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HomeMy WebLinkAbout0039 MOUNTWOOD ROAD - Health If 39 Mount Wood Road, M. Mills _ A= 150-083 TOWN OF BARNSTABLE LOC _TION D'D`� SEWAGE # ?7—/3 VILLAGE /�fl'JAW �i/1s ASSESSOR'S MAP &LOT�So_o83 INSTALLER'S NAME&PHONE NO. ,o/fyLoli' 60e,57- 721 SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (size) & X A9 NO.OF BEDROOMS J? BUILDER OR "'Ale PERMTTDATE: z�Z 7 �� COMPLIANCE DATE: is Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist �/� on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �/� Feet Furnished by �39 �.��� ._ .� ,ZO ��,�. b-b• ��� , O s� � �o,��. No. r Fee THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2t phratton for Mtgoar *pztem Conotrurtton VCrmtt Application for a Permit to Construct( )Repair( 16pgrade( 'j Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. h� 3 d�� �Od,YI � Owner's Name,Address and Tel.No.� Gti�r'S y`i�'d! �IO Assessor's Map/Parcel xe*1 77S P /? Installer's Name,Address,and Teel.No. Designer's Name,Address andTel.No. �°�✓�v��i Comer; f 77/ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(.�6 Other Type of Building R,50`ke No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow J?' 3a gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of epair or Alterations(Answer when ap licable LAI-7— s ©�>✓ Sri//�u��'/�� in r s erg llp Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his o of ealth. Signed , o Date Application Approved by m Date Application Disapproved for the following reasons Permit No. Date Issued —No, �J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACH.USETTS W� 2pprication for Migogal *pgtem Cougtruction Permit Application for a Permit to Construct.(.. .)Repair( Wupgrade( )Abandon( ) ❑Complete System ❑Individual Components . Location Address or Lot No. 3a���'�QC� Owner's Name,Address and Tel.No. Assessor's Map/Parcel 7 Installer's Name,Address,and Teel.NN/o. Designer's Name,Address andTel.No. f 771/- 3,4r Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building /i 1C?lZ e No."of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3_3li) gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r / Nature of Repairs or Alterations(Answer when ap,plicable) ' L✓- 7 G r' Date last inspected: Agreement: err 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 4eration until a Certifi- cate of Compliance has been issued by�his.,Board of Health. Signed - a Date Application Approvedby - _. �,®l . . Date. _ Application Disapproved for the following reasons Permit No. "- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-s'te Sewage Disposal System Constructed ( )Repaired ( �')Upgraded( ) Abandoned( )by at 4 DG/ 7`�C%� /G, `�%`G'�I ,�/! ha ee constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ated ' Installer_ Cf/� /i .,7 Kra,5,r Designer The issuance of this p s 11 of be construed as a guarantee that the s4 a 11 function as s esign ed C Date Inspector A No. -- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogaf *pgtem Cougtructiou Permit Permission is hereby granted to Construct( )Repair(`✓�)Upgrade{ )Abandon( ) System located at 3 9 i�Ili'lA/IG�l1ly� �L ' and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construct n st be pit d within three years of the date oft Date: L Approved by / v NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 1 a I, �p�B/ (� AV IIA16/i , hereby certify that the application for disposal works construction permit signed by me dated ?12,7 7 , concerning the property located at J� OGtd9% /d®� �' meets all of the following criteria: -6,/There are no wetlands within 300 feet of the proposed septic system /"There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility Ahere g g tY is,no increase in flow and/or change in use proposed Y There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the..licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert r. r' GG `A�clnt': NT '� 1_:Tom c7F' t�AraC. G>c t C. p 44-- yA _ It 4ARas. y 6ITC4 Q,A 1 Aj / Rf Zc.A Gid AF' 'Pau.•i.c�'+T —..._ .__ �`•a�p'3.'lti 1 r NYi712/�*a T NQi4p P,,t7�T' E,LEv. s !05•oo� '-Q- -- DISTANCE AS CERTIFIED PLAN I HEREBY CERTIFY THAT THE BUILDING SITE PLAN -40WN ON THIS PLAN IS LOCATED ON THE L_ MG7 tlirl"`��0 LOCUS: - ROUND AS SHOWN HEREON&THAT IT ONFORM TO THE ZONING BY LAWS OF THE MAC c9'ToN•� M iL.1-S ; M/-*-.