HomeMy WebLinkAbout0240 BRAGG'S LANE - Health 20_BA GS LANE, _
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TOWN OF BARNSTABLE
LOCATION a`1G jla, L6✓ SEWAGE#. 3AA
VILLAGE ASSESSOR'S MAP&PARCELJq(3 - 63
INSTALLER'S NAME&PHONE NO.T:)e J�kc,s N -i�-o� .J rr C.
o
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) � (size)
NO.OF BEDROOMS
OWNER �� ez
PERMIT DATE: /LO / COMPLIANCE DATE: S 71SI
Separation Distance Between the: i11®Ne eVMA*-°,'d
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility G�T we-a( eet
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�f FURNISHED BY "TAC
GA(LPk x 2c,s
,3 -SG
C
Sua � i'z3
5'38
OUT-IG
TOWN OF BARNSTABLE
LOCATION aH0�cacg�' SEWAGE#0 -10m7
VILLAGE_Rn f�)-, C1! ASSESSOR'S MAP&PARCEL oZQ �i
INSTALLER'S NAME&PHONE NO. ` e A ,Mg1 L)c
SEPTIC TANK CAPACITYX f►nr e
LEACHING FACILITY:(type) e2,=#i&dg W4 (size) AJ/gr
NO.OF BEDROOMS 3
OWNER
PERMIT DATE: All JOM COMPLIANCE DATE: '/v1 9-,40V 0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility . a'�/ r 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
(Ise( '" opt
PIovP
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer: -Yes
_t,�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(pplitation for Disposal 6pstrm Cunstruttaun 3pPrmit
Application for a Permit to Construct( ) Repair(V)_11Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address
or Lot No;gl/d �fGySS Gnu Owner's Name,Address,and Tel.No.
23oAss Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
2 cOvJ�1 -yCY, -7/ 1 / v G$Gn1
Type of Building:
Dwelling No.of Bedrooms y Lot Size 36.1&G sq.ft. Garbage Grinder( )
Other Type of Building (eS�r7NN��C:1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) yyO gpd Design flow provided_/��� gpd
Plan Date N1�� 0 20 Number of sheets % Revision Date
Title `-
Size of Septic Tank �X/SfiNt Type of S.A.S. �J-ZG 5y0 a�./`(�nJ rktvw bra
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) AA� {I'. C &N b('(' to c iS F fv; c koyi SIC'n 1nz 0n)
�'ce J ✓ t" *is J ea to Go FJ cam 71 _t-( bec)y'1 tw C �
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 ' of Health.
Signed Date A1146 9-
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued -
21
r
i No. s Fee
THE COMMONWEALTH OF MASSACHUSETTS Enteredin,compuier: Yt., .•-
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
0*Iiiation forlDisposal 6p0em Construction Permit 4
N.
Application'for a Permit to Construct( ) Repair(C*) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No:faw /�j�SS d•� Owner's Name,Address,and Tel.No.
t
G'Ass ss/or ivpl/Par cel .�, P} �?�j 4lq PwG
Installer's Name,Address,and Tel.No. f Designer's Name,Address,and Tel.No.
}
Type of Building:
Dwelling No.of Bedrooms ` Lot Size 31<,1 l?(, sq.ft. Garbage Grinder( )
Other Type of Building (c'S�C�PNI',t0.i No.of Persons, 'Showers( ) Cafeteria( )
Other Fixtures 4
Design Flow.'(min/required) J/#y gpd Design flow provided Hs gpd
Plan Date �1!������ Number of sheets Revision Date
Title 4;,
r Size -of Septic Tank ay� 1,5fsm Type of S.A.S. -2t)
Description of Soil 1" j
Nature of Repairs or Alterations(Answer when applicable) AX i fv� d- (Lc^q171o( to &x/S)-'wc
Date last inspected:
Agreement: A Ia
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 's'.Boar of Health.
/Signed Date J 6 .
