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HomeMy WebLinkAbout0072 MOCKINGBIRD LANE - Health 72 Mockingbird Lane, Marstons Mills -� _ A= 013 - 039 TOWN OF BARNSTABLE LOCATION 7 Z r SEWAGE# o0-0 IS VILLAGE M . r'l. ASSESSOR'S MAP&PARCEL M o d 30 INSTALLER'S NAME&PHONE NO. f SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Z� C� h/i�� (size) J 3 NO.OF BEDROOMS --� R �Zr- lS PERMIT DATE: I COMPLIANCE DATE: $ 13 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 ) Feet FURNISHED BY `� �y 4Z. a� q ��S q 9 N:). Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incom M PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplitation for disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.'77 Owner's Name,Address, d V Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. TI-pe of Building: , i/ Dwelling No.of Bedrooms Lot Size `T V sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `j�� gpd Design flow provided 3 gpd Plan Date ���� �2. Number of sheets Revision Date OLO Title Size of Septic Tank 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 is Board o ealth. I ofSigne , Date Application Approved byXt Date Application Disapproved by Date for the following reasons Permit No. Date Issued I No. Fee - f HE COMMONWEALTH-OF MASSACHUSETTS Entered in co"ute�r: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for -Misposal .pstem Construction Permit APPlication for a Permit to Construct Repair Upgrade Abandon Complete System ❑Individual Components Location Address or Lot No.7_L ���G\�tyb���i,l.e,.,p� Owner's Name,Add�res�s, I Assessor's Map/Parcel 3 p 3 CA Installer's Name,Address,and Tel.No. Des`igner's Name,,Address,and Tel.No. �-\.�\may @o,n►cFi- `�Jck.J� -4 161- S' Type of Building: ' // t DwellingNo.of Bedrooms Lot Size «q V s .ft. Garbage Grinder ' q g Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `33b gpd Design flow provided 3 gpd . IJ Plan Date �tUr-�- lZ.- -Number of sheets Revision Date Title Size of Septic Tank 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 is Board o ealth. i Sig a Date f Application Approved by / ,� Date I. Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of Compliance THIS IS TO CERTIFY,that the On site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(to ) Abandoned( )by at -7'L e 1u NrA L\„L has been construc.Wd in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Y/dated / Installer Designer #bedrooms Approved design 3 c gpd l The issuance of this e its all no be construed as a guarantee that the system will ct as designe . Date 3 Inspector - 1! - - -------------------------------------------------------------------------------- -------- No. -- -- - - Fee -- ----�..�� THE COMMONWEALTH OF MASSACHUSETTS PUBLI HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction.vertu Permission is hereby granted to Construct( ) Repair( ) Upgrade(✓) Abandon( ) System located at -7 7 V- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co con t be leted within three years of the date of this permit. Date Approved by r �J _ /O� E;GY i T� c 3-0 S \I�l( All -pas F. Goiler,Direct or Public Irlealtrh Divd,Sion Thomas lY cILK eon,director Office 508-962-4644 Fax: 503-790-6304 mtaDer &Designer tCert cation Form. Dote- 0 �f P �e���e permit-4 �� ��—a ssessor's Ma-p 11Farcell 13 `3 n n � ,[ Pesi�iera Uln��^ 2• v�,Pii') Ti�nst�Illleme C) ✓�1 r��1]Ol�- Address: X Address: 3 0 01a was issued a permit to install a (date) (installer) g septic system.at Nl0C14 vim' based on.a designdravai.by (address dated 2 Oto% ( igaer) I certify that the septic system referenced above was installed substantially according to the design, which-nay include minor approved changes such, as lateral relocation of the distribution box and/or septic tank. I cezt_ify that the septic system referenced above was installed with major changes (i.e. neater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local p,.egulations. plan revigiaD-or certified as-built by designer to folio vs. 4 OF Mgssq y 0 DANIELA. GN OJALA (Installer's Signature) `�' CIVIL Cn No.46502 LASS/ONAL l esi er's Signature) / (A.fi x De-i g reT's Stamp Neie) FIET-U.