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HomeMy WebLinkAbout0041 HILLTOP DRIVE - Health 41 H111top Drive Marstons Mills A= 077 - 020 No. THE COMMONWEALTH OF MASSACHUSETTS FEE UU BOARD OF HEALTH fit/✓'~ OF t'J 0'r Y6 6I{ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (grade ( ) Abandon ( ) - Complete System ❑Individual Components 4( #.'!(*0 " CA%fe ��/��kr��>��.� H���y Lee Location Owner's Name el �� Q Z 0 say. Nn Map/Parcel# Address (2 4 13 S� � -�z? -/8z Lot# Telephone# .0-e- g4/I�c'"tLeJ t, 6 (e�, � • (^!A .�: vl q _e• n, /2•S• e ova �iI a DesiR H dame � Address Address Telephone# Telephone# Type of Building: t(,t'. nn r Lot Size Z 7, C 00 Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder ( rO Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 3 70 gpd Calculated design flow 730 gpd Design flow provided 7 Srgpd Plan: Date L 7 OG Number of sheets Revision Date Title Description of Soil(s) ell7 Z 6 Soil Evaluator Form No. Name of Soil Evaluator AO0-r Date of Evaluation E D CRIPTION OF REPAIRS OR ALTERATIONS ✓��/�Cf 3 A-'(erl Ce1j dool i w/lam q lTO - !V S¢s.4yS? tP-. 14 dD Cc n1�-3 ff/-20 V`r7ox * 2 b- Lo Syoyal/•�, Gka...,��.f It (N '2 17 /X 2� /ea�.�, f►'Zh[Gi. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of / TITLE S and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. IDate plketion yw, a o 7 FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. �GO —�0� THE C�OMMONWEALTH OF MASSACHUSETTS FEE /00 t r, + -BOARD OF HEALTH p (r - OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components tve /1410 FNr,1 Z y�1711 �/P Location Owner's Name 6 77 i9 Z Map/Parcel# Address Y Lot#� Telephone#G E° S [all is me Desi is Name je Z I P � Address < Address Sob- 2Ro-- 75- S� C` Z[7 7- 716 Z Telephone# % Telephone# Type of Building: ru I dG.U Lot Size Z 9 ( 0() Sq.feet Dwelling No.of Bedrooms 3 Garbage Grinder (Ao Other—Type of Building No of persons Showers ( ), Cafeteria ( ) ✓' i, Other fixtures Design Flow(min.required) 170 gpd Calculated design flow 770 gpd Design flow provided �Srgpd Plan: Date 1 1 7�1OG Number of sheets / Revision Date Title — Description of Soils) // 7 6 Soil Evaluator Form No. Name of`Soil Evaluator 19 r ►-, Date of Evaluation 6 2 z oG DESCRIPTION OF REPAIRS OR ALTERATIONS rr e,��A [r 3 °! .���� C�1�,✓oJ/J Gt i q /j?iU 5y^/�� -( tO lrlL, , 7U C( I/D e-1 //-70 �7' t7ay -{y 7 Zy TVC, 5a//oti CGrw..,h�, f r ,u , Y e J-Ecr^R �� 71 ry ! 7 'Jr7 ' 10r. 6 f.pvrG�, - .; ---•• The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of i 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. R,R Signed / Z­fe z Date e I 0 Jp tions UIiV S � / v 7 FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. 107 THE COMMONWEALTH OF MASSACHUSETTS FEE /00 7 - OZD RGLvt, J•Ec 61,9 BOARD OF HEALTH. 0 , CERTIFICATE OF COMPLIANCE r� Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: �o5r e0 �rCJS has been installed in accordance with the provisions pf 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. OU-7-l -7 dated ��/ u 7 Approved Design Flow 7 S^r (gpd) 'f Installer i Designer: =l9 i h iT0 Inspector_ �e ' � Date- 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 No. DOu-7 - IO7 THE COMMONWEALTH OF MASSACHUSETTS FEE l (Jy i I�0" BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair (�pgrade ( ) Abandon ( ) an individual sewage disposal system at Z/ as described in the application for Disposal System Construction Permit No. )U 0 7 ' 107 dated ?/7(,/n '7 Provided: Construc/rtio .shall be completed within three years,of the date of this ppr-mi..Alhlo cal conditi ns must be (m'et�,.k Date 2 b �t 7 Board of Health 1 /l/v. le r _ FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON TOWN OF BARNSTABLE LOCATION, SEWAGE # 2o07-0/7 -VILLAGE ,WVr5 r"3 M,%/s ASSESSOR'S MAP & LOT O Z7-0 20 -r f r1 n INSTALLER'S NAME•&PHONE NO. TDB-y20-9738 JOS�i�Li ,//e U�i�rOS SEPTIC TANK CAPACITY 1500 LEACHING FACILITY: (type) S^lo �`rK'�il�G/^S (size) NO. OF BEDROOMS-3 BUILDER OR OWNER 1-VL rX 61,9 OaF� le PERMITDA;TE: 3 —2 G,O7 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 leachi g facility) Feet Furnished by wy r i e o s '1 �h II Y h .l Town of Barnstable Regulatory Services Thomas F. Geiler, Director SARNSMIX HAM 639. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# Assessor's Map\Pareel __7 7 20 Designer: __&(eAA Installer: Address: Address: On 2e gHA�w 5 was issued a permit to install a (date) (installer) nst.a I er-)­1 septic system at 10�0 V. -A— based on a design drawn by --(address) —6 _Olarr dated i (designer) I certify that the septic system referenced above was installed substantially according to the design, which May include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Ltocal Regulations. Plan revision or certified as-built by designer to follow. �AOF o GLEN ERIC ta_tl erl S-Signature)" --- HARRINGTON No. 1070 "0 T A V0 ..........(Designer's (Afllx Designer's Stamp 1-1ere) PLEASE RETURN TO .. BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNT111. _QQTIJ THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: I lealth/septic/1)esigner Certification Form 3-20-04.duc /I TOWN OF BARNSTABLE ��KATION AI 1 �( , lD a 4D"t� SEWAGE # VILLAGE ��t�-� � / �/l1_ ASSESSOR'S M/AP & LOT 029 0620 INSTA T r ER' YYll SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (s NO.OF BEDROOMS B OWNER �.;✓` �� ��.�1�- - .�—,� PERMITDATE: COMPL ATE: Separation Distance Between the:, Maximum Adjusted Groundwater Table to the BottokoKeaching 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 Town of Barnstable P# lO Department of Regulatory Services A t,AIMMaTABM ftfi itc Health Division Date 1ach Street,Hyannis MA 02601 9 Date Scheduled tJ Time Fee Pd. Soil.Suitability Assessment for Sewage Disposal Performed By: L t E• H/�IQ�Ii(���� �'� Witnessed By: LOCATION& GENERAL INFORMATION Location Address �STo^S tl;r CtSOwner's Name 65-fA �L / /3rt� T©lam ���Nc� l7vr-'�1N_ v •J �"4� 6J B Address 4/ _1V 2,To P Assessor's Map/Parcel: Q Engineer's Name NEW CONSTRUCTION v•REPAIR t, in tPTielep6n�i, J-P T,' i Land Use ►"G 1 r C C wf Da I Slopes(%) © 3 Surface Stones Distances from: Open Water Body > Possible Wet Area ft Drinking Water Well V//q....ft Drainage Way > 70 ft Property Line j 0 7 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands to proximity to holes) �l t ✓��� i7 Kok Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face N11/q Estimated Seasonal High Groundwater Nf� DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: __ in. Depth to Soil mottieS: in, Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Ad+,Factor- Adj.Groundwater Level,. PERCOLATION TEST Date,s Time..�� Observation I Hole# I ,, Time at V, Depth of Perc 2 04 Time at 6" Start Pre-soak Time @ ([:O 1 'rime(V-6") (l•'Ib 2tf �L1 6Y J�© 7,,;irHr�/ End Pre-soak 6 Rate Min./Inch Site Suitability Assessment:Site,e,_Pagse(t',` \� Site Failed: 4�Additional�Te ng Need (Y/N) ti\ Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPI•ICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Slones;Boulders. L S o isten ravel /o y2 h do 0 i3 w 7v- �3L C 1 /k DEEP 013SERVATION H414 Hole# Z FSuTpfa'ce(in.) Soil Horizon Soil TextureSoil T Other (USDA) Mottling (Structure,Stones,Boulders. Consi ten % ravel ,vvdo/lid DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soi4 Other Surface(in.) (USDA) (Munsell) Moulin�, � g (Structure,Stones,Boulders: C i to c Gravel , a DEEP OBSERVATION HOLE LOG Dole#`- a Depth from Soil Horizon Soil Texture Soil Color �h• .."golf"-------� Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. ons' ten i'1\Ij. 77\, ,\ Flood Insurance Rate May: Above 500 year flood boundary No_ Yes ✓_ Within 500 year boundary No_ Yesa Within 100 year flood boundary No Yes . Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? � If not,what is the depth of naturally occurring pervious material? Certification I certify that on :� (cute)I�haYe passpd<the soil evaluator examination approved by the Department of Environmen 1 P XeOon.and that the above analysis was performed by me consistent with . the required trainin pje'ruse and erie described in 310 CMIR 15.017. Signature / Date 7 Q:ISEPTICUPERCFORM.DOC Town of Barnstable FTHE 1p� o Regulatory Services snxnsrns ' Thomas F. Geiler, Direct6r 1619.MASS. ••� Public Health Division ArFD MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 12, 2006 Estate of Althea Duffin P O Box 396 Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 41 Hilltop Drive, Marstons Mills, MA,was last inspected on May 20th, 2006 by, Mark Poselli, certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System is in Hydraulic Failure You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health iL COMMONWEALTH OF MASSACHLaSE TTS W EXECUTIVE OFFICE OF ENViRONiYEN-r_,L,A'FIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION; VO/"" 0 72 od-O Z-0 7L /3 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSEssMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Da'� Property Address: #/�/ 0 Owner's Name: Owner's Address: o oX e Ot of v!s /�� • /fly Od 6�d� �w. F Date of Inspection: a o p (� Name of Inspector lease print) Company Name: Mailing Address Telephone Number: 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 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 aril a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CAM 15.000). The system.: Passes Conditionally Passes eeds 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(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' i gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional 6tfice of the 1 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority., ' - Notes and Comments- ****This report only describes conditions at the time of inspection and under the conditions 6f use at that time.This inspection doesnot address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 611512000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ✓' it �/19� ©oZ G'CL� Owner: o, Date of Inspection: oZo p 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: B. Sys em Conditionally Passes: One or mores stem components as de =_Y mp 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,N-D)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: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed' (s).The system will pass inspection if(with approval of the Board of Health): pi-pe broken pipe(s)are replaced obstruction is removed ND explain: 2 ` Page 3 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD PART A / C/ERTIFICATION(continued) Property Address: ! r N Owner: Date of Inspection: o�0 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 C_NIR 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 I 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 and-volatile organic compounds indicates that the well is Tree from pollution from that facility 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: T;*lo r o r;, r ,r, sir tionnn 3 Page 4 of 11 . OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �� / 70 -all ©o 4�417 Owner: Sty. Date of Inspection: s 02 0z 0fo 1 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes o $aekup 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 �e!p'gged SAS or cesspool _✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or y�pool V _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow :Z�: equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped Any portion of the SAS,cesspool of privy is below high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface �'�'ater supply. _ (/ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and 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.] 15?PYes/Nio)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no Xo e system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection area—IWT'A)or a mapped ne 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 is accordance with 310 CIMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUI-TAR Y ASSESSIVIENNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: q( #1 � " ''� _ Owner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the followinn6: Yes o 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? P f ----Has t 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 /v Were as built plans of the system obtained and examined?(If they were not available note as 13(A) d/ C// Was the facility or dwelling inspected for signs of sewage back up? v _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? 