�s•.. OWN OF . `3oo,Gr 7-44• "�ACa•G 15'� THEN CONSTRUCTED. DATE ._ REF: T- I G!to „e_ e6a Mown Cope. enor/neeo'ffif PREPARED FOR' CIVIL ENGINEERS - -_ LAND SURVEYORS +REO.LAND SURVEYOR 1 N:341IN SCALE . Yarmouth&Orleans,MA DATE: Z-, .. . .. �tOlyl�jQ.Rygj101d►. `p�QQQ�A r. . TOWN OF BAMSTABLE LOCATIONr'/G'�f/1r" JBDD�'� SEWAGE # —93 VILLAGE A,01�2myy !gills ASSESSOR'S MAP& LOT ISo 083 INSTALLER'S NAME&PHONE NO. ,t'P/fi6111 i�-41W'57 7, -93AP SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /l'l'D1'y/ (size) (o X/O NO.OF BEDROOMS BUILDER OR PERMITDATE: z/z 7 J� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) &Lo Feet Furnished by �39 O S� b COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 39 Owner's Name:Owner's Addres Date of Inspection: .D P Name of Inspect�q lease ) Company Name:. • +" Mailing Address: ) Telephone Number. .. � �. 221- � crc` �f Y CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information repgi-ted 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. 1 amfa'DE.P', approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000): The system: «i Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Ta Date: L f 6 Inspector s Signature: �' �� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the.buyer,if applicable, and the approving authority. Notes and Comments � Z• �� � �L� �`�-� ° ""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. Title,5 Inspection Form 6/15/2000 page I Page 2 of l] OFFICIAL INSPEC TION FORM-NOT FO R VOLU NTARY RY ASSESSMENTS • SU - BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: r w Owner Date of In ection: , . Inspection Summary: Check A,B,C,D or E/AII.WAYS complete,all of Section D A. System Passes: .I have not found any information which-indicates that any of the failure`crit y ena'descnben m 310 CMR 15.303 or in 310 CMR 15.304 exist.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. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If`.`not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board Of,Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND explain: 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 pipe(s).The system will pass inspection if(with approval of the Board of Health).: broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 1 OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM PART A CERTIFICATION(continued) Property Address: 10 l Owner Date of In pection: ,._ ✓' r „� J 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 a.ccordance.with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a.salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is,within 100 feet of a surface water supply or tributary to a surface water-supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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.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. 3. Other: 3 I ' Page 4 of 1 1 OFFICIAL.INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYISTE.M INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner Date of Ind ec ion: 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 fheilit or stem component due to overloaded, `clogged b _ SAS or cesspool Y Y P. ..� P 1 Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool LJ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool, _ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times.in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y Any portion of the SAS, cesspool or privy is below high ground water elevation. 1� 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 privyis:less than 100 fe.etbut.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.facilityand 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.mustbe attached to this form.] (Yes/No)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 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. