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0076 DEACON COURT - Health
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I " I I , -�;�,X,,�',, , -'t;t,I I�1-11 Ir"-c,,,.,,�;,,J,i�:i,�-,�� , -" ::,.� r 11!1-1, ��,ii...1:r�1.1,1�11 � . I , - "-1�.�1,1,�ll,�1,"."t,"�_,� f - �z -- - - ,"o L�x , ,) , ,ly � �7, � ! I ,, L,-�I I � . 'n,�.�, .� � ,,��" �'. -I t I ,,�,-,t, t i , , 11 "ll -1'�I'l iv ",I'.� � �",� . I et � ,,� , I -.., . I, I �I , , � I . i.-,'f,��,z,"I . . I...,4, ., ,�!,L -',-4, � q- �-, I , �, ,'�`A�" I I- li � ;�l ,. i I-�`ll I , � I , �,,� ; L ,� , -e�,.',,,�,:,t�,,-,����� t��,:;,,.tkl"�:",4 ��,-"�,`.',Z�.`,eil'L:'I��ll , ,?�,,, , I,1,I�,-�, 1�1 .; I I I - - ,,.:i 1 ,�, .,�� , -,:� ��� 1 I . , ".;-t� , � . I ,. , TOWN OF BARNSTABLE LOCATION SEWAGE # d 0 Co - 3 S,' VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. Rv 1?,Oout C'o 'XL- SEPTIC TANK CAPACITY /aa-o LEACHING FACILITY: (type) 'Y- (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: F I a u I 1 y COMPLIANCE DATE: i t gh D Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Ala Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) NO Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachiin}/acili �d Feet Furnished by L,4� Z�C� (�0 :r q 13_ � d � rTo C 3 = t7. s' S Q is �� _. ._ � -., 4 - ��-.e -__-. -.. .- -.......-, e ,�, w. .. •Fw.-an+y-tea- T .4^. -t1� �...---.... ...- ...�-.�- ♦ "�- �`.-_ .. No.OC Dl V t Fee �-- Tb'E-COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,.. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYfcatiou for Miopooal *potem Conotruction Permit Application for a Permit o Construct( )Repair{ )Upgrade(/andon( ) O Complete System ❑Individual Components Location Address or Lot No L7�w �n ('tz u(z-T - Owner's Name,Address and Tel.No. F' 3G.1 S S U Assessor's Map/Parcel 3oz/ o,5cf krnlbIR i. Jcau Installer's Name,Address,and Tel.No. 549 - IV O S 3 0 Designer's Name,Address and Tel.No. S 4f iZu1�.z..J1"�3: 01.�,. CS .�c. �6ti,c+..IdL �•E c.�J?i LLece �y w -.mow, R d�ox 5 Type of Building: Dwelling No.of Bedrooms Lot Size �14 6..S-o sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow q g- gallons per day. Calculated daily flow L-1`(U gallons. Plan Date -JU 14 I Oct Number of sheets l Revision Date Title Size of Septic Tank 0QC7 Type of S.A.S. rle+v r F Fzc cacti Description of Soil /1 j► n. Z44./M Nature of Repairs or Alterations(Answer when applicable) f n a- Ei , j°-� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oard of Health. nn Signed � .r,H��sia� 1? Ike �.�. Ll c Date IFa� 0 Application Approved by YYNL,t t 4v 2- Date L5 it Application Disapproved for the following reasons Permit No. Q Date Issued No. y�D I �( - ,.{ ' `' � Fee ' Jr. Entered in i if computer: TI ,E. .QAMONWEALTH OF'MASSACHUSETTS�- P yes UBLIC HEALTH DIVISION TOWN.OF BARNSTABLES MASSACHUSETTS ZfooYicatton for Construction Permit *^ Application for a Pern t�to Construct( . )Repair(.' ) /A Upgrade( andon( ) El Complete System ❑Individual Components Location Address or Lot N O u u rc — owner's Name,Address and Tel.No. 36 Z- S`s^U LAJ Assessor's Map/Parcel O� Installer's Name,Address,and Tel.No. 5_12 Y- ��3.? b`'3 U Designer's Name,Address and Tel.No. v U I�u� t�3. Ow. Co .L�t.c. �cs�� off,LI �J i1 e.�c� lt�-v..� GJw+ IZc� r��u r�n ,1 <; ay- I Type of Building: " Dwelling No.of Bedrooms�_ Lot Size 6�Q sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( )'Cafeteria( ) Other Fixtures Design Flow A/q g, gallons per day. Calculated daily flow z'/ `c) gallons. Plan Date 1'l 14 a ti Number of sheets 1 Revision Date f Title .� Size of Septic Tank Type of S.A.S. 7c F Fu ce_�,rc Description of Soil; _ Nature of Repairs or Alterations(Answer when applicable) r' Date last inspected: Agreement: _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Q Signed,, fl4t w�� 1? I�, . `v. 2k�•c Date Y ab_ / Application Approved by t 1 Y�G rtn,�.c �'�7 r Date L Application Disapproved for the following reasons Permit No: et Date Issued--- d THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance a. THIS IS TO CERTIFY,that the On-site/,Sew ge Disposal System Constructed( )Repaired (- ) Upgraded(✓) Abandoned( )by 1 0 6 L-,* l3•Q.u.. C- e 1 at ?G -vie 0,-- *- has been constructed/in accordance with the provisions of Title 5 and the for Disposal System Construction Pen-nit No. 