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HomeMy WebLinkAbout0186 BOULDER ROAD - Health 186 Boulder Road Barnstable - A= 315—.032 r �. m . � w 49.r rr S6SO. P 71 a �a„ OT flot V I , v h j q2; L or o Qj� — - ;:L 'N . t _ t' �J /QT Ut 2 /^} •� , v+. No. 10617 LU aig -------------- S i PLAN 7tig, paw•;-.�..�.,as<e�.x„� SCALEe�J� �,� DATEe�� a li _ o LEVY & ELDREDGE ASSOCI A , INC, CPI �T L I CERTIFY THAT THE F2a.Ur",/�r) ENGINEERS-LANDSCAPE ARCHITric*O SHOWN ON THIS PLAN IS LOCATED i Rl.�►NNEPS-LAND SURVEYORS i.�� � . 1- ? ON, THE GROUND AS INDICATED A4� ...4 - OMFORMS TO THE . XONINO LAWS. MAS � O � I r. ATE Rt LAND SLeRV Yo rLD D) Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04l17/10 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted;on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector. only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name - P.O. Box 896 Company Address East Dennis MA 02641 'BQ°0 Cityrrown State Zip Code 508-385-7608 S13742 ` Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b the Local Approving Authority Y Rp 9 F a C, 04/19/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Au ority $oard of Health or DEP)within 30 days of completing this inspection. If the system is a share system, or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall s mit 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. ""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 4 the same or different conditions of use. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 186 Boulder Road y Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of thefailure criteria.described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria,not evaluated are indicated below. Comments: B) System Conditionally Passes: Ell 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 breakout 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 El obstruction is removed f Commonwealth of Massachusetts V Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 186 Boulder Road Property Address Louise Gentile Owner Owners Name information is required for Barnstable MA 02630 04/17/10 . every page. City/Town State Zip Code Date of Inspection B. Certification cont. B) System Conditionally Passes(cunt.); ❑ 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 O ❑ obstruction is removed ND Explain: C F . urther Evaluation i Required . s u red b the Board of Health:. h:q y ea t ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System!will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that:the system is not functioning in a manner which•will:protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water r ❑ 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 functioningi in a manner that protects the public health, safety and environment: El 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. r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable _ MA 02630 04/17/10 every page. Cityfrown State Zip.Code. Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or Pore from a private water supply well**. Method used to determine distance- **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 . El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow El 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS, cesspool or privy,is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.. 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No El Z Any portion of a cesspool'or privy is within,a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within.50 feet of a private water supply well. El 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well'with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] 0 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Z The system fails. I have determined that one or more of the above failure criteria exist as described'in 310 CMR 15.303, therefore the system fails. The system owner should:contact the Board.of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must,serve a facility with a design flow of 10,000 gpd to 15,000 gpd.. For large systems, you must indicate either"yes"or"no to each,of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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 31.0 CMR 15.304. The system owner should:contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is Barnstable 02630 04/17/10 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner; occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained;and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected,for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? M ❑ - Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been.determined based on ® ❑ Existing information. For example, a plan at the Board of Health. ® 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?,[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)) Sump