�N TO .BARNS ABLE FGYMC MAMEIL t,.MSION. CERTI MCAT—B OF Oeui L�s dCa+� L i�JinT �- 65�oJ-D Trq-1-'� MO H THIS FORM A-�J� AS-BST C ARDA G:geali Sr-Qtic/Design.er Cer ificatiou Form 3-26-04.doc Town of Barnstable )Departinent of Regulatory..Services Public Health Division Date a Ae�9. 200 Main Street,Hyannis MA 02601 Date Scheduled - Time �'� &+'0e Pd, vU nn L� 1 G Soil tSuatabilio .A,ssessmentfor ,Sew e D° pose Performed-By: �a n' Goo Sal y,6 \ S � S Witnessed By: LOCATION&GENERAL]INFORMATION Location Address / 0J' , I {� .� Owner shame / .. e e !`I/�J� � V.D'l Address Assessor's Map/Parcel: r l z p Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use: L a we-7 Slopes(%) Surface Stones Distances from: 'Open Water Body /oU It Possible Wet ��pG / fk Drinking Water Well�` ft Drainage Way ft Property Line 2 Z V ft Other ft SIMTCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands Igproximity to holes) 10.0 SI . c HI " 23I c n w a '� L /-\J c N v - Parent material(geologic) l a C I'Q I G f/l I INa S Depth t9 BadrgclG J 2aC/ Depth•to Groundwater. StandingWaterin Ho1c: / ///"C - WeepingfrotA pltl7noir Estimated Seasonal Hlgh Groundwater /V XA Method Used: D��ERWMUTZON FOR.SEASONAL 1HGH WATER TABLE Depth Observed standing in obs.hole: In, Deptli to s411 mottiost 4. ln, Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well loyal _ Adj,Actor ,� Ate,Groundwater Leval PERCOLATION TEST Date___ ' huh Observation Hole# I _ Tlmv at 9" Depth of Perc. � ` Tlme at G" ' Start Pre-soak Time O - -- Tirna(9"-G") End Prc-soak Rate Min./Inch Z-2n'I) Site Suitability Assessment. Site Passed Sits Palled: Addltlonal Testing Ne'edcd(X/N) N t 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) weep prior to beginning. Q:ISRPTIC\PERCFORM.DOC U r. DEEP-OBSERVATION DOLE LOG- ]Gore# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munscll) Mottling (Structure, Stones;Boulders, o i ten;y.%'Craven o - w u— I g S � �- 3`f ' C, 5; 1 — 13Z C2 /0 11/6 16'A' 6 at e DEEP OBSERVATION HOU LOG Hole#_� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConslstrngV,90 Crave -- 3�-13Z Cz AIA 0i� l�la Grave ' DEEP OBSERVATION _ O S RVA7CYON HOLE LOG ]EYoYe#. Deptliftni Soil Horizon Soil Texture Soil Color Soil Other* Surface(in.) (USDA) (Munscll) Mottling (Structure,Stones,Boulders. VEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, Flood Insurance- ate NMaM Above 500 year flood boundary No Yes "Within 500 year boundary No 7 Yes _. Within 100 year flood boundary No.. yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious materlal exist in all areas observed thrpughout tht} area proposed for the soil absorption system' Yf If not,what is the depth of naturally occurring,pervious-materlalo. Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Bnvironmental Protection and that the above analysis was performed by me consistent with . the requited training, expertise,and experience described in�10 CMR 15.017. Signature 6-1- liTi' — Datt ' Q:\S,EI'"f'1C11'L�1tCPORM.DOC ' © 13 - 035 I� .\ COMMON VEALTH OF MASSACHL SETTS 4� ,y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS >� DEPARTMENT OF ENN'IRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. I•tA 02108 617•29;-5500 WILLIAM F.WELD TRUDY COXE GOVCM07 Secretar% ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: Address of Owner: Date of Inspection- a��— / (If different) r "Nu / ,,cc-- Name of Inspector: �:- F C �`® .