Application Approved by Date Ze')
Application Disapproved by Date
for the following reasons
Permit No: Date Issued / �j�;/� •
THE COMMONWEALTH OF MASSACHUSETTS '
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( {i} Upgraded( ) ,;
. Abandoned( )by (C3..t ily rV
at Z.q Q Ilj(f✓ �,c, (..N {`�w(A)3 C. P has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No., dated 10h 41 Jq
L� � C�
Installer � � >( W etilc- Designer _1gol,J wnsr....✓
#bedrooms `' Approved design flow `��� gpd
The issuance of thus-permit shall notibe construed as a guarantee that the system will function�ta�§designed.
Date Inspector 1� � h Ar �
rFee
i r
f
1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
misposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair'(t�JJ__JJ Upgrade( ) Abandon
l System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
V.
Provided:Construction must be completed within three years of the date of this' �ermit4Date Approved
_ 4,7 ..,.. _
i
�4.._... - - t- .-. .. ♦. .. .. d M.... .< :-.{. .e � y^ Nay„
Town of Barnstable
Regulatory Services
P Thomas F. Geiler,Director
• a
•" IAM Public Health Division
039.'�saa Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax:. 508-790-6304
Date: 5 7 2 Sewage Permit# P-WO 3.23 Assessor's.Map/Parcel a��
3
w
Installer &Designer Certification Form,
Designer: _
g Installer:
Address: _ t��'J � "� Address:
�c±-;) �rUd�fV tl�P 1 U1C� O 2 `3'L
On %Oj/ 7.CJ f _was issued a permit to install a
(date installer
septic system at O f&c_-s, based on a design drawn by
dress)
M dated
(designer)
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. Stripout (if required) was inspected and the soils
were,found'satisfacto ry• ,
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 o, ""ions. Plan revision or
certified as-built by.designer to follow. Stripout (if r- acted and the soils were found satisfactory. OF Mqs\
DAVID
�� r ,.
(Installer's 9�gnnature j' M 6
5
t '
No. 70 Z-0 10 7 Fee G IoCJ Ck)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9ppliLation for Disposal i�pstrm Cunstruttiun Permit
Application for a Permit to Construct( ) Repair(+Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address Qr Lot No. J,yd j3lG,ypr 44 Owner's Name,Address,and Tel.No.
i�rs�fdt', s
Assessor's Map/Parcel acr82� �ii--�cr! /C� "--
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
0 4 5 X0(A)4 rjc 60-7/51 d�ar�:� :,re /
Type of Building:
Dwelling No.of Bedrooms Lot Size _sq.ft. Garbage Grinder( )
Other Type of Building (,'s ,A5h0 cd No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided 31YJ, gpd
Plan Date kog-ow Number of sheets / Revision Date
Title
Size of Septic Tank'eXi;her1 Type of S.A.S.I f/ ,L7'._-2�„lr,,,,
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) go D bp
4 Mbb &ice 1 ` 5 We 4.5 p ei 07&V
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 Health.
g .......... a Date
Application Approved by Date '
Application Disapproved by Date
for the following reasons
Permit No. ?mil-G1 d` Date Issued `
Ov
Nos 70 70 /D 7 Fee C1'!
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i''r
Yes
PUBLIC HEALTH DIVISION.- TOW ?F•BARNSTABLE, MASSACHUSETTS
t Ylcation for Nod i Construction Pamit
Application for a Permit'to Construct( ) Repair(4 1.6pgrade( ) Abandon( ) ❑Complete System •❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
13t�g�+s Cam' "y 1
SKI t` ,r� ..
Assessor's Map/Parcel .� T"IC�CC'l
Installer's Name,Address,and Tel.No. .. Designer's Name,Address,and Tel.No.
NK
Type of Building:
Dwelling No.of Bedrooms Lot Size 1 9 /; sq.ft. Garbage Grinder( ) r
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) -ajo " gpd Design flow provided '�yqP gpd
Plan Date ,/�. a Number of sheets Revision Date
Title
Size of Septic Tank i��cdr�r Type of S.A.S. 9—.-son p,- '44_. e ,„,T�,�ySfti�up
Description'of Soil
Repairs or Alterations nswer when applicable)
i
P ( 6AA gal /l! 11-J e-11L1�6/1—
Nature of Re A h
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 Cobb,and not to place the system;in operation until a Certificate of,
r Compliance has been issued by this Board of Health.).