pump? ❑ Yes ® No Last date of occupancy: current Date t Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based'on 310 CMR 15.203): Gairons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged to the Title system? ,ed 5 stem Ye N s o 9 Y ❑ ❑ Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is Barnstable MA 02630 04/17/10 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: ti Source of information: Was system pumped as part of the inspection?. s ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 10/15/07 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 186 Boulder Road - Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 every page. Cityrrown State Zip Code bate of Inspection D. System Information (cont.) ; Building Sewer(locate on site plan): Depth below grade: 1.6 • feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): . Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1.0 Depth below grade: feet Material of construction:" ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: y years Is age confirmed by a Certificate of Compliance?(attach a'copy of certificate) ❑ Yes ❑ No Dimensions: - 1000 gal 4". Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" measured How were dimensions determined? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee o'r baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete 0 metal ❑fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 186 Boulder Road Property Address Louise Gentile Owner Owners Name information is required for Barnstable MA 02630 04/17/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 'No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and.tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No,, r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 every page. Cityrrown State Zip Code:> Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ; ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ 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, etc.): The system has four flow diffussors in al VxW field of stone. There was no sign.of ponding or failure in the stones. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is required for Barnstable MA 02630 04/17/10 every page. Citylrown State Tip Code Date of Inspection D. System Information (cont.) . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool f , Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.•''4 186 Boulder Road Property Address Louise Gentile Owner Owners Name information is required for Barnstable MA 02630 04/17/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 31 31 e i - r l Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 186 Boulder Road Property Address Louise Gentile Owner Owner's Name information is Barnstable ,'MA 02630 04/17/10 required for "' every page. City/Town State L. Zip Code Date of Inspection D. Systemi Information (cont.) . Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells` v Estimated depth to high groundwater: feet ' - feet ' Please indicate all methods used to determine the high ground water elevation: ' Obtained from system design plans on record- If checked, date of design plan reviewed: ❑ Observed site"(abutting property/observation hole within1150 feet of SAS) ❑ Checked with local Board of Health=explain p ` ❑ Checked with local'excavators, installers-(attach documentation) ® Accessed,USGS database'-explain You must describe how you established the high ground water elevation:' USGS maps show an elevation of over 20.0 feet No. _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for air ogal 6 ptem Con0tructfott Permit Application for a Permit to Construct( ) Repair( ) Upgrade(p,�'Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. � � G iAGC 0 ner's Name,Address,and Tel.No, Assessor's Map/Parcel Installer's Name,Address,and Tel Nq*� esigner's Name,Address and Tel.No. P zaZ�� 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) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i9-Qi�•►.a� 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 by t ' Board of Health. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons / Permit-No . Date Issued 01 f, No; � '` �" " J Fee / t �J, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ar PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes l Rpprication for �igpogar �&pgtem Cottgtruction Permit t , Application for a Permit to Construct O Repair( Upgrade(kf Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No. /�V � 0 ner's Name,Address,and Tel.No. Assessor's Map/Parcel ' Installer's Name,Address,and Tel.N Qomd�/ esigner's Name,Address and Tel.No.�P' . r 3o�au:Q1 > f+ � 39 ass . Type of Building: `- Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) f Other Type of Building No.of Persons Showers( ) Cafeteria( ) tier Fixtures �y� Design Flo gtriied) gpd Design flow provided gpd Plan Date Number of sheets Revision Date j Title Y Size of Septic Tank Type of S.A.S. Description of Soil �.aBt. 