HomeMy WebLinkAbout0115 ACRE HILL ROAD - Health 115 Acre Hill Road D �
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9116103
Notice: This Form Is To Be Used For the Repair.Of Failed
Septic Systems Only .
PERCOLATION PEST AND SOIL EVAI.UATION EXEMPTION FORM
I, �(JeA U v t • MLA4W hereby certify that the engineered plan signed by me
dated 0 concerning the property located at
meets.. all .of the.
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or
business.uses associated with the dwelling.
• The.soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
test holes and percolation testss at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Fnimptor method when applicable]
Please complete the following: .
A) Top of Ground Surface Elevation(using GIS information) J 1
B) G.W.Elevation ;9 0+adjustment for high G.W.
D \ NCE'1517 Qy A and B =t� yto
MLSIGNS : ( ATE:
NOTILVE
Based upon the above information;a repair permit will be issued for bedrooms
maximum, No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptWpercexemp.doe
� -TOWN
�OF BARNSTABLE
LOCATION // C��At- SEWAGE#
VILLAGE 114 e- �nASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. � � VCd -7%--2k(X3
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (.i)1A Ai15;2 � .05'7 S (size) .9 55- Loa
NO.OF BEDROOMS 3 _
BUILDER OR OWNER A Y6 �
PERMIT DATE: COMPLIANCE DATE: j 2- �
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
Caw-, '
03;
a.
No. .Z� R. Fee V ..
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[ppYiration for &.5po5al *pftem (fongtruction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑ Complete System 2 Individual Components
Location Address or Lot No. �� � / Owne}'s Name,Address,and Tel.No.
Assessor's Map/Parcel �9►e�n'
Installer's Name,AdA�&Bid CO Designer's Name,Address and Tel.No.
ain Street n/jCt/ers 3�d'd�a�
W. Yarmoutn, MA 02673
Type of Building:
Dwelling No.of Bedrooms _3 Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
q �
Design Flow(min.required) 33o gpd Design flow provided 33�1• ,F S gpd
Plan Date //���S� Number of sheets / Revision Date ov 11q
Title S/1� —ccJact.
Size of Septic Tank rX;j J;r 4 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �•C i' P/4 j
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of H alth.
Signe (2(, (,( C, Date /C l'S
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. D-a 0 S (o dL Date Issued 2 U�
No. �.., 1 Fee U
r Entered in computer: LX
THE COMMONWEALTH Of, MArr,SACHUSETTS Yes
. PUBLIC HEALTH DIVISION - TOWN OF A`ARNSTABLE, MASSACHUSETTS
ZIPPlication for Th5pont *pgfft Cowaruction Permit
Application,fq a Permit to Construct O Repair O Upgrade(,,Abandon O ❑ Complete System ®Individual Components
Location Address or Lot No. !��/^e �i r// XV. Owner's Name,Address,and Tel.No. r
Assessor's Map/parcel D 19
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�yef s 3&J -a(3a4
Type of Building: '
Dwelling No.of Bedrooms ! Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33o gpd Design flow provided 33el. FY- gpd
Plan Date ��5 r Number of sheets / Revision Date OU f 1q
Title �1 /�c —����✓-a�e
Size of Septic,Tank ram;J l G rn u Type of S.A.S.
Description of Soil 14,
Nature of Repairs or Alterations(Answer when applicable) �t i� [A ,I
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in,operation until a Certificate of
Compliance has been issued by this Board of H alth.
Signe Date
Application Approved by 1 / vL e. .tt jDate l
v
Application Disapproved by: a; P bate
for the following reasons {
Permit No. aQ d S (�02�, Date Issued /.2.
r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( )by q IAJ(�0
at C Lr e has been constructed in accordance J
with the provisions of Title 5 and the for Disposal System Construction Permit No. a dlu��'"-����j dated
Installer ir�e '� Designer Y r vv
#bedrooms Approved design flow ? U gpd
The issuance of this permit shall nol.be construed as a guarantee that the system ,w 1'f c�designed.