Sgne3 '=— Dane Application Appro, D t°e / ^y
Application Disapproved by Date
for the following reasons i
Permit No.
.-77070 Date Is
FI
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired `(4/) Upgraded( )
Abandoned( i.)byat
'. .Y provisions of Title 5 and the for Disposal has been constructed in accordance
with the
p p sal System Construction Permit No'07-0 107 dated 817��
Installer Designer A1111�
#bedrooms a Approved design flow and
The issuance of this/permit shall notbe construed as a guarantee that the system will fur cn as designed.{
Date / � Inspector
-- ----. _ _ ___.. _._._. ---------------------- _---- .-- __..._.,._...,_.. ,__...... _
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposar bpstem- onstCUctlon i3ermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at-2 6/d 2/gr -7 ,,, ar Joe
0
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
.J
Title 5 and the following local provisions or special conditions.,
Provided:Construction must be completed within three years of-the date of th5's permi
Date t, / ,�Q�7A Approved by
I
Town of Barnstable
Regulatory Services
o� Thomas F. Geiler, Director
Public Health Division
MASS
1639. ,�� Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: Sewage Permit# - Assessor's Map/Parcel 8`�
Installer &Designer Certification Form
. l (�/� lot -
Designer: c����� �'/��� Installer: �"'I
Address:
j� J f+^/�(�t�GiE'I Address: C. J �
On w_ was issued a,permit to install a
date) (instahler)
septic system at
D based on a design drawn by
(ad ess)
lV7 0• dated ) C)
(designer)
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
distrib'ition box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory,.
I certify that. the. septic system referenced. above was installed with major changes,(i.e.
greater than 10';lateral relocation of the'S'AS or any vertical.relocation of any component
of the; septic system):but in accordance with State & Local ,R `-tions. Plan revision or
certif ed as-built by.designer to fo 'low. Stripout (if rp tcted and the soils
were found satisfactory.
_
(Insta,l'er's Signature) , �1aA466 0
S01STO'
„i Nl TA,R\P
q
n TOWN OF BARNSTABLE o
SEWA E #hh
VIE:AGE ASSESSOR'pa —
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) — e e ( ize)
NO.OF BEDROOMS
BUILDER OR OWNER
I
PERMUDATE: COMPbb DATE: ci
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 facility) Feet
Furnished by Ct
r
AA
�tC
JA�f 2 E �9g9y
�-� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
Tea Ticket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEG PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 240 BRAGGS LANE BARNSTABLE MAP 298 PAR 083 L 62
Name of Owner n/a
Address of Owner: Mr.Kennedy;16 Coach Lane Barnstable Ma.02632
Date of Inspection: 1/21/99
Name of Inspector:(Please Print)John Graci
I am a DEP approved system inspector pursuant to Secfion 15.340 of Title 5(310 CMR 15.000)
Company Name: John Graci Title V Septic Inspection
Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636
Telephone Number: (608)664-6813
cFRTIFI ATE 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 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 Passes
_ Conditionally Pass
_ Needs Further Ev a n By the Local Approving Authority
Fails
Inspector's Signature: Date:1/23/99
The System Inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within shirty(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.
NOTES AND COMMENTS
The septic system passes Title V Inspection.All components are structurally sound and functioning properly.Recommend pumping system every
two years to prolong the system's useful life.
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
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.
NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
111Q 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).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
111Q 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
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:11/21/99
C. FURHTER 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 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nta_(approximation not valid).
3) OTHER
nta
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
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.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X 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 back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is'at issue,approximation of distance is unacceptable)
[1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART A
CERTIFICATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: nla
Date of Inspection:1/21/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described 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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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 ompounds,
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 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)ora mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):Wit
Total DESIGN flow: Wa
Number of current residents:)
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): Wolf yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): n(a
Sump Pump(yes or no): NQ
Last date of occupancy: n&
COMMERCIAIA gANDUSTRIAL
Type of establishment: nLa
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n/a
Grease trap present:(yes or no):�LQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:n1a
Last date of occupancy: Wit
OTHER: (Describe)
Wit
Last date of occupancy: nLa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last.pumped 1 years ago by AABCa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped I gallons
Reason for pumping: n&
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: Wit
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Origin I yatem����inM�lled in 1973 with a new nit in 1980
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2/98 Page,6 of 11
L
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: Town
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: St"_
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
D&
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NG
JI&
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: M
How dimensions were determined: Measured
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.)