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 by t ' Board of Health. i Signed i Date _ ApplicationApproved by / Date j - ApplicatiomDisapproved by: � � �, Date for the following reasons Permit No.` y - Date Issued.> i ! THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS yr Certificate of Compliance THIS IS TO CERTI th t he On-site S age is osal y t Co st cted ( ) Repaired ( ) Upgraded( ) Aband ) - at hV b n construct d i a�rdance y with the provisions of Title 5 and the for Disposal Sys em Construction Permit No �" / dated Installer Designer #bedrooms Approved es \ i n flow !,/ gpd r t �° J The issuance o - is irmlshall n t be construed as a guarantee that the syste 1 u.cti)n as design edf / Date ® Inspector �!/ - y<j- No. �� Fee " V r ............�/�v �gT;E COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS � - F 1wigpogal 6pgtem Con4truction Permit Permission is hereby gran te ons `cctt�( ) Repair ( �) Upgrade ( ) Abandon System located at i i i 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: Construction must be orn d within three years of the date of''this t. I 5 Date Approved by `� 11 ' i 4/ SWEETSER ENGINEERING P.O. BOX 713—SOUTH DENNIS—MASSACHUSETTS 02660 TEL (508) 398-3922 FAX(508) 398-3063 LAND SURVEYING—ENGINEERING—TITLE 5 SEPTIC SYSTEMS SEPTIC DESIGN PROPOSAL PAGE 2 PROPERTY SURVEY AND FLOOR PLAN SKETCH Please fill out this form,including the floor plan sketch, and return to us with the signed proposal and retainer. This information is necessary to properly prepare your Septic System Design. IF YOU ARE PLANNING AN ADDITION PLEASE INCLUDE THAT INFORMATION ALONG WITH THE FOUNDATION DIMENSIONS AND LOCATION FOR THE NEW ADDITION. lr� Year Round Home !� Seasonal Home J_�i_owner Occupied / U Rental Total#of Rooms 3 #Bedrooms N V Family Room/Den �S Living Room �� Dining Room �#Bathrooms Washer/Dryer Dishwasher �U Garbage Disposal fe5__Gas Service fC Town Water In-ground Electric Wires* Q In-Ground Oil Tank* N In-ground Sprinkler* ?In-ground Gas Pipes* T * Please note on sketch where located. Sweetser Engineering assumes no responsibility if in-ground components are damaged during Soil Testings, Inspections, Locations of and/or Installation of New Septic System. Cellar: �5 Full w!� Partial(Crawl) Slab Wells: Main Use Irrigation Only (please provide location of all wells) PLEASE USE THE SPACE BELOW AND THE BACK OF THIS SHEET TO PROVIDE US WITH A ROUGH SKETCH OF THE EXISTING FLOOR PLAN(ALL FLOORS). Also include any items that should be avoided,IF FEASIBLE,i.e.shrubs, trees,patios,electric lines,tanks,etc. IF YOU ARE PLANNING AN ADDITION,PLEASE PROVIDE THE LOCATIONAND FOUNDATION DIMENSIONS. RJA C) vLOD 2 ►� Rim BecP �� 6T ooti v S+ r2 � r� n dJ Town of Barnstable Regulatory Services Thomas F. Geiler,Director • snaHsreaie, Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: / k Sewage Per mit# 8" Assessor's Map\Parcel 3 a Designer. ` )e* S meC2 r t t , Installer: (i1CtS(?. 4j 14Vkk�a c.Z)d,n+ �Ccc U�'�c.et5 Address: -J&_r,4 {q&n Address: p. 80Y 15 On 5- U A�`e Iu" was issued a permit to install a (d e) (installer) septic system at tk 16 )k r AS �S (address based on a design drawn by - sl �fheod.or2. � �.vv►cts, - P,66k yn l o. w 1 ICox . O ks dated_.P�. o766 / (designer) V I certifythat the septic stem referenced above was installed substantial) according to eP Y Y g 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. Of JWAs�cti T.A. G� (Inkalleenigna a DUMAS N No.619 �`�oisTtiar`� 5 S� OTAR1PN (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO -BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DMSION. THANK YOU. Q:Health/SeptidDesigner Certification Form 3-26-04.doe �N { -` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a J l TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �1 C Property Address: 186 Boulder Road,Barnstable,MA 02630 �(1 Owner's Name: Louise K.Gentile Owner's Address: 186 Boulder Road,Barnstable,MA Date of Inspection:07/17/2007 Name of Inspector:Reid C.Ellis Company Name: Ellis Brothers Const.Co. Mailing Address:23 Enterprise Road Yarmouth Port,MA 02675 Telephone Number:508-362-6237 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I$m a DEP approved system inspector pursuant to Section_15.340 of Title 5(310 CMR 15.000). The system:1 c CD PaXes onditionalty Passes Needs Further Evaluation by the Local Approving Authority w Fails _ Inspector's Signature: i�'�' ee� � Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthbr DEP)within 30 days of completing this inspection.If the system is a shared system or has a design fl w of 1 Q000 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 f . 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. 