'a o/0 "3 5-1 dated Installer 1 a.". 0. G. pa � Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date �.Z� Inspector - ` - i No.�y�" '� 3�S(-------=---------------—-------- Fee (0 6 !/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS 30igogar *pgtem Congt�ruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 7C, C>A.IAwC�►n .._f 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 completed within three years of the date of this'permit. p / G t/, ..t-e Date: 1) �� — V Approved by�V� L Sep 09 10 08:28a Ronald J. Cadillac 508-790-6963 p.1 Town of Barnstable °ft"E T°wy Regulatory Services Thomas F. Geiler,Director BARNSI'AUM MASS Public IUalth Division 1039. 10 Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 . Office: 508-862-4644 Fay:: 508-790-6304 Installer & Designer Certification Form Date: 9 Q Designer. .� 01 Installer: �� y Address: PCoo, Bpi ZS _ Address: A/ yigY/no m _/L D Z67-3 On ZO d > Our was issued a permit to install a ti {date (installe )-- septic system at 7 based on a design drawn by (address) 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. I certify that the septic system referenced above@ was installed with major changes (Le. 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. `4 (Installer's Signature) _ +. ol (Designer's i. ature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.' CERTIMCA.TE_ OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:HealthlSeptic/Designer Certification Form Town of Barnstable P# �1ttE l� Department of Regulatory Services BARMABIE. : Public Health Division Date NUSHrEa 200 Main Street,Hyannis MA 02601 01 Date Scheduled Time Fee Pd. Soil Suitability Assessment for Se ge isposal Performed By: )eo u4y I , 1 Ll Witnessed By: Olv' 61�"' ', LOCATION & GFNF;I At IrIFORIVYAmtON Location Address /'7 A� Owner's Name �t/ J , rie AS S Address 7fJ r,L�Aj C—�Lh'" Assessor's Map/Parcel: 300/014? Engineer's Name J CA jj/4Z,4eJ NEW CONSTRUCTION REPAIR _ , • Telephone# c�� Z 7N 176 Q Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) N r 3 2 N_ l2 I Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETtiNIT ATION: 'OIt ASO A .HIGH' ASTE S A Method Used: -D Lj N U CZ i`• W.k f- Cl, Depth Observed standing in obs.hole: h in. Depth to Soil Mottles; �'1 _ _ in, Depth to weeping from side of obs.hole: ia. Oroundweteg A ustment _ ft• 6457 j In `yell# 2 SZ Rradiag Date:�yN� trdex ell level - AdJ:iaCtot Ad),Ortaundwater"I,eve1 �� PEP.COLATI"N TEST Observation r(Qfr2 Hole# Time et 9" _. Depth of Pere �JO Time at 6" Start Pre-soak Time @ �� Time(9%6") End Pre-soak Rate Min./Inch. C2 � Site Suitability Assessment: Site Passed 11 Site Failed: Additional Testing Needed(Y/N) �N� wl 01"/`, Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEYnC\PERCFORM.DOC ti DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) !/D' C/ 2,� 6 4. DEEP OBSERVATION HOLE'.LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel ZD'/ X/' r- Adm DEEP OBSERVATION HOLE.LOG Hole# . .3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel 32,i 8 DEEP OBSERVATION HOLE:LOG ..Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) Flood Insurance Rate Mai): / Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? /Uo Tl�- 1 6¢ 714Z 2 OZ If not,what is the depth of naturally occurring pervious material? / Certification I certify that on /UO0. i9g3 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above.analysis was performed by me consistent.with the requir ert' e a e erie de cribed in 310 CMR 15.017. Signature Date 9 Q:\SEPTIC\PERCFORM.DOC Z)2 L ' � �t�c13 R oo m 81l�a0m .` 1 ,Z yqI 1(i r01FN FKsl I r P o ie c 4 . ! 8�D l�C�O�i7 x . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION V FEB 2 . TITLE 5 "rowN . ?ppl OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSE IN o�PT,gB�E SUBSURFACE SEWAGE DISPOSAL SYSTEM-FORM PART A CC RTIFICATION Property Address: / , ' Owner's Name: ✓ c/ Owner's Address: Date of Inspection: IZ2 5Z Name of Inspector please riot r a3or1� e Company Nam + 1� Mailing Address:p ^ .' Telephone Number: 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 systemsA am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: asses Conditionally Passes ds Further Evaluationby the Local Approving Authority F ils Inspector's Signature: Dater /' d The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,-the inspector and the system owner shall submit the report to the appropriate regional office of the DEP:The original should be sent to the system owner and copies sent to the buyer, if applicable,and the.approving authority. Notes.and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2`of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) R f, Property Address: / ' Owner: Q Date of Inspection. Inspection Summary: Check A,B,C;D.or EJ ALWAYS complete all of Section D A. ,System Passes: I have not found any information which indicates that any of the failure 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: 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: Observationof sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass.inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 is ;y Page 3 of 11 ". . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A ".. 7 CERTIFI..C'ATION(continued) Property Address: Owner: Date of Inspectio . C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system. is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines.in 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 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines-that the system is functioning in a manner that.protects the public health,safety and.environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS.is within a Zone 1 of.a public water.supply.' _ The system has a septic tank and SAS and the SAS is mithin 50 feet of a private.water supply well, _ The system.has a septic,tank and SAS and the SAS.is.less than 100 feet but 50 feet or more from.a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria ar d.volatile organic compounds indicates.that:he well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that'no other failure criteria are triggered._A copy of.the analysis must be attached to this-form. 3. Other: rt Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- /(p. 0,4�(_ Su4v Owner: Date of Inspection( D. System Failure Criteria applicable to all systems: Y PP Y You must indicate"yes"or"no"to each of the following for all inspections: Yes No V Backup of sewage into facility or system component due to overloaded or clogged SASQor cesspool ~ Discha rge arge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or P clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or q bg cesspool V Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number. of times pumped Any portion of the 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. Any portion of a cesspool or privy is within a Zone I of a public well: Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis: [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: To be considered a large system the system mustser4a facility with a design flow of 10;000 gpd to 15;000 gPa• You must indicate either"yes"'or"no"to eachl of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a.public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B CHECKLIST Property Address: 41 (0 Owner://L Date of Inspection. Check if the following have been done.You must indicate"yes"or"no"as.to each of the following: . Yes No V" 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? /JL — Were as built plans of the system obtained and examined?(If they were not available note as N/A) I— Was the facility or dwelling inspected for signs of sewage back.up Was the site inspected for signs of break out )/ Were all system components,excluding the SAS,located on site. V _ 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?. 1/— Was the facility owner(and occupants.if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems.?: r I I ,A+ of !3 The size and location of the Soil Absorptio,n.System.