6 _ 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? _v _ 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-- Yes no ✓ 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 Cy1R 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME_�S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: oO C � Date of inspection: S o ¢� LO CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#ofbedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):W[if yes separate inspection required] Laundry system inspected(yes or no): /1V Seasonal use: (yes or no): Ap Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): 497 Last date of occupancy: 614/YEvfl- - ` COMMERCL4-L/INDUSTRIAL Type of establishment: Design flow(based on 310 CTMR 15.203): gpd Basis of design flow(seats/persons/sgft etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— ,Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):&4e If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system _S' a 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: GE/ dd Grfci Date of Inspection: of p © 6 BUILDING SEWER(locate on site plan) p iJ i/ Depth below grader O Materials of construction: ast iron._ _40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting,evidence of leakage,etc.): ' SEPTIC TANK:///(locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth. Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural inte��ity Iiouid levels as related to outlet invert, evidence of leakage,etc.): T�rlo C I.,c*+o�rinn rn 4/1 VInnn - 7 Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-NI PART C SYSTEM INFORMATION(continued) Property Address: �C Owner Gr-e l P7 / Date of Inspection: 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: gaHons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: /(/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover; any evidence of leakage into or out of box,etc.): PUMP CHAMBER:-(/ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ' r Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) Property Address: L / 7 C) /✓/!(i'� G"- Owner: �� r Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):z (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,level ofponding,damp soil,condition of vegetation, etc): CESSPOOLS: (cesspool must be p ed asp of in rion)(locate on site plan) Number and configuration: � 3 / �.v�Depth—top of liquid to inlet invert: l Vl Depth of solids layer: Depth of scum layer: Q ii '✓��� I� /���7rC� Dimensions of cesspool: -Yflo (v, Materials of construction:d hv< o /5/v<l Indication of groundwater inflo (yes or ): Comments(note condition of il, signs f hydraul a ue,leveI ofpgnding-ogpdirion of egetat�on,etc.): / PRIVY:A-0(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.): Air ci)nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A.SSESSNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: p?p 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. b 1 .Y' a _ , �. 3-5 11-3 - 3 y 10 Page 11 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /11�0 Owner: Date of Inspection: SITE EXAM Slope Surface water (J l Check cellar Shallow wells ( y Estimated depth to ground water 3a'S'feet C 0 V14-o✓ Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan feviewed: 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 d es 'be w you established the high ground water elevation: no v-7 7 ' j C2f ao �� �e�OG✓ i i Y G i vL V a N SITE PLAN 9%33' N Main Street SCALE: 1 "=20' BENCH MARK ON CORNER OF CONCRETE BULKHEAD ELEV.-100.00' ASSUMED - 9%40' tr LEGEN y� PERK TEST LOCATION I T E gPi 6ti °A Hillto 0-0-0 PROPOSED 1500 GAL sod, �� j Drive H-10 SEPTIC TANK O X 104.46 DENOTES EXISTING Ck: SPOT GRADE 3` O 95 EXISTING CONTOUR la ROUTE 28 np post ties' DEEP TEST HOLE _ LOCUS APPROX. LOCATION 99.44' —W W PROPOSED WATER LINE SCALE: AS SHOWN 3 TH i2 h64� 97.42' 99.7 ' O 3 GRAVEL ORtJE 919' o LOT 12 AREA = 10,000± SQ.FT. N 3 TH 01 u' PROPOSED SAS eSlQrl Calculations ;.::. p 1-25'L X 13'W X 2.0' D leaching trench using 2 Number of Bedrooms: 3 Existing w N-2000— allon chambers Garbage Grinder: N0, GRINDER NOT ALLOWED WITH THIS DESIGN with 4 of one all around.FISH EXISTI Septic Tank Capacity Required: 330 gpd X 200% = 660 gpd , NG B• 3_gEDRQ�M PDND $ Septic Tank Provided: 1,500 gallon PROPOSED WELLING N��� Leaching Capacity Required: 330 Gal./Day 9&74' erro g ounca6ee- x 97.94• Leaching Area Required: 330 Gal./(0.74 GaI jSq.Ft.)