1 . Title 5 Insp ection Form 6/15/2000 page 1 'v Page 2 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 186 Boulder Road,Barnstable,MA Owner: Louise K.Gentile Date of Inspection:07/17/2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: /VO have not found any information which indicates that any of the failure criteria described in 310 CMR 303 or in 310 CMR 15.304 exist.An failure criteria not Y o evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in t te"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacemen or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the r the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or he 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 proved by the Board of Health. *A metal septic tank will pass inspection if it is structural y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availab e. ND explain: Observation of sewage backup or break out or hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven tribution box.System will pass.inspection if(with approval of Board of Health): broken pipe(s)are laced obstruction is remov distribution box is 1 elect or replaced ND explain: The system required pumping more than 4 times 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 re laced obstruction is removed ND explain: 2 , Title 5 Insnection Form 6/15/2000 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 186 Boulder Road,Barnstable,MA Owner: Louise K Gentile Date of Inspection: 07/17/2007 / C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the oard 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 iin accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protatt public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface wa — Cesspool or privy is within 50 feet of a bordering ve getated wetland or a salt marsh 2. System will fail unless the Board of Health(and Pahl 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 sys em(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water suppl . _ The system has a septic tank and SAS and the SAS within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS s less than 100 feet but 50 feet or more from a private water supply well".Method used to determine d istance "This system passes if the well water analysis,performf d at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is ual 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 L Page 4 of 1 I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 186 Boulder Road,Barnstable,Ma Owner: Louise K.Gentile Date of Inspection: 07/17/2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: y V;ischarge ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 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 4c spool iq id depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _ quired pumping more than 4 times in the last year o es pumped NO T due to clogged or obstructed pipe(s).Number y portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within'100 feet of a surface water supply or tributary to a surface VlwgKr supply. _ ortion of a cesspool or privy is within a Zone I of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. EAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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: /dJ To be considered a large system the system must e 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 Mowing: (The following criteria apply to large systems in additi n to the criteria above) yes no _ the system is within 400 feet of a surface ng water supply _ the system is within 200 feet of a tributary a surface drinldng water supply the system is located in a nitrogen sensitive ea(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. 4 Title 5 Insnection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 186 Boulder Road,Barnstable,MA Owner:Louise K.Gentile Date of Inspection: 07/17/2007 Check'f the following have been done.You must indicate"yes"or"no"as.to each of the following: No — _ umping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? — _ Were all system components,�ox luding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of th affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y 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)] 5 Title 5 Inspection Form 6/15/2000 5 Page 6ofil OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 186 Boulder Road,Barnstable,MA Owner: Louise K.Gentile Date of Inspection: 07/17/2007 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMI 15.203(for example: 110 gpd x#of bedrooms):. Number of current residents:�_ - Does residence have a garbage grinder(yes or no) Is laundry on a separate sewage system(yes or no /jj Laundry system inspected(yes (if yes separate inspection required) no) Seasonal use:(yes or no):, Water meter readings,if available(last 2 years usage(gpd)� Sump Pump(yes or no):/'c�!