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: A Owner:Wtl/�A (i Date of I spection: Check if the following have been done.You must indicate"yes" or"no"as to each of the following:. Yes -No Pumping.information a as 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? _ kJ/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 N/A) V 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 tt'h�baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum T 7 _ Was the facilityowner(and occupants if different from owner)provided with information on the proper P maintenance of subsurface sewageAisposal 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 CMR 15.302(3)(b)], Page 6 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: m E✓'r r d Date of In ection:Cyz x rpy- 0(P FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-.` Number of bedrooms(actual).: DESIGN flow based on 3 10 C5.203 (for example: 11.0 gpd x of bedrooms): Number of current residents: ' Does residence have a garbage grinder(yes or no);do " Is laundry on a separate sewage system.(y s or no); .[if yes separate inspection required] Laundry system inspected (yes.or no): Seasonal use: (yes or no): Water meter readings, if av ilable(last 2 years usage(gpd)): (�G�- u� - � rno Sump.pump.(yes or no): y Last date of occupancy: 9 - �� .�� ✓ fi`'Q '- a C C ✓ ✓� b COMMERCIAL/INDUSTRIAL„/() Type of establishment: Design flow(based on 310 CMR 1.5.203): 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: PAI-fG Was system pumped.as part of the i spection(yes or no):.,A/C-) If yes, volume pumped: gallons--How was quantity pumped determined?. Reason for pumping: TY ,EIOF SYSTEM VSeptic 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). Tight tank _Attach.a copy,of the DEP approval -Other(describe): A roximate age of all components, date installed(if o• n)and source of information. Were sewage odors detected when arriving at the site(yes or no):� f Page 7 of]7 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION-FORM PART.0 SYSTEM INFORMATION(continued) Property Address: Owner: J r Date of I°spection: a �i�d ✓ �. BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast 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: 5�l Crete_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) C��y Dimensions: tJ t". 6 Sludge'depth: V0 Distance from top of sl dge Scum thickness: rr to bottom of outlet tee or baffle: % . r/ Distance from top of scum to top of outlet tee or baffle: 7 r Distance from bottom of scum to bottom 01 outlet tee or baffle: How were dimensions determined: , . Comments(on pumping recommendAeions, inlet and outlet tee or baffle condition, structural integrity, liquid levels /9s)related to outlet invert rt evide ce of leakage,etc.): j r i GREASE TRAP on site plan) �'�� � ° ' � � �� Pam.- G 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 integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 1.1 OFFICIAL INSPECTION.FORM NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . � ��C1 . Owner: f Date of In pec ion: �ff TIGHT or HOLDING TANK"V(tank must be pumped at time of inspection)(loc.ate on..site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain):. Dimensions:. Capacity: gallons Design Flow: gallons/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: <ifesent must be opened)(locate on site plan) Depth of liquid level above outlet invert `- Comments(note if box is level.and distribution to outlets al, any evidence of solids carryover, any evidence of ,-4 kage into 0 out of box,etc 10 2: 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.): A l) Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:- _ � • Owner: - Date of In'pection: v - SOIL ABSORPTION SYSTEM (SAS): L—(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 of ponding, damp soil, condition of vegetation, -'j, V 11'0 '1.1)Af AA; -.4 mw' j � Zen 6 CESSPOOLS (cesspool must be pumped as part of inspect ion)(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 or no): . Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:): PRIVY: .L V (locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM.LI'1SPECTION FORM PART-C SYSTEM`INFORMATION(continued) Property Address: r� w Owner: Date of ection: .('� ° ( 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. Of T me_ • e �:r0i e d� 0 1\0n, Px��c d y { Page 11 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , VCZ '� ` VC� a Owner �V Date ofl7spectioc R Cyr SITE EXAM Slope . Surface water Check cellar Shallow wells Estimated depth to ground water" feet 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 reviewed:. 