Septic tank and all components are structurally cound and functioning proyrlyl Recommend pumping every two years,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete metal_ Fiberglass Polyethylene_other(explain)
D&
Dimensions: nta
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:ji&
Distance from bottom of scum to bottom of outlet tee or baffle nLa
Date of last pumping: nla
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.)
n&
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 BRAGGS LANE SmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n(a
Dimensions: n&
Capacity: nLa gallons
Design flow: nLa gallons/day
Alarm present: NO
Alarm level:llLa_ Alarm in working order:Yes_No_ MO
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
nLa
PUMP CHAMBER: MO
(locate on site plan)
Pumps in working order:(Yes or No): M
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nla
Type:
leaching pits,number: 2-1000 gallon leach pots
leaching chambers,number: 11/a
leaching galleries,number: jVA
leaching trenches,number,length: iVA
leaching fields,number,dimensions: n/a
overflow cesspool,number: nLa
Alternative system: nLa
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY ONE PIT WAS FULL AND THE OTHER PIT WAS 1/2 FULL
CESSPOOLS: _
(locate on site plan)
Number and configuration: nLa
Depth-top of liquid to inlet invert: nLa .
Depth of solids layer: n&
Depth of scum layer. Wa
Dimensions of cesspool: Wa
Materials of construction: n&
Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:n&
Depth of solids: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1121/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
GA
C6 q
cc 60
� e
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 BRAGGS LANE BmARNSTABLE MAP 298 PAR 083 L 62
Owner: n/a
Date of Inspection:1/21/99
NRCS Report name: Wa
Soil Type: Wit
Typical depth to groundwater: Wa
USGS Date website visited: n&
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS Maps and Charts
�T1
f�
revised!9/2/98 Page 11 of 11
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f No.-_,/,r�f-- --•--- F��..��' 11. ..
THE COMMONWEALTH OF MASSACHUSETTS
�c�°� BOARD OF HEALTH
p .�dPJw .............oF... sr 6 ...............................
Appliration for Disposal Works Toustrurtion rumit
6:14 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at- r
X
. .. .....- ---- -----
Lo tion- rest` or Lot N
--- ..............................
-� ----..-•-•--------Address
W
Installer Address LL
Q Type of Building ! S +.�� Size Lot.__ ,� _�d____Sq. feet
U Dwelling—No. of Bedro ms-_---.__-----------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—a Type of Building •------.• ----------------- No. of persons............................ Showers
( ) — Cafeteria-(--•--)-
dOther fixtures --•--- ...............................................------......--•-•--------------------------••-------•-•-----.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitytl3aa...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 ( )
aPercolation Test Results Performed by.......................................................................... Date--------------------------------------
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
--------------------------------•----.-------------------------------------- - ---------- -------- - ---- -----------
O Description of Soil -------
x
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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu y the boa f ealth.
Signed �✓�-. ..........
// -------------------Date ------•----_-
Application Approved Y----------�+-s:�----�/-----:---------------------------------------------------------- ----------------------------------------
Date
Application Disapproved for the following reasons:........................................------•------------•-----------------------------------•---------------
-•---•-•-••------•------------------------------------------------------•---------•-----=----•----------------------•---------------------------------------------------------------------------------
• 041
1ee7_3
DatPermit No.••--f�- I.......••-•--•-------•---------•-- Issued.---� - ��/ ---...-----
Date
No.-k- -•------- F��.. :..�.. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
OF HEALTH
`....................OF. �4 4-7-------------------------------=--------
Applira#ion for ] iipagal Works Tontitrurtion Permit
Application ishereby-m' ade for a Permit to Construct (s^ ) 'or Repair ( ) an Individual Sewage Disposal
System at: r
w. R�
Location- ddres,*„..++. or Lot N��
` Own Address .
a (_. --.._.. ----------------- -----------------------...........................................................................
Installer Address
UType of Buildings Size Lot.. a .....Sq. feet
Dwelling—No. of Bedro ms.___ ..._ ........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
o' Other fixtures ......................................................