Date / V 4-) Inspector (`
----------------------------------------------
No. GvS Fee U U
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
1=i0poat *pgtem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( Abandon ( )
System located at � C l� // r� AS A,) -146 i%P
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: Cons ction ust be completed within three years of the date of this(perm'
Date 12 I ! 5-/os, Approved by
r p ,f )
Cti 1' / r`nP('/ or l�c'tl �� Sr n OJ� InICI�Ur/r. j/`/� r 'r�c �L jjo f�r° /oC! do />f,vr�
rr l_
�I c,�J n(•�� lU f 15�.�j C O C,
J -
Town of Barnstable i Lxf1 f\
��FtHE TQk� Regulatory Services
Thomas F.Geiler,Director
• RAM 5ThBLE, +
a Public Health Division
Ep e, Thomas McKean,Director
200 Main.Street,Hyannis,MA 02601
Office:.508-8624644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer: &Y-'(eA Installer: p & B _Arm
�Address: . P �1 350 Main Street
� • � ^, Address: W, Yarmouth, n(�A n�67$
- SCE ►���lcAa OZS39
On /o) / _ C/ /'� Q was issued a permit to install a
date) (installer) l
septic system at LL 0 11 1�0�-based on a design drawn by
(
(address)
Mr �.s.
dated_
(designer)
Lj
1-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&Local Regulations. Plan revision or
certified as-built by designer to follow.
� N�N OF ssq
C
'J � DARKENra
yG�,
(Installers Signature) M R
� d1 >
N D 0
o 0
V SgNITAF0PN
(Designer's Signature%ABLE
(Affix Designer's Stamp Here)
PLEASE RETURN TO PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT BARD ARE RECEIVEDBY THE.BARNSTABLE PUBLIC HEALTH'DIVISION.
TRANK YOU.
Q:Health/Septic/Designer Certification Form
ECO-TECH
ENVIRONMENTAL � �k991
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MA USETTS Z
N
DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 4/25/97)
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 1 15 Acre Hill Road,Barnstable Address of Owner 129 Saddler Lane
Date of Inspection: June 19, 1997 (If different) West Barnstable,MA
Name of Inspector:David D.CoughanowC,R.S.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name Eco-Tech Environmental
Mailing Address 43 Triangle Circle Sandwich MA 02563
Telephone Number: (508) 888-0185
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.The system:
_X ��H OF.MgS
naally'PYs +
s Ft OEva * By the Local Approving Authority
D.
o 0 HAN /
Inspector's Signature J� Date: b Z2 6
�Q/SI
Inspector's Note=_> e�r�tsPda d to pass this Real Estate Transfer Inspection if it does not trigger any of the
failure criteria listed below.T as been evaluated according to the conditions observed on the day it was
inspected.No estimate or guaran e o s m longevity is made or implied by a passing determination.
The System Inspector shall submit a copy of this report to the local Approving Authority within thirty(30) days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the Department of
Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,
and the approving authority.
INSPECTION SUMMARY: Check A, B,C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CMR 15.303.Any failure criteria not evaluated are indicated below.
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 exfiltradon,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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 115 Acre Hill Road,Barnstable
Owner: Sue&Lee Sarafin
Date of Inspection: June 19, 1997
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 leveled or replaced.
The system required pumping more than four times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) 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 the public health,safety and environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water.
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
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 1 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
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Acre Hill Road,Barnstable
Owner: Sue 8t Lee Sarafin
Date of Inspection: June 19, 1997
D) SYSTEM FAILS:
You must indicate either"Yes"or"no"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 1 of a public water supply 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
E) LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of systems is 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 II 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 with the local regional office of the Department
for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 15 Acre Hill Road,Barnstable
Owner: Sue 8t Lee Sarafin
Date of Inspection: June 19, 1997
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ 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
ha;been rpreh4ng normal flow rates duiingthat peeled.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
X _ The facility or dwelling was inspected for signs of sewage backup.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
including
X _ All system components,emiuding the Soil Absorption System.have 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.
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper
maintenance of Sub-Surface Disposal System.
The size and location of the Soil Absorption System on the site has been determined based on:
X existing information.Ex.Plan at B.O.H.
X _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of
distance is unacceptable) [I S.302(3)b)]
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 115 Acre Hill Road,Barnstable
Owner: Sue St Lee Sarafin
Date of Inspection: June 19, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design flow:_g.p.d/bedroom for S.A.S.n/a-Design plan not available at BOH
Number of bedrooms: 3—
Number of current residents
Garbage grinder(yes or no): no
Laundry connected to system (yes or no): yes
Seasonal use(yes or no): no
Water meter readings,if available(last two(2)year usage(gpd): 6/96-6/97: 110 rod 6/95-6/96: 118 gpd
Sump Pump (yes or no): no
Last date of occupancy: 2/97
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow gallons/day
Grease trap present: (yes or no):
Industrial Waste Holding Tank present: (yes or no:
Non-sanitary waste discharged to the-ride 5 system: (yes or no):
Water meter readings,if available:
Last date of occupancy:
OTHER: (describe):
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: j
System not pumped in recent past (owner's agent)
System pumped as part of inspection (yes or no) No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
X 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)
I/A Technology etc.Copy of up to date contract?
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information.