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) V Accessed USGS database-explain: You must describe how you established the high groundwater elevation: f' d� 9 �j'�e°✓JY rt' w 11 Permit Number: ,may Date: Completed by: A � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: c�d'�l'� C�� � r /� � /�°-� Lot No. Owner: L" Address: -.___.:.:.....,........ Contractor: s4 Address: 'j :.. -mr ��`d sY Notes: - - - ........_.... STEP 1 Measure depth to water table . / A to nearest 1/10 ft. ........................................:..:..:..:.......................:..... .Date month/day/year STEP 2 Using Water-Level Range Zone;, and Index Well Map locate site and determine OA Appropriate index well ` ��'� '^�� r © Water level range zone STEP 3 Using monthly report"Current Water`::Resources Conditions determine current depth tMet o �,�- 'water le for:index well month/year STEP 4 Using Table:of:Waterlevel-Adjustments for indexwell.(ST;EP.2A),':current-depth `to water level'for index=well (STEP 3), and water level zone (STEP 26) �d determine water.le. veLadjustment .......................................................................................... STEP 5 Estimate depth, to high water S P 9 by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .......................................... Figure 13.-,Reproducible computation form. 15 . /f ,#Goof37 o 09 90 7 L 0,CA T ION � Sn WA G E PERMIT 'NO. o�3 V`4 L L A G E ✓�/ '✓�i Yd' i . INSTA LLER'S NAME AD-DRESS cd d U I L D E R OR OWNER DATE PERMIT-,ISSUED DATE • COMPLIANCE. - ISSUED �/ • 4 Nol �D 7 0 - ........ ��+4i��'�$....y........... ......._ THE COMMONWEALTH OF MASSACHUSETTS LE Co�§ERVA��� BOARD OF HEALTH g� �COMMISSIOA 7MUtz--I�.................OF... ..\. �i . ........................ ApplirFation for Uiipooal Works Tontitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .1A c,�._._.... .......................L:a .....-------•---------------.•.............---------•------- Loc tion-Address or Lot No. �a�• S_ /1. -------------------------------------- ..... O U Q1.1' ...4J0-ouc.................i.a.......................... Q owner Address a ---- ..................................................... ------•11!` 1ZS` v�6 1W .U C.S Installer Address U Type of Building Size Lot.,=.0 .1......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `PL4-4 Other—T e of Building No. of persons............................ Showers — Cafeteria Aa Other fixtures _________________________________ W Design Flow.............�6._�_.•.....................gallons per person per day. Total daily flow..._......'_.--•-....................gallons. WSeptic Tank—Liquid capacityl00...gallons Length.....9........ Width...... Diameter................ Depth.... __.__.- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........A........... Diameter......AP....... Depth below inlet........4.......Total leaching area.4W..._ ......sq. ft. Z Other Distribution box ( ) Dosing tank ) Percolation Test Results Performed by..:...-_�..��)'k�. ......................... Date.... ._� ..- ................... Test Pit No. 1.._.__�.....minutes per inch Depth of Test Pit-_____,_�'........ Depth to ground water_ill ?? t. OV NIA . (i Test Pit No. 2------- ..._minutes per inch Depth of Test Pit.... �------- Depth to ground water---__.:......_.._.� W ........................................... •-----.-- ..•--•- .............o Description of Soil•-•5'-0A-tVc,5—. .. ` � v.� -...... W VNature 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 TIT=% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. eforthe ne ---------------------------------------------•--------•---••-------.----- ----------------------------- g Application Ap v --------••-••---------- Date Application Disg reasons----------------•-------•---•-----------•---------------•------------------------•---.-----------------.....••-- -•---•-----_----- ------.....---------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Datei No.. + d ... Fim..... Q................