/ Last date of occupancy: may COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sgtetc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes r no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL.INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection insp (yes or no): If yes,volume pump_;W ja—�How pum ed determined?Reaso forpumping; ' T E OF SYSTEM j —Septic tank,distribution box,soil absorption system _Single cesspool —Overflow cesspool _ivy —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): Appro_'We e of al�Aecompone ts,date ins 1 (if kn )and source•of info anon Were sewage odors detected when arriving at the site(yes or no):AIO 6 Title 5 InSpection Form 6/15/2000 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 186 Boulder Road,Barnstable,MA Owner: Louise F.Gentile Date of Inspection: 07/17/2007 BUILDING SEWER(locate on site plan) r� Depth below grade:7 Materials of construction:_cast iron 40 PVC_other explain): Distance from private water supply well or suction line:. Comments(mconditiou of joints,ventul ,evidence of l ge,etc.): i3 i SEPTIC TANK.40[ocate on site plan) Depth below grade:,/ Material of construction: concrete metal_fiberglass_polyethylene other(explain) /�fttank is metal list age: .Is age confirmed by a Certificate of Compliance(yes or no):_certificate) , (attach a copy of �� s—� Dimensions: Sludge depth: "15?PI Distance from top of slime to bottom of outlet tee or battle:� � Scum thickness: cS Distance from top of scum to top of outlet tee or baffle: 4—z=�VZd Distance from bottom of scum to bottom of outl t tee or battle: c How were dimensions determined: Comments(on pumping recommendiffions.inlet and outlet or ba a con n,structural integrity,liquid levels ���e�ut�le_t invert,ev' e e of eakage,et�j.): �1� k �_�•;;,- �'� v,Cs,;rY GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fibe s_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 b e: Date of last pumping: Comments(on pumping recommendations,inlet and outle tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFA CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 186 Boulder Road Barnstable MA Owner: Louise K Gentile Date of Inspection: 07/17/2007 TIGHT or HOLDING TANK: (tank must b pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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,a c.): DISTRIBUTION BOX:W,(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1414,7 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of a to or out of box,etc.): r Pt L� �r 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,Condit on of pumps and appurtenances,etc.): g R t Page 9 of I I OFF ICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 186 Boulder Road,Barnstable,NIA Owner:Louise K.Gentile Date of Inspection: 07/17/2007 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T GC) f " 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, -i L�v CESSPO LS: (cesspool must be pumped as part f inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic fai ure,level of ponding,condition of vegetation,etc.): O�fG' PRIVY: (locate on site plan) Materials of construction: _ Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic ilure,level of ponding,condition of vegetation,etc.): 9 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 186 Boulder Road,Barnstable,MA Owner: Louise K.Gentile Date of Inspection:07/17/2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties td at least two permanent reference landmarks or benchmarks.Lode all wells within_100 fee ocate where public water supply enters the building. 26 10 Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 186 Boulder Road,Barnstable,MA Owner: Louise K.Gentile Date of Inspection: 07/17/2007 SITE EXAM Slope •C ,.�� w� Surface water Check cellar Shallow wells Estimated depth to ground water feieet 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) Necked with local Board of Health-explain: Checked with local excavators,installers-(atta�c documentation) Accessed USGS database-explain: [."!"�/� �� ,�✓� /,% � t/ You must describe how you established the high ground water elevation: 11 Title 5 Inspection Form 6/15/2000 11 TOWN OF BARNSTABLE LOCATION I R'6 �W ld-Ce- �� o SEWAGE# 0?00'7— y6-'" VILLAGE 5+A(a� ASSESSOR'S MAP&PARCEL 3/S= 03.2. INSTALLERS NAME&PHONE NO. -see --t- SEPTIC TANK CAPACITY low LEACHING FACILITY:(type) IOU T S)V-�L (size)_( ��T3c. I [) NO.OF BEDROOMS OWNER PERMIT DATE: /6/i S—/ 017 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility `�f��' Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) l . Feet Edge of Wetland and Leaching Facility( any wetlands exist within 300 feet of le in facili ��'� Feet FURNISHED BY m =c w 'a G _ 9 TOWN OF BARNSTABLE B t- LOCATION AK 8 ij dcr SEWAGE# .VILLAGE =U0.,^rA4<21b I C. 0,11,ASSESSOR'S MAP&PARCEL 3)1 - 3 INSTALLERS NAME&PHONE NO. hca. +AA¢f C�OtO+ S�$-2 11 SEPTIC TANK CAPACITY ICO O ja I lcr, LEACHING FACILITY:(type) 47 &eS H2O (size) ILK 3(, A ly NO,OF BEDROOMS OWNER L®Vt'SL cren�, 10- PERMIT DATE: to-- COMPLIANCE DATE: 11- 7- b 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 facili ) Feet FURNISHED BY !