System estimated to be about 15-20 years old(no records available at Board of Health)
Sewage odors detected when arriving at site: (yes or no) no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Acre Hill Road, Barnstable
Owner: Sue 8t Lee Sarafin
Date of Inspection: June 19, 1997
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1 ft
Material of construcdon:_cast iron _40 PVC X other(explain)
Unable to inspect-sewer exits dwelling beneath slab
Distance from private water supply or suction line 25+
Diameter Unable to inspect-sewer exits dwelling beneath slab
Comments: (condition of joints,venting,evidence of leakage,etc.)
Unable to inspect-sewer exits dwelling beneath slab
SEPTIC TANK:-
(locate on site plan)
Depth below grade: 15"
Material of construction:X concrete_metal_Fiberglass_Polyethylene other(explain)
If tank is metal,list age_ Is age confirmed by certificate of compliance_(Yes/No)
Dimensions: 8'x 5'x 4'
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 30„
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: 10„
How dimensions were determined: Probe to top of tank
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.) Pumping not required at this time.Liquid level at outlet invert.Tank and
tees appear structurally sound and functioning as intended.No evidence of leakage in or out.
GREASE TRAP: none
(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.)
. 1.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 15 Acre Hill Road,Barnstable
Owner: Sue&Lee Sarafin
Date of Inspection: June 19, 1997
TIGHT OR HOLDING TANK: none (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
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:_X_
(locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Few solids in sump.D-box appears structurally sound with no evidence of leakage in or out
PUMP CHAMBER:none
(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.)
t
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Acre Hill Road,Barnstable
Owner: Sue ex Lee Sarafin
Date of Inspection: June 19, 1997
SOIL ABSORPTION SYSTEM (SAS): —X—
(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. I
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.) Leach pit contained
1 foot of effluent in a 6 ft effective depth pit.No evidence of lush vegetation,surface ponding,breakout,overlying saturated
sods or other evidence of hydraulic failure was observed.
CESSPOOLS: none
(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:none
(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.)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Acre Hill Road,Barnstable
Owner: Sue ex Lee Sarafin
Date of Inspection: June 19, 1997
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)
i
LOCATIONS
A B
w
1 19' 11'
2 23' 17'
LU
3 32' 28'
3 4 34' 39'
3 BEDROOM
DWELLING
#115
A B
I SEPTIC
o TANK
0
2
LEACH
PIT 3
4
D-BOX
NOT TO SCALE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Acre Hill Road,Barnstable
Owner: Sue 8z Lee Sarafin
Date of Inspection: June 19, 1997
Depth to groundwater: 10+ feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
—X— Observation of Site(Abutting property,observation hole,basement sump,etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators,installers
X Use USGS Data
Describe in your own words how you established High Groundwater Elevation. (MM be completed)
Augured test boring in vicinity of leach pit to a depth of 10 feet and encountered no water.Applied groundwater adjustment
factor(Frimpter method).Well:Al W-247 Zone B-current reading= 20.7,adjustment= 0.Therefore adjusted
groundwater level is greater than 10 feet from surface.
r
LOCATION
L-+sF 29 ►i Es
VI L L A G E c2
INSTALLER'S NAME i ADDRESS
R 114 nr o ns OWNER
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L,3l,� T 10N S EWE E f�RMIT N0.
VILLAGE
INSTA LLER'S NAME & ADDRESS
BUILDER OR OWNER
DA E P RMIT ISSUED Q �-� -78
DAT E COMPLIANCE ISSUED /,75--,_ -7c(— _
Oy�
4�
ri
THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF HEALTH
_ ocs...._.........OF....�O_kr.flS���C'.�..._...... -
A 11ifiratiun -fur Uiiipuutt1 Workii Towitrurtiun Prrutit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--...I 1 cry..............•--
Location_Address or Lot No.
PSMES 1�:. ...7.-h-------------------•--•---------•------ --.-�t A20�s T-FLG
_ Owner L rAddress
W —•.. Q Z_�.�3.. ........................................................
Installer Address
Type of Building Size Lot.... .....111A--------Sq. feet
Dwelling—No. of Bedrooms------9J__________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons--------- ---------------- Showers ( ) — Cafeteria ( )
d Other fixtures ----------------------------------------------------------....
W Design Flow_..._____:________________J.S._...._____gallons per person per day. Total daily flow------------ _----------------------gallons.
WSeptic "funk—Liquid capacitylM-0t.gallons Length------4...... Width...... ..._.. Diameter---------------- Depth._-------------
x Disposal Trench—No_ ____________________ Width_-__---_-_-_----_-_ Total Length........... _.__... Total leaching area_.z ?_.--_-_sq. ft.