(SAS)on the site has been determined based on: Yes no/ V Existing information.For example,a plan at the Board of Health. „ _V-_�_ 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)J' 5 Page 6 of 1] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: P Y Owner: ' Date of Inspection FLOW CONDITIONS RESIDENTIAL- Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 5.203 (for example: 110 gpd x#of bedrooms): Number of current residents: , Does residence have a garbage grinder(yes or no): CJZa Is'laundry on a separate.sewage system(yes:or no)- [if yes separate inspection required] Laundry system inspected(yes or no)-/ /( Seasonal use: (yes or no), Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):1111"Zj' Last date of occupancy:V �/Me' COMMERCIAL/INDUSTRIAI!-2tg— Type of establishment:. Design flow(based on 310 CMR 15.203): gpd Basis of design:flow(seats/persons/sgft,etc.):. Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER.(describe): GENERAL INFORMATION Pumping Records Source of.information: (4� Was system pumped as part of the inspection( es or no): . If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 1?eptic 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: / V— � Were sewage odors detected when arriving at the site(yes or no): --� 6 Page 7 of 11 OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C 4 n SYSTEM INFORMATION(continued) Property Address: ' r n Owner: dtr7X1,WU Date of Inspection BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: _.• ,..•- . - .F., .`, „. .,_ j Comments(on condition of joints,venting,evidence of leakage,etc.): ' 3 SEPTIC TANK: ( ocate on site plan) Depth below grade: Material of construction: /Concrete_metal_fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes.or no):._(attach a copy of certificate) ,,. Dimensions: 5 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:, 3 ' Scum thickness: c2 Il. . Distance from top of scum to top of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffle: /I _ 4 How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels ,as related to outlet invert,.evidence of leakage,e .): GREASE TRAY (locate..on site plan) Depth i Depth below grader_ Material of construction:_concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: 'Distance from top of scum to top of outlet tee or baffle: 'Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 ' Page 8 of]1 OFFICIAL INSPECTION'FOR.M=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l� Owner: Date of Inspection.. TIGHT or HOLDING TANK;/gjTtank must be 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,etc.): DISTRIBUTION BOX: {if present must be opened)(locate on site plan) Depth of liquid level above outlet inverttion A�any Comments(note if box is level and distribu to outlets eq , idence of solids carryover,any evidence of ,IeAage into or out of box,etc. : " L 1 PUMP CHAMBER (-locate on site plan) Pumps in working order`(yes or no); Alarms in working order(yes or no): TM. Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION.FORM . PART C n SYSTEM INFORMATION(continued) Property Address: "/ 02.1 0121 Owner Date.of Inspectio eJ SOIL.ABSORPTION SYSTEM(SAS): f/ (locate on site plan,excavation not required) If SAS not located explain.why: TYPej ✓✓leaching pits,number: leaching chambers,number: , leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: . Comments(note condition of soil,signs of hydraulic failure,.level of ponding,damp soil,condition of vegetation, tc.): 0 CESSPOO-Lyt(esspool 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: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.):'` PRI (locate on site plan) a Materials of construction: k • Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 r. Page 10 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �` Date of Inspection. 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. pp � 1 10 /r Pag; I I of I I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address AA Owner: r .� Date of Inspection. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet.. Please.indicate(check)all methods used to determine the high groundwater 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) F Checked with local Board of Health-explain: hecked with local excavators, installers-(attach documentation) Accessed'USGS database-explain: You must describe how you established the high ground water elevation: G +. r= �r - CO� r No.••-•/'.AS .... � S Fus............. ............._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................OF......................................................................................... . pphratiun for Diupusttl Workii Tontitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......J..LE .. Location-Address or Lot No. ..........Aj?1 h 6l�....... ........1u 1. �l.�l, . ........................... ...�5[ Y✓ �1--....�1tL,M.akwL 4�f.5 Owner Address _V.R.......................................... `' ........ V.&5 ..................................... Installer Address d Type of Building Size Lot. sve9 ?.. ..Sq. fee Dwelling—No. of B ..................................____________________________Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons........ -.............. Showers — Cafeteria ` Q' Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ 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.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ •------•--•.................................•-•-------•-----------------•--...................•.....m......................................................... Descriptionof Soil........................................................................................................................................................................ x U ----•-•---------------------------------------------------------••-•••-•--•.............••...........----------------------------------------............---•--------...._---••---•---.........._...... 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:TII:E . 5 of the State Sanitary ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e d bSty)o, o0 Sig -- -...... -•-------------- ---- --------- Application Approved ._ :---- ---- -- -•----------------------------•---••---------------.......-•.------ Date Application Disap ove or a following reasons:.............................................................................................................. ............................... ..... ...•-----------------------...-----••..._..-----------.........------------•-------.........-•----------------......................... ------........ Date PermitNo......................................................... Issued........................................................ Date f N0 S1':.-loST-.... FEs... �............ ^, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F................................................................................ Alip iration for Uiapasal Works Tnnstrurtian thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_........ L4 G4_! 1...._.�.� a pLocation f.Address or Lot No. r ...........e�1 ............................ ..............20 .... ,- !_Y!✓i4 ......k 1. srofi. ..:� .0tr7 Owner Address Installer Address Type of Building Size Lot.- ..7et _-t.Sq. feet Dwelling—No. of Bedrooms "' Expansion Attic 1rarbage Grinder "'^" Other—Type of Building ............. Showers — Cafeteria YP g -------------------•----•--- No. of persons---------�"- ( ) ( ) aI Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow,...........................................gallons. W Septic Tank—Liquid'capacity............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.......................................................................... Date........................................ aTest Pit No. 1................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........................ ------------------------------------------------ •...... •------------------------------- ._........---..... ------------ ---------- -••-•------------ ODescription of Soil........................................................................................................................................................................ x 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 Tom: E5 of the State Sanitary Q0de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sue by th oa d1 of 4ealt . Sign _.. ... = -----.. -• -------------- Da Application Approved BY' `• �f ----- ---- ---�� " -•- 1-------- PP ........... Date Application Disappr ee�dl f or t e following reasons:------•----...