _�-rea. n 8 h e d F 1--c-, %1--, 1 The propose�ll lea hi ng area is n t withn j00 f e!­ OF- e wetiand, r1or is it within 200 feet . of a rj ver ro n B a s eme- Exi6ting septic f-ank to be pumped dcwn -o add n ew 1 4 T-ins ee and .Llter W�t- - ater 4 0 PI/C L W i No changes are t o be- made n, ad L Lfie w- he of t e of, Health a n d h,e dem-ic S n P_nainec-r, 4 ro-osed, f Z el ' g ed f no-- des- -or 41;S 4� ,i ga rbage, d 4 8r) HA x rF \1 EIV a 4'y L a e _y Paue ci and d :F. o a V Bock #5 0 p� a L n a- s u rve y- P9_0 tL6 A, Rc�,move ar,�T port.- 2: ..-on c f or 0 n. y��-r, a qra�� .A 4,e A; AC S4"014J CA f I n ra sand I-'yc-r e 7- re r*j 0-n encoun�e_ ths, ` ation o,f -h e, -z a c�j n, iq St' log red, dur-Inq thA, 1 0 ract i Con,- - iO tO ensure thal- Lh4 leachina field �a- tec! I 1AR, en�- i aV oamy 4 --rely within the Cj la ver (gr, e1v L_ractor shall veri fy aj� - pl Con' S _tu mb in q.. f- wil 24 PIA. be connected to t.�e new sen L) pa� -*,,t, .4. 0. AID 4r co tic s ys t ern pr:*' or Z3 4A I' I I - c0nstru C Z 4 0,-, Ar4o eovE.,ei -ro (I( t L - any, e x s-i rig ,p I".jr,b i, 0 0. - I . ex, - t srructute is f ound to 't he *hat Vj I r#/"j 0 F 'r 5AL Ce C-21 -�,e n t approved sep4- FMOSR.C6 0�"a -` C Syster, ,_Iat, a 0 desianer. IP �i. r 4p, 0 r-q sh,a 1,'L be j00 - Al t mysric 4 A HE' j't 0 0� AT 14 A 7, Al -rAp r W =CVLATIONS: 17 r 1A 9 f 7' 3 Bedrooms (existina.) 110 GPD/Bedroom X Bedrooms '310 GPD + Pe-colation -ate 2 MP -4 Jk 'A Ll L C i,_R s 0 PVL e rr c-, 1 1. - I � 11 c)eA, '7.3 t ��__10 �6,45 MIDOLE , .00 b, PROPOSED LEACEIN(; AREA: 96,6 0 EA 4W IoV6 HAM8LIAI "14 1­(��aChing Field: v ji Z 'B 0 1:t or-, Ar 4 6,63 1 #4 0 44D #6 - F X F It c. 7 41 L 1 A66 1 L /Sr I/V& 6, /coo > 1,,4 t L E L 70? OF 910 - T-P-1 Ort--- v,_� /,Jo 1ES1qVjT` G. SUBSURFACE SEWAGE DISPOSAL , SYSTEM *12 Hartford Avenue, Maratons -milis 4 APPROVED BY: SCALE il DRAWN W 011 X DATE : 1, nnnsED T %-rtv j I Danial Z Johnson &rod 0400 oflo 0 0+3V ot(co 0 00 0 4--�a 0 10-00 6 Pr*p Tarrall .,Pina (500) 420-8213 A, x, Tor: 72 8artfordAv*nue,. XarStonz Xills, MK02649 DRAWING NUMBER Preparod DCHESTIC SEPTIC DESIGN, I-,4C- (508) 47-7-9909 By V.0- So% 031, osterville,Im 02f5s J-2010