Seepage Pit No....../__-_____--_ Diameter......... ____---- Depth below inlet______! ___.____ T 1) }aging area.A.a1-_-_-_-sq. it.
Z Other Distribution box (� Dosing tj k n !},� /�` -- �� G 4
Percolation Test Results Performed by-------d?l.-__. Y= _r�-_____________________________________ Date.....0'-5�17�'.__'__----___...
a
Test Pit No. 1_._•__�-__-minutes per inch Depth of Test Pit......` ._•_____ Depth to ground water________________________
(q Test Pit No. 2........ ____minutes per inch Depth of Test Pit-------tt-x------- Depth to ground water------------------------
P' ---------------------------------------------------------------------------------------------------'••-----------'--•---"---------•-...------'---•-------.
O —
Description of Soil 0-- 3b" ...�L1b Soi_►- � 'f' $Qi� 5 '►P' d�__"-- 56..-151..........
U --••--•-CJ----�.A-------------- -
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health,
Si —A. 7
` _.
-------- •------------ ----- 8
/lie Date
Application Approved BY ---- •- � Z
Date
Application Disapproved for the following reasons:------------- --•--...•.----------•-'----------------------•-•-••---------•-••---------..._•--•..._..._-'''-'
--._.._._.•...-•--'--------------•-•-----•-'--------••--_-----._.___.__...----------•---------•-----...----------•------'-•-•---'---------------•-•------...----------- ---------•----------...........
Date
Permit No.......................................................... Issued.....-fit --,2,5_..'_7_
Date
®------ - ---- - - -
No&....... f Fmc ...Vf. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 3� `I` __.-.-----.OF...."_ ct; .n.-.: e,.. ...
Appliratiou -for Dhipo,5al Forks Tomitrurtiou Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
•• ......................................................-s......................... --------------•--•------••----- ---- ----------------------.__..-------------_•-••-
Location_Address _ or Lot No.
-= F;1.1C` t��.:... 1 T ------------ ='< -� t-Z =?- s L r
W I Owner — dress
--•---1-=1�•:4 ( _ .' Ca.__.. �5 +::14_ f _ 4tNi-I3LC d
Installer Address
„,.z �� � � 1 q.
Q Type of Building •`' Size Lot__________ ________________S feet
v Dwelling'.No. of Bedrooms._.__-a* __________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—'I, e of Building T
a YP g --------•---•-••--•-•-•----- 1\0. of persons.........G---------------- Showers ( ) — Cafeteria ( )
d Other fixtures -------------------------------------------------------
W Design Flow.....................___.. .__.._.._.gallons per person per day. Total daily flow_.__.__.___-- ..........................gallons.
WSeptic Tcuik—Liquid capacity!. gallons Length------!- h______ Widt .-_. ...... Diameter.......... ..... Depth................
x Disposal Trench—No_____________________ NA idtli_._._..._......._.__ Total Length.................... Total leaching area_-:�4!��..__..sq. ft.
Seepage Pit No____________________ Diameter.................... Depth below/inlet_...__-______ _.____ T �c�]ring area..................sq. ft.
z Other Distribution box ( Dosing tj k � �y p `
~" Percolation Test Results Performed by.__.._.pi._ _S( ii► __________ ........................... Date__.._�`:s�-_'
Test Pit No. 1------- ----minutes per inch Depth of Test Pit...... �.__.__. Depth to ground water-...___________________
!14 Test Pit No. 2---- ____minutes per inch Depth of Test Pit... t?__-____ Depth to ground wa ter__._}'=-----------------
t� ;
Descrtption of Soil-----(�.-. t `�_-_ ,�tip.)-� s L"---�- �•_-`QtL ��rt ,•�a��ed-� �l� �ab'._-- �� -z) � 1lSC,
U �J'aly •----• ..................
W
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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si --- 1 U-
r" Z Date
Application Approved By...... S = ------------- ----- ------ ------------`77 •740
. Date
Application Disapproved for the following reasons:------------
__________________________________________________________________________________________________
...............................•-•-----••••-•----- ---=
9 a Date
Permit No. ------------------•-------------------- Issued. -=-----•--`
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................�.. � ........OF....... : . -. ,T'a sE:.e.......................................
Trrtifirate of T'lantpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed /) Or Repaired.. g P �' ( ( )
by............. w _-- t
Installer_.,•
at................''= t "_zLc�. �1:. e 0c�, 1_ :trt+t at:s Via( a_
--- f I---------------------------------------------------------------------------•••--------
has been installed in acco.dance with the provisions of"A X of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._. -___ _________________ dated......... ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS E® AS A GUARANTEE THAT THE
SYSTEM WILL F N TION SAT SFA TORY.