W Design Flow.....................................:...:..gallons per person per day. Total daily flow...-----------------------------------------gallons.
WSeptic Tank—Liquid capacit}fg� '_gallons Length................ Width................ Diameter................ Depth___.--__-.-_-...
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....;e" . Diameter.................. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by--------------------------------------------------------------------------- Date--------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil--------------- -.- .....................................................................................................................................
U -------------------------------------------=-----------•••-••------••--------•---------------••-----------.......................................---------------------------------------------------
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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu y the board101 ealth.
Signed-- "'- ..................
Date
Application Approved BY-Y " .....................................................
Date
Application Disapproved for the following reasons:................................................................................................................
..---•----------•----••---•••------••----------------------•---•--•----.................................
Date
Permit No. - :_ "�...:............... ... Issued............ .-•;-- -----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
! OF......� ,�',..,� . . ....................
� .yc..... ..1 r ..%,.
Trrtiliratr of Tnntliliaurr �
THIS IS TO CERTIFY, That the Individual Sewage Dis sal ystem constructed (— r Repaired ( )
by--------------------------------------------------- ------------_---- . . � ------ �-----------------------------------------------------------...-----
_ Installerat
--• fie?
- ,r-•••---'; %-�L.�-�:r --as '' e> t-v-•.:.:. :::--------•-•----
has been installed in accordanceAvith the provisions ISt Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No---------/ :. dated....... ` . --a ----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT FACTORY.
DATE.................... �------------...... Inspector---------- ............................. .......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF-. HEALTH -
:....... ..OF !. ...
A F` .�i.I V'rv+mfS.e4arr'a*"- -Fi+'�A'w�.�/".rd�+'".
No....�! � ...... FEE-- ...............
Dinjullittl Mai Tonfitrurtion antic
Permission,is hereby.granted----- -- ----------------------------------•-•-- ----••......-•-----••-------
to Construct 'or Repair ( ) an Individual Sewage Disposal S tem
at No:= = - 15 / ix -----
.-L .1
... Street
as shown on the application for Disposal Works Construction,�Pemit N _ _-. Dated____ I_r,_ ............
_ 101 a ...
0 rd �h {.
DATE.--- --; -- ----------------
/ FORM ,1255 'HOBBS 8F WARREN. INC.. PUBLISHERS
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The installation shall comply with the State Environmental Code Title V and Town
of
Board of Health Kegs '01ions.
Tice septic system as pAiwsed on this Plan shall not be installed until a licensed town installer
L
1:N,E rfc;eives approval..ind an instailationpermit from the applicable row i.
-,Pve -werts, sewer Z�)z 0 "'ar to installation,lhi�ir.:.-calle� shall verify the location of utiKies. se ' :'t
R a—F E R E'.N
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�,�od existing septic cornoutwilts prior to installation.
C'i
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Al! gravity sewer pipieg, s to be 4 inch schedule 40 PVC at 1/8" pp.r foot. fi rs feet out Of
Tw T t e distribution box shall be level. All piping connections to be glue4j.
j
-his septic.design plat, is not to be utilized for property fine determination ur for any other
PU rPose other-thz n the proposed septic:system installation.
ObA
7T
Ail Title V components are to rneet Title V specifications.
0 4
2
.1 ��arking shall be prohibited ove,-Title,V Components unle.',�c-nrnpooents afe 1-120 loaded, 4
131' 67 1
1
5,lcl- 1xit)- ti (6 67- fly 1-6P existing leaching cr cesspools shall be pumped and filled witi-imaterial per Title V
MAP abandonment proceduces Leaching and cesspool(s) and contarninWed soils within the
IN"
N-1 proposed SAS shall be removed and replaced with clean sand pet''Title V specifications.
q.,,-
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7,0 9) Septic components are to he 10' from a water service line. SetA,-er IiAe.,;crossing a water line pit
sleeved with an appropriately sized schedule 40 PVC with er,&Rroutetl. The water servict-
linj�f or vie septic line can be ileeved'-wIth the sleeve being a distance of !(D' or, bvt', -cidps r'
CP
crossing the line.