� /L.� VIII CA z 9 c� ( TOWN OF BARNSTABLE IbCATION `l� �� "l `�r SEWAGE # VILLAGE ���SJ �'� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. J'-rt I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) / (size) NO.OF BEDROOMS BUILDER OR OWNER / PERMTTDATE: / COMPLIANCE DATE:- . l 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 I l + � rut, ZZ4 - �-OCAT16N 4190(a SEWAGE PERMIT NO. k LLAGE igA)!5 INSTA LLER'S NAME a ADDRESS B U I L D E R OR OWN ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED' �1J � a C � E��_ � , y� � r �G � ' �� v .-,.,, ,t Fps..=...�......... . e THE COMMONWEALTH OF MASSACHUSETTS -off I---- BOARD OF OF HEALT i Appliratiun fur Dhiputitt1 Workii Tomitrur#'tun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . oT �..•-- ......................... .._... Locatio - dress oLN .© ......... •.. •.... ... ... ...... .. Owne . Address ... ............ . ........ . Instal-l-er .....• .--�, ------------ K I Address d Type of Building Size Lot.._ �6 ._ Sq. feet U Dwelling—No. of Bedrooms................ .......................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----•......-•-•-•......---•-.... • W Design Flow............................................gallons per person per day. Total daily flow.............. a...............gallons. WSeptic Tank—Liquid capacity_100..gallons Length................ Width---------------- Diameter-___-___-____._- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------------_ Diameter................,.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by-----------J� .------'---=�--�-`-"y.'.`.�-....---•.-__.. Date............ Test Pit No. 1----�___minutes per inch Depth of Test Pit..................•. Depth to ground water........................ (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ----------------------•----------......---- O Description of Soil................................... 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 iITLi; 5 of the State Sanitary Code—.The undersigned further ag�ees not to place the system in operati ntil a Certificat of Compliance has been issued y the boar o ealt ----- ---------------- Y�ateo..., �Si ned Application Approved By -•----------------------ll.� -•--•------.......-•-•-•-•-•--•-•-•--- ----•-•-----•----i . ........... Date Application Disapproved for the following reasons:.............................................................................................................. .............................•------•-••••--•-----•---•••----...---------•....-•-••-•----•-•-------•---•••--••-•...................-----•••-••---•-----------•---------••----......--------.....------. Date PermitNo.__....��...��....._ ..�.�........ Issued........................................................ Date No` .. --«�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF,+,HEALTH �..-.. ........................................ z � .t OF. ..._l.�f........r't.. ._� -_'1 ' ' Alijiliration for j3iijiniitti Works Corm rurtinn "rrutit Application is hereby made for a Permit to Construct (�`) or Repair ( ) an Individual Sewage Disposal System at: � ,r 0. ...... "««... ...... .............. -------- ---' •--•-------------.. .1......_...... J a / Location/,,;Address r or,Lot Nod,' 'd: .. ... 5=!C/r..� r ° .._ ` —G J j ) �'i ! r......... ... .... Owner"...::.( �........Ff....�C7� f.- �i . .... ........ ......... ...._......................... f .r._......... f Installer ,` Address AA Type of Building , Size Lot.._7--J..::_L.._.......___Sq. feet �-, Dwelling—No. of Bedrooms............`2.......................Expansion Attic ( ) Garbage Grinder ( ) a4 Other—T e of Building No. of persons......................... Showers YP g -------•--•----•------------ P --- ( ) — Cafeteria ( ) dOther fixtures .----•--•--------•---•--•------•--•----------•-----•---••-------------•----•-----•-•--•-•-----....-•---....------ r -. . Design Flow............................................gallons per person per day. Total daily flow_._........................... gallons. r Septic Tank—Liquid capacity_jf n U....gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) t i `v G' C a Percolation Test Results�, Performed by.. ........ ......•••-•••-•--•-••--••-•-.....•-•....----••-•••-•_... Date............. / Test Pit No. 1... __5_.._.minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil.. ......................................................................... ._�)CC.� r'..� j... ....