�=446 Sq.Ft. LOT 13 Proposed Leaching Area Provided: 25 X 13 X 2.0 = 479 SQ.FT. AREA = 19,600± SQ•FT• Total Leaching Capacitor 355 gpd > 330 gpd. req'd. ° GENERAL NOTES 99sa• 1. ApDRESS: #41 HILLTOP DRIVE, MARSTONS MILLS j 9e36' 2. ASSESSORS NUMBER: 077-020 gq,ea 3. D LOPERIS LOT: LOTS 12 13 STALL CLEANOLI LI3E �-� 98 9e.3t' E�VVEE do TIE Dt To Extsrtnu l[NE �` t 4. TQPOGRAPHIC INFORMATION WAS COMPILED FROM AN ON THE GROUND INSTRUME14T SURVEY. 5. TOWN WATER IS PROVIDED 1'O SITE do SURROUNDING PROPERTIES. GRAVEL DRr>7: ^\ 6. REFERENCE PLAN: PLAN BOOK 127 PAGE 109 by - 7. IVC 4:711AINCS AI:E LOCAT7C WITH!"d 15C FEET ;F PR SE SAS. - __ 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. A\ 9. UNDERGROUND UTILITIES LOCATED PER DIGSAFE NOTIFICATION #,20062501195. 10. LOTS 12 do 13 ARE IN COMMON OWNERSHIP, THEREFORE ARE CONSIDERED ONE "FACILITY". o� EXISTING CESSPOOLS TO BE O` f ,_2-�,.„«�M,.a, ' CONSTRUCTION NOTES - O PUMPED AND BACKFILLED 97t 0o,a �' (FICA ) 1. Contractor is responsible for Digsafe notification aA p y AO �Q O and protection of all underground utilities and pipes. O \5 ' 2. The septic tank �listributicn box shall be set level on 6 of 3/4 -11/2 ;stone. .. •r,.• ." . 3. Backfill should be clean sand or gravel with no sTEE1.REINFORCED PRECAST CONCRETE stones over 3" in size. 'o PLAN VIEW 4. This system is subject to inspection during installation by Glen E. Harrington, R.S. 5' 5. The contractor shall install this system in accordance with Title V of the Massachusetts Environmental .Code and the Regulations of the Town of BARNSTABLE. 6. Provide an Acme Precast H-10 1 500 GAL. SEPTIC TANK, an H-20 distribution box and 2-600 gallon H-20 leaching chambers or equal. „ 7. No vehicle or heavy machinery shall drive over the f0 0 G O 124" 34 septic system unless noted as H-20 septic components. 8. Install gas baffle or equal on septic tank outlet tee and. 9. All existing inverts and site conditions shall be verified by contractor. 2 H-20 500 gal. chambers 10. BOARD OF HEALTH AND DESIGNER ARE TO INSPECT AND CERTIFY INSTALLATION. END-SECTION 11. The existing cesspools shall be pumped and backfilled. H-20 500 GALLON CHAMBETO SCALER PERK TEST & SOIL ,:EVALUATION Perk Test " USE ACMENOT PRECAST OR EQUAL �\��toFMgss90 PROPOSED SEPPTECARED YOR UPGRADE DATE OF PERC TEST do SOIL EVAL.: JUNE 22. 2006 Depth to perk hole= 42„ - 60 TEST PERFORMED BY: G. HARRINGTON, R.S. 24 gals added In less than 15 minute soak period p WITNESSED BY: DONALD DESMARAIS, R.S., HEALTH INSPECTOR Use <2 minutes per inch for design purposes o RI ESTATE OF ALTHEA E. DUFFIN EXCAVATED BY. JOEY DEBARROS, JOEY'S SEPTIC SERVICE p AT ,q �o #41 HILLTOP DRIVE Test Hole Test Hole �' FraI�Z No. 1 No. 2 qAi Fk\P BARNSTABLE (MARSTONS MILLS), MA DEPTH SOILS ELEV. SOILS ELEV. 10' min. from NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. house to septic tank Finished grade over system-2X slope away NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. o D Existing House Srpea t�covers mast be PREPARED BY: lonw/a 1oYR3/3 wNhln a of finished grade H HOLE "-20 ONthln 8 BER cover mast be Existin Grade Elev.=99'f GLEN E. HARRINGTON, R.S. `°""Y ° P 1 13 2 6 ansn GIST.max wRhmn e-of frfabd grads 9 LEDA ROSE LANE 8• tAAMY SAND 10- f U D-eox aawr mast be Prevtde r>It.r fabric or Bw 8w f _ within 6'of niehed grade Mom. 2'of 1/E--t/2- 2;min. • LOAMY SAND �" LOAMY/16 9AN0 cellar , level for 2• dable—wash tone mas. , ,,,,E,_J2 Fl. one Elev.=96.0 f MARSTONS MILLS, MA 02648 Lim I.M. 1500 CAL. T 13 , LSTMEo.coo SEPHCI ANK = _ o 0 0 o e 2a Mw, _ _ 3862 sA,rD O Ea 2S' Trench Elev.= 93.48' FAX: 508-428-3862 Mm Ex. LINE 1=98.22SAND ; ,"OF 3/4""-11/2-STONE p �,_ , LEACH TRENCH 6'f (5' REQ'D) • ashesµ Ex. LINE 2=96.97 P= SCALE: 1"=20' DRAWN BY: GEH DEC. 17, 2006 NO GROUNDWATER ENCOUNTERED SYSTEM PROFILE e•of a/4•-11/2•sTaet Not to scale BOTTOM OF T.H. #1 ELEV.=87.11' DATUM: ASSUMED FILE: LEE SHEET 1 OF 1 WVWSIVL9018LIZ1 - L 30`dd 331 90 8L ZL N010NRA&VIA—1I'dW3 JI-M-M