0
Pre ;VD 4-41W.P. WF-7Z 10) If 8 garbage grinder exists in the structure, it is to be. removed if the septic system is not
-)mmodate a garbage grinder,
C� dc�signecl to ac(:(
1 Th- installer is respow;iblefoi care of excavation around di; �J i ti the pro and
t li es or e pert n
during the installation process of the sepi i,:
protecting the structural integrity of all structures
S."s-em.
is Tl)i plan only represents that a septic system can be installo-1 on the, prope rty meeting Title V
Lb
` �`` 1requirements.
-T;FCKk1 -,:66 GAL/DAY
13) The property owner ,-hill review desig�-, criteria to approve tj,e total number of bedrooms and
k f,Oil/ 9�;:
design flow. Installatico of the septic system as proposed and receipt of payment for the design 1
J shall be deemed approval of the design criteria by the properly owner or agent of.
Z(�' 0- 1-4) Tile validity of this plan stall all expire with the expiration of the town installation permit Issuec,' ki
01 -t;flcate of Comp
liance:
nce
UIX plan or the vallclitt.-of this plan shall expire on the expiration of the Cfji
issued for the i,,istallei i,r� of the propuled systeir, on -1-his plao.
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D8C E"N"VIRC,NME N
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1-7 T The instaRaltion shall caniply v-,6th the State Environmental Codt;.-Title V apd Town o
3fyard of Health Reguiations.
EVA .,A %-JC 2) T;i-:!septic system as proposeci on this plan shall not be installed until a licensed town installer
,
L
rp(.eives approval:end iin instailatior, permit from the applicable town.
3) PriOr to installation,this ; ;Y, -ify the location of utifilies,sewer ariverts, sewer lines
R E F E R N,', Ci .'E ir: ille�, shall vet
�-4�0 .1,------ and existing septic conloonentsprior to installation.
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4) All gravity sewer piping Is tr. be4 inch,schedule 40 PVC at 1/8"p The first 2. feeer foot, t out 01
X
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the distribution box shall be level. All piping connections to be g!u,?d,
A-04W4
5, This septic design Wan is ri,.A to beutil'zed for property line determination or for any other
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PLI f POSe other thr;i the proposed septic system installation.All Title Vcompor:entsare to meet Title V specifications.
.......... Parking shall he prohibited paver l"WeV components unle3,,i.nrnpooif nt� are H2O loaded.
8) The existing leaching cr cessspoai-Sha!! be pumped and filled with;iiateriil per Title V
anandonment procedu,^--:� Leach'ing ard cesspool(s)and covitarninated soils within the
proposed SAS shall be rem. rwecl an6 replaced with clean sand pp..f specifications.
Title V sp i ations.
3PD
91 Septic components are to be 10' fro-r!z water service line. Sewer lioescrossing a water line sh':':
>1:5
at-sleeved with an appropriately siHd schedule 40 PVC with en&grouter. The water service
Lo.C)o line or the septic line(;ai'i 1,)e Sleeved &Iih the sleeve being a distance c-f 1-C; Jr ridP5, r"
crossing the line.
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garbage grinder exists in The structure, it is to be removed if the sepl",,- ;stem is not
dr_-;Jgned to accommod,-,te a garbage grinder,
C,
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C -T r,1 4 V, installer is re�,pon.-;ible for care of em-avation around ail Aiiii es or, the property and
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protecting the structural integrity on all struct;jres ouring the installation PrOCess of the septic.
s'IsT e M.
W
5 e ty meeting Title.r
I'lliz,pian only represents that a wpti,- system can be installod on the prop
requirements,
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The property owner--hal! review design,criteria to approve tbf-total 11101i rol'bedroornsan,
` �• \ L � Y design flow. Installatioo of the septic system as proposed and receipt ol pawment for the design
All
0 stia;lbe deemed approvelof the design criteria bv the property oo!re --nt of.
4', Tine validity of this pian stall expire with the expiration of the town installation permit issue.; i
thil4 plan or the validity of thi5 planshall expire oo the expiration of the C-PI-Tificate of Comp!ifanc..44-0
i 1C "i`�../ Y \ l _ -'-- -i ` f � //��i�" N`- 'h���-� t l�f Y�(}r1r Lam'
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