- I am a DEP appro ed system in pector pursuant to Section 15.340 of Title 5 (310 C-MR 15'" 26 L- 9 AS T 8 Company Name: •K 0W,q ,9 vi Mailing Address: S� Telephone Number: j C� —7 -7 Jai —� `z% y�0 Ha�TTABIF CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inforination3repo is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and exp hence-ink proper function and maintenance of on-site sewage posal systems. The system: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fail Inspector's Signature: �G' � 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: Aj',ZSYSTEPASSES:ave 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. COMMENTS: 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. Indicate yes, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 conforming septic tank as approved by the Board of Health. (ravimed 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/hvww.magnet.state.ma.us/dep Printed on RecyeJed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B]SYSTEM 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced '1'��The'system requ`ed pumping more than four times a year due to broken or obstructed pipe(s). The system will pass > mspec-tion`tf(with approval of the Board of Health): 0 broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION 15 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 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. ® The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless 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. Method used to determine distance (approximation.not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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 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. 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 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 coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Ei LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The 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 health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/2S/97) Hags 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes No r. _ Pumping information was provided by the owner, occupant, or 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. l/ s The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components)excluding the Soil Absorption System,Chve been located on the site. .%. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _✓ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ® Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r, PART C SYSTEM INFORMATION Property Address: Owner- Date of Inspection: FLOW CONDITIONS RESIDENTIAL: , Design flow: O p.d,/bedroom for S.A.S. Number of bedrooms:.- i Number of current residents: 0 Garbage gn=der (yes or no):—ALA) Laundry corrected to system (yes or no):-- Seasonal use tyes or no):_L)O Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):A Last date of occupant},: COMMERCI AUINDUSTRIAL: 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 S system: (yes or no)_ Water meter readings, if available: Last date of o cupancy: OTHER: (Describe) ' Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information- 902 , System pumped as part of inspection: (yes or no)�D If yes, volume pumped: eallons Reason for pumping. TYPE OF M 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) YA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: /. — (c— —7 g 660 //Zxn Sewage odors detected when arriving at the site: (yes or no)`✓0 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: -i,1 Date of Inspecti n: at — q 8 BUILDING SEWER: (Locate on site plan) r I Depth below grade: / Material of construction: cast iron V 40 PVC other(explain) Distance from Ovate water supply well or suction lir.i Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: I D Material of construction: L/oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: L/ Y Sludge depth: 10 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 10 l� � Distance from top of scum to top of outlet tee or baffle:�40 0 Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: _ .�- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/da� Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet 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 box, etc.) ix-tZ PUMP CHAMBER: IV/!I} (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.) (revised 04/75/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address Owner: PGA., Date of Inspection: 17 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: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) 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.) (revised 09/25/97) Page 0 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Property Address: Owner: i r Date of Inspection: 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) l Pgck op v , i /y,S (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: i vi Date of Inspection: Depth to Groundwater �°2 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions tI Check with local Board of health I/ Check FEMA Maps Check pumping records /Check local excavators, installers l/ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) L J (zaviaed 04/25/97) Page 10 of 10 LOCATION �E ACE HERMIT N�. VILLAGE. >' INST LLER'S A E • A��REf: -' BUILDER oil OWNER DATE PERMIT ISSUED < DAT E COMPLIANCE ISSUED 7j Ir l i / - .� � I'I �1 L-O CATION i E ACE PERMIT Of. VILLAGE: A /Z IN T LLER'S ACE t AROREts Z-5 BUILDER OR OWNER DATE PERMIT ISSUED 1/ DATE COMPLIANCE ISSUED «�; yc ti Q y 6 � . 1 � � - o '0 v ..... .. ... �1 �� �de%;���ip� L� No.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................... .............OF.....,6�...911e��'P% � ................ Appliratiou for Di-s#osal 10orko Tomitrurfivit Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ...,n17 --'4 ...................... ....................... :.. ® ------------.............---........ Lot 01 . . Owner Address -s-'�2�t e i .� Tt� .............. 1 1'?'cars r�4�'.. �'" ' �............-----.... Installer Address U Type of Building Size Lot_ 00-140 .Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—T e of Building a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------•---------------•---------...----•--------•----------.......--•---....------.......-•---- W Design Flow............ �`tee? •-•---•---•------_gallons per person jQe rda�. Total dailyw__._.__.. ..................gal ons WSeptic Tank—Liquid capacity� allons Length_.___._____.a-. Width./rt� Diameter................ Depth_ .-..--_. x Disposal Trench—No. ................... Width..... .....`............. Total Length......... f..... Total leaching area.................. q. ft. Seepage Pit No......./--------- Di meter.... Depth below inlet.. Total leaching area..-mia— q. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by dA!0—*Vkt r.��-',1��-. .....0 Date... .. . _-- -- a Test Pit No. 1_...�Z-minutes per inch h � � p Dept of Test Prt.,��.�P..�,Depth to ground water.... l.L� �� •.__. (s, Test Pit No. 2....� minutes per inch Depth of Test Pit..l.�_�__�P._.._ Depth to ground water.. ......... O Description of oil---- -•-------�...-----•�---- -----��i...-------��- �-- --�:�----�'f/�.----��-��.� a U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------•-----...--------------------------•--••--------------------------------•---•.............••---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeD issued by the board of-Health. Signed_.WW.W.7 X G-VX r-ACJ-C`r AW �� 7/,(.,���9._. Date ApplicationApproved By...............