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratiun for Uhipati a1 Works Tonstrurtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: (, =+-��,]`.Lr`oc tion-Address y T orr�Lot No. C __ D.04.14� ".'!t:4-------------------------=----------•- ............ •----.1`I` S.� S�.+sst...--------•-- •\ ----^-----------...--•--• Owner Address are�.4S. ..... ... .0► tar��.... -- ..............................................................l -••----------- v-- Installer Address Q Type of Building Size Lot_.;�U._-__J------Sq. feet Dwelling—No. of Bedrooms.__....................................Expansion Attic ( ) Garbage Grinder ( ) pa,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures _______________________________•__ W Design Flow........... ...........................gallons per person per day. Total daily flow......_._'a:2.._..._....................gallons. WSeptic Tank—Liquid capacity!-__.____gallons Length____-9___.... Width__.... Diameter.....:.......... Depth...��-....._. x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No.........k------------ Diameter......AP....... Depth below inlet.........�`....... Total leaching area,;L. �......sq. ft. Z Other Distribution box ( ) Dosin tank� )_ r Percolation Test Results l Performed by k__�_:.......!.�L ? rU t�__._______. u �" Date y aTest Pit No. 1____.�. ..... per ', ch Depth of Test Pit__:___A- Depth to ground water.N_Q!'v5_ F0 U.N4� f? Test Pit No. 2.......�-_-_._minutes per inch Depth of Test Pit.....�.7.......... Depth to ground water-----k________________ P -•-•--'----••-•------------••........................... ....... ---•-------�••-------•---......................................................... O Description of Soil.... :',.L .2 'J - ''-��-•••-•.....•-_����/�V_ L-.. ........................................................... x V ..............................................---•-----•-•-•-••---•--•---•------•-•••...---•-•••••-•••----•--•••-•••-•-•---•-•-•-•-••-••---- W -•••------------------------•------•--•••••••-•••••----------------•----•-•-----•-•-•--...---------------------------•-----------•••-•--•••--•--•--•••-----••----•••----••••••............-•--•-----•-•- UNature 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 bpn, issued by the board of health. Signe --- - - - ate ApplicationApproved - tra .............-------••-------•------------------------••---•------•...........----- `" ------------- Date Application Disa ro f the following reasons:.............................................................................................................. ................................. .... •---•-•-•-••••---•--•-•--••-•--•---•............._.............. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Vrdifiratr of Tunip1iFaurr IS TO, RTIFII, That the Individual Sewage Disposal System constructed (�) or Repaired ( ) bY� =-_- fie :C jaA ..... ......................................... --- --4th ----- Installer -----inst-•------------------------------------------at has been installed in accordance witprovisions of LE 5 of The State Sanitary Cod as d ribed in the application for Disposal Works Construction Permit N ............. date T___ ..._.__.._...... THE ISSU NC OF THIS CERTIFICATE SHALO. NOT BE CONSYRID A UARANTEE THAT THE SYSTEM WI F NCTION SATISFACTORY. DATE.-•��l.. ........................................................... Inspector----•• --•-- ---•-•------•--•---•-••--••••---•--........_...-----------........-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p+� .................................I.........0 F..................................................................................... N101....0__... .... FE /b................ Disposa1 ks Tuns#rudiun rrmit Permission ' . ereby granted •� ..................................----------............................................................. to C c ) r Repair - n I d I wag isposal System at .. •......-••- --•----•••..... ........ AV Street as shown on the application for Disposal Works Construction Permit N . .......... . ate,._. ' ....... oard of Heal DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON COMMONWEALTH OF MASSACHUSETTS DETERMINATION OF APPLICABILITY OF THE WETLAND PROTECTION ACT G.L. Ch. 131 sec. 49 / TO: Mr. Charles Duchesny DATE: November 18,' 1982 2187 Route 6A Barnstable, Mass. 02630 RE: Lot 3 Mountwood Rd. , Marstons Mills + Pursuant to the authority of G.L. Ch. 131 sec. 40, the,,BARNSTABLE CONSERVATION COM14ISSION considered your request for a determination of applicability together with the plans submitted , } .. with it and has made the following determination: The area shown on the plans is not subject to the Act. r, ( ) The entire area shown on the plans is subject to the Act and shall require.a T filing of a Notice of Intent. a (XXX) The area shown on the plans is subject to the Act but shall not require a. fi11ngFr of a Notice of Intent, provided that: 4 Work shall be coi)fined to the area on �he road side of the old ditch. only the area described below is subject;kc the Act and shall require a filing of �. the Notice of Intent: ' .r XX .j'(fihe area shown on the plans is subject to the Act but the proposed work is not „"dredging, filling, removing, or significantly altering. Therefore, a Notice of .' Intent is' rot required. This determination does not relieve the person requesting the. dete nination from complying with all +other applicable federal, state or local statutes, ordinances by-lawsr ` and/or r, r regulations. , f7.' . Failureto comply with this determination and with all related statutes and oth er regulatory _ measures shall be deemed cause to revoke or modi- g� the said determination. , 8. No workfmay be ,commenced under this Determination until all appeal periods have"" ave elapsed. : h /o Chair nman, Conservation Conunissio y ISSUED' BYJ �� �-�2 G4 -- ------ Where the Department o u f Environmental Quality Engineering issues a;negative superseding''. yt -determination, you are hereby notified of your right to a formal hearing provided it is 'made :=. within ,ten ,(10) . days. from the date of the superseding determination of .thE Department of Environmental .Quality Engineering.' COMPaONWFALTH OF MASSACHUSETTS DETERMINATION OF APPLICABILITY OF THE WETLAND PROTECTION ACT n 7 G.L. Ch. 131 sec. 40 TO: Mr. Charles Duchesny DATE: November 18, 1982 2187 Route 6A Barnstable, Mass. 02630 RE: Lot 3 Mountwood Rd. , Marstons Mills Pursuant to the authority of G.L. Ch. 131 sec. 40, the BARNSTABLE CONSERVATION COMMISSION has considered your request for a determination of applicability together with the plans submitted with it and has made the following determination: 1, ( ) The area shown on the plans is not subject to the Act. 2, ( ) The entire area shown on the plans is subject to the Act and shall require a filing of a Notice of Intent. 3. (XXX) The area shown on the plans is subject to the Act but shall not require a filing of a Notice of Intent, provided that: Work shall be confined to the area on the road side of the old ditch. 4. ( ) Only the area described below is subject to the Act and shall require a filing of the Notice of Intent: 5. ( XXX) The area shown on the plans is subject to the Act but the proposed work is not dredging, filling, removing, or significantly altering. Therefore, a Notice of Intent is not required. 6. This determination does not relieve the person requesting the determination from complying- -- -- with all other applicable federal, state or local statutes, ordinances, by-laws, and/or regulations. 7. Failure to comply with this determination and with all related statutes and other regulatory measures shall be deemed cause to revoke or modify the said determination. 8. No work may be commenced under this Determination until all appeal periods have elapsed. ISSUED BY: �� r �Q/I� �-�� Chairman, Conservation Commission Where the .Department of Environmental Quality Engineering issues a negative superseding ` determination, you are hereby notified of your tight to a formal hearing provided it is made within ten (10) days from the date of the superseding determination of the Department of Environmental Quality Engineering. SECTION - SEWAGE -SEPTIC TANK - - "D" BOX - - LEACH _?-I__I. -Top OF FDN \ Cos.CS 13 - - -- - - - (MSL)a '2"OF 1 aT0 Nz" _ f�WASHED STONE: i T j \ ->t IN - \ f - \ =Te-A- OUT - IN - OUT- IN - - ^-- 6>o) 1 \ r-- I�uELEV. ELEV.ELEV. ELEV. ELEV. 4 -ELEV. ;'U-ice r=j+`.