DATE 1 ........... Inspector ;r:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�,............OF....... c n�.,..z,. e.y : ................................... a►d
FEE--•-•------•----------•-
Dinporial ork,q you,5trurtion amit
Permission is hereby granted......... �. _ � ..... ..... '.-.�4-- -__�_-____-_._
to Construct ( .vj"or Repair ( ) an Individual Sewage Disposal System
{. Ci `
----------.......
Street
as shown on the application for Disposal Works Construction P r N _._ .: ..___ Dated_...►.—���
1 Board of Heal
DATE-------Y_C � , 7Qi I
i}I
FORM 1255 HOBBS& WARREN. INC.. PUBLISHERS _ '�
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'-=- -'� ASSESSORS MAP : 2� TEST HOLE , LOGS NOTES:
WAYS W PARCEL: 075 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
SOIL EVALUATOR: r,_ ��I C
HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
FLOOD ZONE: NoO �PCZA-�-D BOARD OF HEALTH REGULATIONS.
WITNESS : vi a'D
"y
DATE 2UDS Z THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
je�M
REFERENCE: �I�- �� S l )
S
PERCOLATION RATE SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
'; L E�J 1 N
INSTALLATION.
CLASS I So;' 1�4
TH- I L l. 59.4 Z THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
�� TH-2 �",cj°I SS U 3) ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
DETERMINATION.
3 Sib 35 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "r FOOT. (UNLESS
� ��' JK�T iO � I O 1 �_D A Lt
j prm L Q�� A ID��Z�j SPECIFIED OTHERWISE)
425°I1. 40 S� 4�
5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
LOCAT I ON MAP Id R S
12500 fr Vw�+"I 'n^.A Y GARBAGE DISPOSAL.
�,
6� S4'4 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
pp MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
E
('v � , S v'r1"' 2 A BASE OF 6"OF CRUSHED STONE.
is c yz_ s �
SAN�p Y 52 9Z � �Y /y l ICE vm C
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No G w oP�S- NG �i w UPS
$�_I`I o Now� �►Zl vtrrE wEus �f�r� �5� Prop. ��a cti j� -
SEPT I C SYSTEM DES I GN l't\k> we"V::� wJ,A) 115b' or Prof L�*a(Alvl
y
10) �lt�tOVE �t✓L VNSUIT $(.� SD�I.`7 S IrT. ULN1�
'
FLOW ES'j'I MATE
BEDFOOMS AT 110 GAL/DAY/BEDROOM - 330 GAL/DAY
w/ CbEATJ Meot vAl ,dub.
$ SEPTIC ",;ANK I I. 0 WI kNtc-1`7, I
GAI./DAY x 2 DAYS - GAL a
'gam� �--[3 p• >< f��r�_�-�v c �v7v5 ____
1 Z USE
GALLON SEPTIC TANK -t(1S77/ C -(L
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SOIL A83ORPT I ON SYSTEM pk U/vr XIS/ZEb.
I
I uSp— (3)wN i ,T me, 3020 UNI€S wj i.3 51D)ve- 6lu END 5
\` S'PA,l r- taw S►DeS.,_ r2S'L x 12 •I1"k)x +CFF
SIDE AREA:L5)2-x-(12 -16��7X 2 Y /a9. 95 o A N
To Ent. D.4 Z BOTTOM AREA: 25 x (2. l 6 x O. )�/ '
ZZY.9� YER N
v \ Olt lvP OF No. 1140
• _ 33Y. 9S FQ/ TS- �
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NITAR�> 330SEPTIC SYSTEM SECTION
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8
-BOX
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SEPTIC TANK �b✓ le'��weZ) .��.Sa Sy►�
m
Cws r7A� Dg- 3 25 c- x l2•►6 W og i
m t 7,
CROSS SEC-/-�OA/.
0
M-4 $ (A -1 o s �17.
�$ Z ��
- N
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> �/ 2 /e S I TE AND SEWAGE PLAN
-� � DvWr
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LOCATION : 115 t�C g fflt.L. l�o
i m �
Skcd
3/4
4a" sv 48 PREPARED FOR
IE
livask��l /° Cvcb
lI �," SCALE /''-30
SbM e, DARREN M. MEYER, R.S.
12soo fr _"
,�_g o C DATE:
/! 0
P.O. BOX 981
c PAVE SIDEWALK
�E P�� EAST SANDWICH, MA 02537
W ACRE HILL ROAD DATE HEALTH AGENT Ph: (508) 362-2922
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