--------------------------------------------------------- .............................................................. V -------------------------------------- •------------ ...-•----------- •---------- `----•---f ---•----•-•-'�=.. �..----._--------•- ---{�•-.-— r`-- - -------•--••-------•----—••------------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------•-•---------------------•---•-•---•---------------------•-•-•-------------------•-•--••-••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Dispo al System.in accordance with the provisions of TITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operati nt'I a Certificate of Compliance has been issued y the boar o ealt . • r' Signed................... G ;r t_' .... Application Approved By......................................... ' Date Application Disapproved for the following reasons:---•--------•---------•--•-•--•--•---•-------------------------------------------------••....----•-........._.« --•----------------------------------------------------•---.....-----------•-----•---------................----------------------•------...---------•--•------•-------•---------------------•••---...-••- Date Permit No............'_... .,r�.........�..��.._.--�-�------• Issued........................................................ Date 'THE COMMONWEALTH OF MASSACHUSETTS �,.�, HEALTH_ BOARD OF ,HEALTH ,' ! ..............OF....................................:................................................ Trr#if iratr of Toutpliatta THIS I� TO CERTI ;,,, �I„the Ini ual Sewa a Disposal System constructed (, ) or Repaired ( ) by-- - .nY--w'— ..!.. --•-- . -- ...-•--------•----•----•--------------------------------------- ---...... Insta ler }at----Y----'-.:r.j..�----•- ......•- �f..=-.rr, ... ` try` has been installAd in accordance with the provisions of TL'E 5 of The ,State Sanitary Co a sc >bed in the application for Disposal Works Construction Permit No... dated.._.-___ �?�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONY SATISFACTORY. DATE....... .................. :( ...................... Inspector==...........-------•----.........-•--•-••------•--------------................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , z (a ............. :.✓ r oF.............................................`." ( L.'....................... No.. `?........... f FEE........................ 0topusal Works Tunotrur#Uatt "prrntit Permissionis hereby granted--..•-----.V :NN Y.----•--•---•........................................... -.......-•--••------...................--•---........«._.. to Construc ( ) or Repair Indivi I Seta D osal S sty ;.ram 62- Street " r as shown on the application for Disposal Works Construction Permit No..................... ted_,--_._.:_./....... ...._._........ ...........................--- =..... "-^•---,... DATE.............. '-- b.(z................................ Board of Health FORM 1255 A. M. SULKIN, INC... BOSTON ,,, . _-`: . .. ._..-..-..-... ..-_• ...w...rr....Iw,w�+F�+'-•wr't-. 1^...�'r�••ri•+rw'.. �y1 ' lL ►2 I2,Z .000, 3 t' 0 / GG7 22. We do- 121 R A��/ a c�2• Ia; A(J�. P Rio 41 , v�V ��. � 0 00 0 Q tj `j 10 (� / S7.4Ke t) � r 1 /1�► 3 3 ¢3o 56o t sf S/DG SFTB1 uct L0T 34zF;-)��v i CCir=cam r j t \ 11.E i Fl A l 11. 1 L. E r //'l 4 i f. LEGEND / . :X1.1TIN0 SPOT ELEVATION Ox0 � t F ` CERTIFIED PLOT PLAN :XIOTING CONTOUR --- 0PA) 'INISHED SPOT ELEVATIONi� • `' L07 f wIL1o:e/Z '`° o�3D 7INISHED CONTOUR 0 8 ELDo.I DoE _ -- %PPROVED BOARD OF HEALTH �fs� f) IN ` s41L LAMS d ..��l ji J`�,.V : •i�1.:��J�,� ASS* DATE AGENT SCALEu DATE . LM & ELDREDGE ASSOCIATES, INN SLIENT �� I CERTIFY THAT: THE PROPOSED ENGINEERS 1 LANDSCAPE ARCHITECTS ' JOB NO. BS,0 D BUILDING SHOWN ON THIS: PLAN PLANNERS•LAND SURVEYORS k/. CONFORMS TO THE- ZONING .LAWS ti DR.BY MA BARNSTAB;. , SS. 712 MAIN CH. BY: P,L r HYANN I S, MASS. to l rt4 r ✓J SHEETS OF � DATE,E � REG. .LAND SURVEYOR 1 - 4( NJQ s Z W \lb�Ot .;�_54 y4,4 l),`C 111� � V Q \ r ' ' h Wtill h o �i �� Ni : �9 , q � in _ W ,, 0 OC h W 4 W V Q f Q Q •O ° 4 Y a W � O ° e. ° ooa • � 0 � 0 y WQ -I ., K \ JZitiop �; �. e e.4... o • 4 h b W cj QjaQ � p. I Z Q \ hi Qri a heQ N > tL n1 � U1 � •, . W QI 0 � hVV w [ � 2W � . e yIQ• • e • f I �` 2 Q 4j4r ►V 1 W WLF 'r• 41yZWIL _...__._ e . v • a 4h 0 � 2}� e aZ ' s• _ p p � � J � 3 4 � � tz � • ova � ih � r� � b � •• � � � �� 2 v • Q� F v 4 V � i Lk 42 ti k: X o �, l-6 loll r _ 7411 N 2 O ri •0 �� V F�`t� � � � � � � li � h � y h �,�S�Tis � 4?� Q k � qL exwr �� •� W�.� +ram-~ - .4 _U kj (. • ' �\\\ + ` I' r' ^�,'�`ti���t c 4[ � •� `. V. � � V .� Il \ � ,•� T V ? \ !. 1 'y '.t 7..r QWyh � V oa W' �• 5 5 '•� =t'• � Qs.; 14}� f rf �t��t k( . !i' ;- '> �I M` � � 'v � � h ` Q e H44 y s°'sVJ - ., ... Nwz%,11 . tilt - W .. � _.. : s• ^- :- _. ' _ T ^ • • - - - '" " 7e . . :,:d„ •. .'�'C-.:. 'Yo. �::`.] - ,t` v,:,a+:..:^FT-.:, - "L.T 6`3 .a .far e - ::. ...r •:., •.: d:.. .KEY>,:.