(• '_�_ '� � /^ ...._... _.�` _ 't \ ELEV. ELEV, . 1 C� WASHED STONE \ TEST HOLE LOG TEST BY IZICH�:eb ,2Y 1+.►rL acc>,3Y j — -- p�-_ ►�k C 7 i 1 �c41 nZ WITNESS '? J \ DESIGN - BEDROOM HOUSE J 3 TTy C o TEST DATE T.H. a� 1 �3.Z T.H. � 2 ��.-L- � ... ___ . . . �s( �_� �""e�-�••-•...I� � _ �''� ELEV. n0 ELEV. s -� (d3J� ! +vt PERC RATE _ __._MIN/IN. _DISPOSER DISPOSER_ CoZ I S �. `r233v w�w ~�-��`}- �'•/ FLOW RATE (GAL./DAY ) �u -i �r 4,0.z_ SEPTIC TANK 4r -- ? REQ'D SEPTIC TANK SIZE I �oA2 a S 1,,0 COAL 51Au7 LEACH FACILITY gY ; SIDE WALL 'O(TT)4 = 1Z�'rs lz.� 1 = �'�A :1- G/D. BOTTOM _ '�'�' .��oca� _ '1a•,- --g.r,,. , rnt;U.� G vMl Ine � v(EA-- - '-�( I.ca ) _ -- _1 . _ G D 1 3`�.CDC ' - - I TOTAL 2_W4.1, `lr'_•L.Co GAD . _ cAzc�i �ss���� ' E9G>% C.,F ts`L.r 1o3.'tp ( ,. ` —St.Z t4 -- - St.Z USE: _�_�` ---- .. __. -,-J t r— - - - 1�/i G7 t_J P.! f \/`/ n p l l� _. LEACHING Op, p t-4 U WATF_R ENCOUNTERED —__._---- --�_;_ _. _.._- - --- ----'- — - __ �� ���d�t,\ NOTES: (UNLESS OTHERWISE NOTED) ���• : � •Q6 5 t;ASgurn�•O i 1. DATUM (MSL)!-TAKEN 2.MUNICIPAL WATER____-___-� AVAILABLE _ --•------- -----•-- 3. PIPE PITCH: W"PER FOOT w. uF 4.DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO _ (Q 44 5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIESC(1) FT. r /// ---f� ---- DISTANCE AS CERTIFIED 6.PIPE JOINTS SHALL BE MADE WATER TIGHT /r PtiiJ[ \J �. -3 ARNE- In � 7.CONSTRUCTION OF-TAILS TO BE ACCORDANCE WITH COMM. F MASS. If �( �� ( 0,13 i E r STATE ENVIRONMENTAL CODE TITLE 5 01!ALr. zs� i.. 1t_ f I HEREBY CERTIFY THAT THE BUILDING SITE PLAN «�i348 0 0792 HOWN ON THIS PLAN IS LOCATED ON THE iq. ,GROUND AS SHOWN HEREON &THAT IT_ _ LOCUS: Lo I - MpwNTWG e=>r-, t� ~ k, 1X CONFORM TO THE ZONING BY LAWS OF THE TOWN OF iU pFF_SS ,� R WHEN CONSTRUCTED. DATE _ Vt_Ana P6CPcatC_ 7,••44 REF: y� down cope englneerlog PREPARED FOR: CIVIL ENGINEERS - LAND SURVEYORS -------------- CONTOURS (EXISTINGf BOARD OF HEALTH REG. LAND SURVEYOR „ (PROPOSED) O-O-O-O- APPROVED DATE SCALE `� -� rt - MA Yarmouth&Orleans,MA DATE SECTION - SEWAGE SEPTIC TANK - - "D"BOX - - LEACH TOP OF FDN , Co3. .. (MSL)x 112"OF irsTO ih" (3�. C?Z WASHED STONE _ = _-_•__ —— '_ — '— -- _ _ _ y�— l v� wlr-)c_ 1 IN OUT IN OUT I N CoO.�lZ I SEPTIC �c'Q.1•L/ TANK �5q..� S9. 70` )C,, ELEV. ELEV. ELLV. FLEV 4 =4 Cyr. rl . ELEV. ELEV. -�z' WASHED STONE TEST HOLE LOG �_ '� s .__ 4-4. (_ TEST BY21Ca•1AeDZ��Y..�-wl�.TEST DATE WITNESS _�___ BEDROOM HOUSE V --- DESIGN _ T.H. # 1 T.H. # 2 ELEV. ELEV. N NO _z_ I DISPOSER DISPOSER Los*Nt J>f' u35o�L Lode" S+Ssc)IL PERC RATE _ __— _MIN/IN. FLOW RATE ( AL./DAY ) 3Co / 6110.2- 79r." - moo. SEPTIC TANK '�7v (\ ,= i , 4�R � REO'D SEPTIC TANK SIZE --- - �sae �\z. } �.�-•,�. (�j.��� i I cow S nrfl cc�A%c uo LEACH FACILITY �}� SIDE WALL I TT 4 =)ZS.Cn (2.S ) 31 4 . ! G/D �- �. _ MAD. G vc` BOTTOM /q_�too� , d°r 1 0 ) �i�� _ GID --� to G, vE L_ TOTAL 7 �.4•'�`� c�Tcti 3,a — — • USE: —. __a t'j F' LEACHING __ .- _ ..__`___ . w44* —I I —SI.Z � )' ti -, bra. . ' iYF�. — WATER ENCOUNTERED ' W'C�'�''s>t•.eT NOTES: (UNLESS OTHERWISE NOTED) Nan Px - 1. DATUM (MSL)+TAKEN FR�M� ��`�' k;_. t,I�.+C.-. 2.MUNICIPAL WATER----•---1_.9_.........._................. VAILABLE ���G `� �� •tk\ { 4 3.PIPE PITCH:4."PER FOOT 4.DESIGN LOADING FOR ALL PRECAST UNITS: AASHO-- —_ 44 f �' y / �-. -- 5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. 10�1 N. vJ1 ;� ARNE ri V ---DISTANCE AS CERTIFIED 6.PIPE JOINTS SHALL BE MADE WATER TIGHT t}IA`._A 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. H. ' STATE ENVIRONMENTAL CODE TITLE 5 p OJALA \11l c I HEREBY CERTIFY THAT THE BUILDING _ SITE PLAN +8 H PLAN I LOCATED ON THE . 263 p i?7�' OWN ON THIS L S OC h _ GROUND AS SHOWN HEREON & THAT IT �-a i MpLatvTwc�D TtL�_— __ LOCUS: CONFORM TO THE ZONING BY LAWS OF THE MAZ STUNS NA I L__G. o - 4 O _ ! _ Sly oFESS G111 WHEN CONSTRUCTED. DATE REF: ��",o.l.I � �- 7-44 �ActG 15`� l�OM✓d CQp@ e/!ff�/1e@!//!g PREPARED FOR: G�A�4 I�`� s�UG4d�5 t.►E`( CIVIL ENGINEERS _ BOARD OF HEALTH LAND SURVEYORS REG. LAND SURVEYOR CONTOURS (EXISTING)------------- - — I �— (PROPOSED) —O—O—O—O— APPROVED —DATE MA Yarmouth&Orleans,MA SCALE DATE FFz CoNg£RV�T\oI.\ APPQO'JPL ATI-AcK1_T)