-------------•--•--•----•-•-•-------•-------............._.........----•-...._..__ Date Application Disapproved for the following reasons----------------•---•------------------------•-•-•---•--------••---------------------------...._........--_...._ ............................••------------..........---------••------------•-----.........---••--•------------------.....-----•-----------•-----•------------•-------•--•----•-----------------------_.. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... . .....OF... � �-`... .. %lurrtifirab of Tompliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by....L ��' al.W��l ..... .� �-�`............. X'/dam---.fir . •�� n taller has been installed in accordance with the provisions of TI 5 he State Sanitary Cod /s described in the application for Disposal Works Construction Permit No... ... ....... ................. dated_nr_-.. -__� '___7.-/..�._........ 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 ! G� .........OF.....X'5IA. Appliratiun for Disposal Murks Tonstrnrtiun ramit Application is hereby made for-a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: r . ......................................................... - - - ------...............---.............. .......------------.... Location-Address of Lot No .._ .�`. *L..! G . l ?1, ................. �... � Owner _ Address i a_r.. t.l sa {� t'S 'a)�i✓ t e t.4..r .. .. ./..� .. ..................... Installer Address M Type of Building Size Lot.�'' CQ .Sq. feet U Dwelling—No. of Bedrooms._._.._....��................. .....Expansion Attic (k,,, Garbage Grinder ( ) Other—Type T e of Building No, of persons............................ Showers — � yP g ---------------------------• P Cafeteria ( d Other fixtures----•••----------------------•--------------•-•--•----•----------•--------------------------•----------- ...(_...>----... ....>. W Design Flow............ `�Z ..............._-gallons per person er�d Total daily flow......... ..................gallo IxSeptic Tank—Liquid*capacity/<2-tgRdlons Length.__.._.. .... Width.etK".4 Diameter................ Depth....' .....� x Disposal Trench—No. .................... Width.,..'.._.......... Total Length............a,..... Total leaching area.._....._._ q. ft. Seepage Pit No......./--------- Diameter.... Depth below inlet.. . Total leaching area . q. ft. Z Other Distribution box ( Dosing tank ( ) '-' Percolation Test Results Performed by,_.,..A .f`�'J'?, r'�o .:+- + ` 1.� Date.... , Test Pit No. 1....�'.�_. __-minutes per inch Depth of Test Pit.l r*R'... Depth to ground water_.__ �t�:IA,;7_: (s, Test Pit No. 2-.•_�.... -_minutes per inch Depth of Test Pit._�.:��!f!.r�Dep�th to ground water........................ O Description of S.Oil.. .?.... "�../ ...._. _ �r�._ .. ..../�.f'�>/t/- /_ 1 �l e%!i........................................ ,^ _ ... V _..1,� / ....... .'....�,t.........,? �" �' ........_.."''"""'_"�: )G'_..__v��'/f�/ F !..---........................ == - ---------- d�Z. ......... „---------------------------------•-..... U Nature of Repairs or Alterations—Answi;r when applicable............................................................................................... n Agreement: _r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Coded The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued:by the board of health. Signed----.��� .�4.t"t:.�.±,�r__ >4.s.a��a....: �.�------ ----------- ---•-•-•---•-- � --•- -... f Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:....-------------------------------•----------------------------------------------------- ......._.....------ x_ ---------------------------------------------•---------------...........--------......-_._....-----...---•••••••----•--•••••-----•--••--•-•-•••-•...