---•-----•-------------------------------•----------------....................................... Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... T.Wrrtifiratr of Toutp ianrr THE$ S T,6 CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( } bY...../1...a-YV. ...�-.r% . ... I---nst l -------------- -- ...------------------------------------------............----- •''� al at--••--.AP.-T J 1...... --------------- •-----------------------------------------------------------------•-- has been installed in accordance with the provisions of L I. L of he State Sanitary Code fas -cribed in the application for Disposal Works Construction Permit Nom_ .......... da.ted_._f _"_.._._.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................ ......... Inspector................ .11.14.4.--•-------•-••----••••----••••••...........•...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF........................................................................:............ 6 .• No..a?.�. ., ... FEE....................... Mops or o tallmAr ion rrmi# Permission is reby granted.....-... •• `. .. to Construct ( or Repair ( ) an Individual Se a �isposal Sys at No. jD_T.._5..:1-•--_-•- ...�. � �! .. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ............................ ---------------•-••--------••••-----...--••--...... _ DATE............................� _ _.....------.......... 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ELEVATIONS SHOWN ARE ASSIGNED (WITHIN A FOOT OF TOWN GIS SYSTEM) rn DEPTH (inches) ELEV:(feet) 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED JULY 2, 1992. Rey. 0 36,4 4: ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED) A layer 10yr 3/2 5. MUNICIPAL WATER: IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER. 5„ sandy loam 6. COMPONENTS TO BE AASHTO H-10, UNLESS NOTED. z 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". 3 z 8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW 0 N/F B s4ndy10oam/6 D`-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. RTE 6A a 9. DEPTH OF COMPONENTS NOT TO EXCEED 3 , OR VENTING MUST BE PROVIDED. MARSHAL- 30f` 33.9 COVERS:: BUILD UP COVERS: 1 ON TANK, 1 ON D--BOX, 1 ON LEACHING 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 T0 '1/2" PEA STONE ON TOP. LOCATION MAP 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND, Cf layer 2.5y 6/4 CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC. medium sand 12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING TEST DOLE 1 1 24%7 4.9 x 24.6 N 88'58'55" W IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3). x 23.7 200.06' 102" 27.9 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN DEPTH (inches) ELEV.(feet) C2 layer 2.5y 6/6 LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. 0 37.4 sandy loam 14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS. A layer 10yr 3/2 24- 24.0 106 C3 layer 2.5y 6/4 27.6 18" sandy .loam I x 25.4 x 24,9 P NUMBER: 12620 _ med. sand 120 26.4 TEST HOLE DATE. July 8, 2009 B lsandyl0 om/8 no water PERFORMED BY: Ron Cadillac, Soil Evaluator NO GRADE CHANGES WITNESSED BY: David W. Stanton, RS 46" 33.6 2s ARE. PROPOSED' PERC RATE: <2'-00"/inch (Medium Sand) x 25.5 HAND BORING 5 37.56t SOIL SURVEY(1993): Cdrver coarse sand I Top Foundation GEOLOGIC MAP(1986): Harwich outwash plain deposits 26.8 x 25.3 Unwitnessed 7/30/09 invert 34.80t � C1 1med um sand /4 LOT 57 DEPTH (inches) ELEV.(feet) Exist. Cast Iron Invert 34.09 W 26 36.0 Use Gas Baffle 4 FLOWDIFFUSORS "� I 26,4 51 5 5 0- - S. F. o x 27.8 x � Fill 6�Max. Invert 33.38 H.;_20 110110" 28.2 28 Proposed 27.5 18" 34.5 S=1/2 /ft ___�-��'� H-20 Covers to 33.8=Top Units C2 layer 2.5y 6/6 x 27.4 --�'-___ . -'-f-� Existing ' S=1/i�"/ft Grade 33.6=Top Peastone/Pilfer Cloth silt loam I I I 10% gravel 28.7 x 29.1 I 1000 Gal. I - __-___ 12$" 26.7 Septic Tank f __ no water 1 C1 layer 2.5y 6/4 i------- - „ Screened •u : 15 Vent 28 28.0 x 29.5 medium sand T TEST HOLE 2 WOODS INSPECTION SCHEDULE Invert 33.55 Invert 33.23 v0 x 28.5 114" 26.5 CALL R.J. CADILLAC` TO P p roposed DEPTH (inches) ELEV.