`h .. •?•f. ��'z:,.• - BUMwR1C SOIL TEST - - TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR OR CRAWL SPACE __ P 11908 -� DATE OF SOIL TEST SEPT. 7, 2007____ 100.00 i0 FT. MINIMUM FROM SLAB SOIL TEST DONE By SWEETS- ENGINEERING ELEV. (ASSUMED) i 10 FT. MINIMUM J CLEAN SAND WITNESSED BY _� --------- In CONCRETE INSPECTION PORT COVERS 4" SCHEDULE 40 PVC PIPE \ LOAM AND SEED OBSERVATION HOLE 1 ELEV.= 92.3_ -'�'--- MIN. PITCH 1/8" PER FT, l 2 LAYER OF ___ _ iNCHE5 PERCOLATION RATE ___<__z__ MIN. 'INCH AT 7C 1;8" TO 1/2" � -- 4•� 4" CAST IRON PIPE A 9" MAX. WASHED STONE VENT DEPTH HORIZ TEXTURE COLOR MOTT OTHER (OR EQUAL) MINIMUM " �• ��• NOT REQUIRED 0-3" 0 ORGANIC _ NO ? 4' PER FT. -__ ------ PITCH - -- - - / Z 3-Ef" £ MEDIUM SANfl 10YR7/1 - - - TEE - - -- - -- --- - i \ fi-9" A LOAMY SAND 10YRS/3 _ ROOTS - FLOW LINE 84,fi �- �' 9-24" 8 LOAMY SAND 10YR7/3 ROOTS ELEV. _ QQ_ 10" -- �MIN. r -_ -- -- 24-132" C MEDIUM/FINE SAND 2.5Y7/2 --- --- 1OX COBBLES,_ o o ~ ELEV. _ _--_-- f LEVEL o � L I r ', � � i tOr o = �.Z7 ELEV. _ _�¢,�Q_J ADD GA J 6" SUMP '` �.___' _� 1_,_ I' 1_. ELEV. ELEV. = 89.45 "ELEV = 89._28 _ --" NO WATER ENCOUNTERED AT __t 32" BAFFLE DISTRIBUTION -_ ELEV. _ _ Si•3 _ LIQUID OUTLET - ELEV. OBSERVATION HOLE Z ELEV.=__92 5_ DEPTHBOX - Q- 4 " HIGH CAPACITY INFILTRATORS W'TH STON£ i `T-RIZ --- 4 FEET 14 INCHES (EXISTING) 70 BE WATER TESTED � DEPTH NORiZ TEXTURE COLOR MOTT. OTHER 5 FEET 19 INCHES ;F MORE THAN ONE OUTLET IN AN 11'X 36'X 10 " ?P£NCH F0�'_MAT10N 6'97 " 6 FEET 24 INCHES 1000 GALLON in 0-3�� O ORGANIC - -y� NO -� -- -- 8 FEET 34 INCHES SEPTIC TANK (TO BE PLACED ON FIRM BASE) SO4L ABSORPTION ZONE N A 3-7" A/E_ LOAMY SAND_ 10YRS/3 _ ROOTS_ 3/4" TO 1 ? 2" CLEAN J 7-29" B LOAMY SAND - 10YR7/3 ROOTS 4' / SYSTEM (SAS) INDEX DOUBLE WASHED STONE ADJUST 29-132' C MEDIUM/FINE SAND 2 SY7/2 5% COBBLES FREE OF FINES & SILT - -- - ---- - --__�_ _ ------ --- -- - - - - - USGS PROBABLE WATER TABLE ELEV. = ------ NO WATER ENCOUNTERED AT __132'_ ELEV. _ _ $1•5_SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / ) ELEV. _ - NOT TO SCALE BOTTOM OF TEST HOLE ELEV. = g NOTES: 1 ALL WORKMANSHIP AND MATERIALS SHALL CONFORM -0 D E P. I TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. �y 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE. �f 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THE ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 98 8 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL i 100 8 DESIGN CALCULATIONS BE MORTARED IN PLACE. 0 p0� \ NUMBER OF BEDROOMS _3 _ 5 NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH �.� GARBAGE DISPOSAL UNIT NO DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO TOTAL ESTIMATED F ov\ OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. ( 110 GAL/13R./DAY X 3 BR.) _ 3 4__. GAL./DA�' 6, UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR REQUIRED SEPTIC TANK CAPACITY _B�4 GAL. IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS ACTUAL SIZE OF SEPTIC TANK (E)GSTING) 1000 GAL, PRIOR TO COMMENCING WORK ON SITE / SOIL CLASSIFICATION I 7 CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS DESIGN PERCOLATION RATE S_�_ _ MIN./IN. SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE ANY VARIATION 95.2 EFFLUENT LOADING RATE 0.7 GAL./DAY/S.F IS TO BE BROUGHT TO THE AT rENTION OF THE DESIGN ENGINEER 482 / / LEACHING AREA 474.i3 SO. FT. IMMEDIATELY (11X36)+(47X2X10/12) 8. PARCEL IS IN FLOOD ZONE _. _ 1 S. LCT IS S;-t3'41?�1 ON A_c:�SSDRS V tr- --315 ,!; '�AP E _ 32 r: CAPAI ' AREA X RATE . b.W 3AL. DAY+ G�:1.;CB� � r 94 4 �EACliINv �. l � /F 474.33 X 0.74 10. EXISTING LEACH PIT IS TO BE PUMPED AND BACKFILLED. 97.6 J RESERVE LEACHING CAPACITY _I�01 _. GAL/DAY 11. THE INSTALLER IS TO GIVE THE ENGINEER A MINIMUM OF 48 HOURS (2 WORKING DAYS) NOTICE FOR THE FINAL iNSPECTION (NUMBER BELOW) f / 99.4 ■ 97. / 99. O 99.2 \ �.0 v ,,.r �.%J\ o�v ago �• 8.7001, 2Vc�,� 92.7LtN OF MSS I / 961 T A p 9410. g �k APPROVED: BOARD OF HEALTH . 9 ' 97.8 _/ '�NfTAR\"" Q` / � 92.0 • DATE AGENT 92.8 ' 94.8 a RO OSED SEPTIC DESIGN0s � PE3 94.5 FOR (94) LOU ME GENTILE SOIL 36�` \ ,> " 92.9 4� Q w �,�_ \��vU T� 6A LOC. 186 BOULDER ROAD Y 92 i Q PARNS TABLE, MASS -0AR Psi STi4BLE V1LLAaE7 92.? 92.5 93.2 SWAMSMI `OT 12 x i 31, ( 235 GREAT WESTERN ROAD 45,604 S.F. � T I ,' � � + 3 8_ SOUTH DENNIS, MASS. P. 0. BOX 713 X / LEGEND. 9JD3922 0266D EXISTING SPOT ELEVATION 00,0 I RQ k C EXISTING CONTOUR ----00---- I O� DATE SEP-i. 7, 2Q�7 � , SCALE � " _ 2O' 92 8 FINAL SPOT ELEVATION FINAL CONTOUR l90 SOIL TEST LOCATION r}� • UTILITY POLE -0- I SCALE 1" = 100v� 91.4 REVISED JOB N0. �' / TOWN WATER -W W_ I 1 , `00 �1 CATCH BASIN ®'\ \� GAS LINE ----1 �� T c, ,� SITE OVERVIEW 90.6 CLEAN O LOCATION MAP REVISED ( SHEEN 7 OF__? * �1 ; CESSPOOL C.P. 0 S8 ! FF0,' 6585-00 '. dwg ! 6585-sas.DWG 0 2007 SwEETSR'R ENG. �