-•---•••-••-----•-•----•-•-•--••-••---•-•-••-•-.--- Date PermitNo......................................................__; Issued....................................................... Date a T THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G>. .....0F... C... .. ..... Trrtgfiratr of Tuntplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� or Repaired ( ) by....�'lc��'.? .� ��.. ..�+�.....0 n ���{��.�".'Q?,o ��' ...... Installer at--- -4...(2.1-------1�•�- --- �C��• 'I.... !�Me. � �/' ... ----G•---= -- has been installed in accordance with the provisions of TILT 5 off The State Sanitary Code as described in the application for Disposal Works Construction Permit No. .......... dated---------: _Z% -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ............................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....... .....°.. FEE......:.7............. Disposal Works Tuuntrudiun rrntit Permission is hereby granted_...A.0.,Vj&A.... .. . .............................................................•------ .io Construct ( . -or Re air ( ' ) an Individual Sewage Disposal System -- i at No... f'•�••-.... .._...>'' c` .,!' .•-/ 'J' (-'o"'? ''�,`: f' =� - ......... Street as shown on the application for Disposal Works Construction P it Nos ;.... Dated..... '4' ` !..7t.......... Board of Aealthrr.•sr DATE......../..... ..................•--- 1 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ��ts� �.6�t.Se ��a���- �� s� III I �f ! II � Z I I � I �� i � � ICI �j' �� � � � � � � � � - � � � 2 L� �� � ; ' � _- _ � it .. t � a ^ _ A ,. � .. . .wt.yn... - .. - .. _ _.-. 1 . .- _ t e .. � � .� * p - � r. � t * - { i - y � � n _ _ � �. .. � }. « - i ,. _. .-.. _ t �F ' f' ' + _ ... F ti f i .. � t , 0 7 _ 45)4:::7 o4 Oq I lot, l 102 0 ` Pry315 01 ' N n q0" 03 ' -o•o o ,'9,c,/�`i'o� S �0 LV 16�:le S _7 A6 F' A66"14-I 7"O GC�" rra ..�t-s ,r cGr.E�A,c� `-.1` �7 � 1 rci ''C/.V/SNECs G .s;?Q� 0 i tr _ • .o1rcl,�%f� ,rr /S7' /-vveT 0: P�1bop o vv�E' sE.o /C �,�9•v / �rEAe 7- y /� o p c: Lv�IsNEo sroNE 105) A / DG 1 2 D F ,0 7- ' 1 N iA PROFILE OF - SANITARY DI SPO SAL SYSTEM e NOT TO SCALE DE Sl C N DATA � BE.D'ROOMS CONSTRUCTION Olr SANITARY pISPOSAL DESIGN FLOW ..�24 GAL.�DAY SYSTEM SHALL CONFORM TO MASS , LEACH RATE MtNJINCH ENVIRONMENTAL CODE TITL. EM �, ��,G�.. 7 �� PROPOSED LEACH CA PAC IT 1( • { AND THE:' TO WN OF ..,� HEALTH REGULATI ON,S, � ? / ey -410 7 GAL./DAY -SITE PLAN = SHOWING PROPOSED CONSTRUCTION L o. C A T I O N FOR APPROVED 19 SCA,LE: ' ''=- DATE: �"0%�/�11?2 BOARD OF HEALTH REFERENCE: 6 P407` /0 9 115 DATE AGENT i %it y C ate a� 'JOSEPH M. Iva. ?748 'iabbo 10 � .���. � J M. MONAHAN, JR . & ASSOCIATES REGISTERED LAND SURVEYORS & ENGINEERS ' s� 651 MAIN S rR E ET DENNISPORT, MASa;, 02639 NOTES ALL SYSTEM OMPONENS SHALL SYSTEM • ' "OFILE MARKED WITHCMAGNETICTTAPE OR BE 1. DATUM IS NAVD88 As Me' s SC ool COMPARABLE MEANS FOR FUTURE LOCATION. (NOT To SCALE) 2. MUNICIPAL WATER IS EXISTING j Q � ACCESS COVERS TO WITHIN 6" OF FIN. GRADE " PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE 2 3. MINIMUM PIPE PITCH TO BE 1/8" .PER FOOT. a o TOP FOUND. EL. 104.6' FILTER FABRIC OVER STONE 102.5 1 4. DESIGN LOADING FOR ALL PROPOSED PRECAST �a c z luer Rd MINIMUM .75' OF COVER OVER PRECAST 2X SLOPE REQUIRED OVER SYSTEM 102.0 UNITS TO BE AASHO H-LQ BLOCKS OR PRECAST H-10 NOTE: MIN. WALL THICKNESS 2" k PRECAST RISERS c S 2� ��� 4"05CH40 PVC 5. PIPE JOINTS TO BE MADE WATERTIGHT. s 0° � Q, MORTAR ALL INVERT IN 98.17' PIPES 1ST ' CO LEVEL 2 COMPONEN TS ENDS (Typ,) , 4' , 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE '� Q, Lon SIDES 99.0 WITH 310 CMR 15.000 (TITLE 5.) $ 10" EXISTING 14" E °�°� . fi 5 011d ` - TEE SEPTIC TANK** TEE ° ° ® ® ' ;: ®® ® °o°o°°o°° a Locus o� t*100.4 " ° ° °°°° ®�®® ® ®®®® ®® °°°°°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND { 0 9 .y' o 0 0 0 0 6 MIN. SUMP °°°° ® ® ®® °°°°°° NOT TO BE USED FOR LOT LINE STAKING OR ANY �' o 000000000000 " p >oo °°o°° °°° •� C °°° ®®®® ®®®®® ®® ®®®®�® GAS BAFFLE , o 0 0 0 0_ 12 MIN. INT. DIM °°°°° L ® ® ® °°°°°°°° °o°o°o FnE ® ®®®®®®®® ° OTHER PURPOSE. ° 98.84' 98.67 96.17' WATERTEST D'BOX " o¢P6 n. 8. PIPE FOR SEPTIC S .y YYTEM FOR LEVELNESS f TO SCH. 40-4 PVC. poQ H-10 500 GAL. LEACHING CHAMBERS BY ACME PRECAST OR EQUAL =o ** 3 4"-1- 0 0 1 2" DOUBLE W ASHED STONE 4' MIN. **INSTALLER CONFIRM MINIMUM M . 9. COMP - NIMU SEPTIC TANK SIZE (2) UNITS REQUIRED COMPONENTS NOT TO BE BACKFILLED OR � AT 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. ALL AROUND PRECAST STRUCTURES CONCEALED WITHOUT INSPECTION BY BOARD OF �01 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00, X 12.83, HEALTH AND PERMISSION OBTAINED FROM BOARD REPLACE WITH 1500 GALLON SEPTIC TANK APPROPRIATE COMPACTION. (15.221 [21) OF HEALTH. TO SITE CONDITIONS IF NOT SUITABLE �; ( 9 x SLOPE) ( 5 76 SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR EXIST LEACHING CALLING DIGSAFE (1-888-344-7233) AND FOUNDATION- SEPTIC TANK 18 D BOX 12 9t.o' BOTTOM TH-1 VERIFYING THE LOCATION OF ALL UNDERGROUND & FACILITY NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL WORK. UTILITIES AND ALL BUILDING SEWER OUTLETS AND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED LOCUS MAP ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF SHALL BE REMOVED 5' BENEATH AND AROUND THE NOT TO SCALE SEPTIC SYSTEM PROPOSED LEACHING FACILITY. w 12. EXISTING LEACHING FACILITY SHALL BE PUMPED ASSESSORS MAP 13 PARCEL 39 AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. LEGEND sae 99- EXISTING CONTOUR 99'1 SYSTEM DESIGN: EXIST. SPOT ELEV. � � -[991- PROPOSED CONTOUR GARBAGE DISPOSER IS NOT ALLOWED 198.41 PROPOSED SPOT EL. Y � EXISTING 3 BEDROOM DWELLING TH1 rEsr HOLE DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD MAP 13 MAP 13 USE A 330 GPD DESIGN FLOW 2 -- SLOPE OF GROUND PARCEL 39 PARCEL 40 �Qo UTILITY POLE 0. 4 6 A C. SEPTIC TANK: 330 GPD (2) = 660 I, FIRE HYDRANT 4 USE EXISTING SEPTIC TANK** NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING oo. LEACHING: N`Lh oti SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD TEST HOLE LOGS �, / BOTTOM 25 x 12.83 (.74) = 237 GPD TOTAL. 472 S.F. 349 GPD DANIEL E. GONSALVES, SE #13587 F c ENGINEER: o° �0 \ USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) DAVID STANTON RS WITH 4 STONE ALL AROUND WITNESS: o DATE;i 6/1 0/15 /o / BENCHMARK.• TOP OF EXISTING BULKHEAD 1 EL.=103.8 (NAVD88) PERC'. RATE _ < 2 MIN/INCH CLASS I SOILS P# 1471 1 / ��\ �� I �\G �0 ELEV. z ELEV. p" 102.0' p1, 102.3' r ��f � \ -`-E ��� MA , A A / APPROVED DATE BOARD OF HEALTH � LS LS / �- i �� �� 102 OYR 4/2 10YR 4/2- -INVERT OUT OF = 4pt 6 0 ST = 100.4 ± o TITLE 5 SITE PLAN B B �� OF TH SL SL / TH1 72 MOCKINGBIRD LAN i „ 1OYR 5/4 10YR 5/4 I ` ( E 11 101.1 12 101.3 \ ,\ MARSTONS MILLS, MA SiL SiL �l / `y ��• h�0 PREPARED FOR •O F O � T ZH 0 MqS 2.5Y 5/4 2.5Y 5/4 �� I �� &, ELIZABETH BADACH 34" 99.2' 36" 99.3' MAP 13 ( ' ��NOFMq � ti \ I y�� s'�61111 moo DANIEL G� �o� DANIEL A. y�N o A. u, DATE: JUNE 12, 2015 PARCEL 38 OJALA No.40980� PERC �\, v OCIVIL o v `SJ C2 C2 ` A No.46502 op Sao, P M/CS M/CS ` off 508-362-4541 EXISTING fax 508-362-9880 1OYR 6/6 1OYR 6/6 TREELINE LA�OSG �o�'� DANIEL 9cy�N m A �, I downcape.com (TYPICAL) OJALA Cn " NO 46IL o No-4 80„ down cQ�e engineering, iac. 132 91.0 132 91.3 �' o o aP 0 � F civil engineers � NO GROUNDWATER ENCOUNTERED Scale:1"= 20' �s OVAL��� �q�o RJ land suveyors 939 Main Street ( Rte 6A) LICE 1 5- 1 D4 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 15-104 HICKEY-BADACH.DWG