(feet) 6" Stone or compact Proposed I 8.5' 4'+ 31.98 C2 layer 2.5y 6/3 INSPECT PRIOR TO BACKFILL r y I i I 2 Bottom 0 37.4 sandy loam I - I--- A layer 10yr 3/2 106- 27.2 ' c� 15 I Bottom med. sand=27.9 sandy,loam C3 layer 2.5y 5/6 < i 20 w • 1; x 29. 120" sry loamy / 26.0 DESIGN DATA ) y / 529,4 C3 layer 2.5 5 4 Bottom TH 2 (1981 =23.5t B layer 10 5 6 _6 30 30,2 loamy sand sandy loam N 32 3 2,1 125." 25.6 EXISTING BEDROOMS: 4 no water LEACH AREA 62" 32.2 x 32.7 x 32,9 GARBAGE GRINDER: No REQUIRED CAPACITY: 440 GPD USE 4 FLOWDIFFUSORS, AS SHOWN WITH 32.8 z EXISTING SEPTIC TANK: 1000 GAL. 4' OF STONE ALL AROUND AND 4" UNDER C1 layer 2.5y 6/4 O HAND BORING 6 T( MAKE A 12' X 40' X 15" [SEEP medium sand N o BOTTOM LEACHING AREA: 480 SF Unwitnessed 7 30 09 [(4o x 12 ] » 29 7 30 4 36,3 o w / / LEACH AREA. PROVIDE SCREENED VENT 84 30.4 I w ,!�� x� 34.3 DEPTH (inches) ELEV.(feet) SIDE LEACHING AREA: 130 SF34.7 0 36.3 [2(12'+ 40') X 1.25' DEEP)] ° C2 foyer 2.5y 6/6 / I w x 36.5 Fill DESIGN CAPACITY: 451 GPD 10% gravel silt loom ----- 30,4 30, 16" 128"[(480 SF + 130 SF) X .74 GPD/SF] 34, G1 layer 2.5y 5 6 � no wotef' 26.7 3 i i sandy loam 24" 34.3 30 2------------- 347-- In 36A m I U x 36,6 x 38.2 C2 layer 2.5y 6/4 I DOLE 3C/) xI35.7 EXIST. DECK 36.6 TES .......... .............3519m I X medium sand < I :: DEPTH (inches) ELEV.(feet) ........................ ............................................. I BDRM A layer 10yr 3/2 BENCH MARK--TOP & CENTER OF 0 6.9 I ; HB 4 i EXISTIN WOOD STAKE= 38.33 ASSIGNED 101" 27.9 BDRM 6„ sandy loam 36.4 I I G HOUSE NO 76 C3 layer 2.5y 6/3 DOWN DNRM BATH ,w 3 •70 �----=�6•4 Slab I Basement " sandy loam LVRM B layer t0yr 6/8 5, I f 108 27.3 GAR. BATH sandy loam TH B (1981) 8.4 o C4 layer 2.5y 6/4 w 5,8 ::::::............. . Ly :......:..................:. 41.1 medium sand 2 ,\ :: .. :. KIT 34 2 LFT --------- .: .: BDRM IV .5 W _�� 7.2 :: 110" 27.1 m x 36,4 " W ::::::::::: 37.0 x 38,3 no water DEN 5 �' ay / -i 37• C1 layer 2.5y 5/4 ,14 + rn j I ,_3" i sandy loam 111 HB 5 - ° = 37.0 46 �37,07 I 38,33 M -3 -36.0 _ 37,1 � C.� f EXISTING FLOOR R t 4.7 ► I- I x 36.9 TH Z 37,4 ._L /(i�7L/a-IleA- � U�4 L \l PLAN r�,W 10• 1_ ' 36,8 I 7.0 / y,, �_ f NOT TO SCALE x ---- -pA -------E3PIVE I TH 3 36.9 r _ i�� ��� x 39,3 d f��G f L �'/l� J f i W. t I �\� �•3 37,4 132" no wa et 25.9 ® 34.55 1 ►,` HB 6 X X X--x 37.0 -- TH 1 0 1�Y 10/,' -14-0 /of //A�,, x 40.6 I Z fry C4 BENCH MARK--TOP MAKE NAIL I Z > ,^a„ , x 37.4 x 37.3 x 38.1 C�G(n 39,0 IN PAVEMENT=34.55 ASSIGNED I x 3 ,„ 40 \'�` x 39.4 38.5 40.0 �° W 3 460 208.63 x 38.8 I w N 89*15'59" E 34.9cTEST HOLE 2 N/F SITE PLAN (8/6/81--Down Cape Eng ) PARKE [EBB ®34.96 34.99 BENCH MARK CONCRETE WALK DEPTH (inches) ELEV.(feet): ��� WHITE PAINT® JolNT=37.07 ' 0 36.5f THIS PLAN IS A VALID COPY ONLY IF IT BEARS �, Topsoil AN ORIGINAL RED STAMP AND SIGNATURE. WARREN T. & JEANNE R . JONES LEGEND 6" Dense fine LOT 5� 76 DEACON COURT BARNSTABLE IAA TH 1 TEST HOLE LOCATION, NUMBER (WITNESSED BY AGENT) " sand � Mq of � , � HB 4 HAND BORING LOCATION, NUMBER (NOT WITNESSED BY AGENT) 60 3t''.5 s9c S�cy �✓ WATER LINE MARKINGS CAUTION UNDERGROUND ELECTRIC--HAVE MARKED w R ` AL GNP ID GN AUGUST 19 2009 SCALE: 1 't-20' E UNDERGROUND ELECTRIC WIRES IF SHOWN CADIL C CADILLAC ( ) UNIDENTIFIED CONDUIT FOUND=' AT HB 6 LOCATION. #1060 "O #35779 x 9.5 X 8,7 EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) 10 �0r GISTS CESS\0 /--"6 EXISTING CONTOUR clean med. sand S�rv�rA�tiP�' ��O suRv '40 g-- PROPOSED CONTOUR b RONALD J. CADILLAC, PLS, IRS, PC 6[ (q ( UTILITY POLE (IF SHOWN) PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN ® EXISTING DRAINAGE CATCH BASIN P.O. BOX 258 X FENCE (IF SHOWN, NOT ALL SHOWN) WEST YARMOUfiH MA 0267 0 TREE (IF SHOWN, NOT ALL SHOWN) 156" no water 23 5t (50$} 775--9700 HEALTH AGENT APPROVAL DATE PAGE 1 OF 1 REV. 8/19/10--FLOWDIFFUSORS & RESERVE C 2009 BY R.J. CADILLAC