HomeMy WebLinkAbout0050 INDIAN TRAIL - Health 50 ;Indian 'Trail
Banistahle
A= 336-016
I
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARR A S ALT
SUBSURFACE SEWAGE DISPOSAL SYS ENf4'�VED
y
PART A
'CERTIFICATION APR 2 5 2002 _'
Property Address: t hCC,% pv" TOWN OF BARNSTABLE
C� 81 HEALTH DEPT.
Owner s Name: ,
�w1wl G G V�C 1 m
n Vie.. a r•e_��fJ ^4 ��G.. S
Owner's Address: l oZ3
Date of Inspection:
Name of Inspector: please print) M1 L ,.
Company Name: i' /1MQ✓1,-61k 1 v 5per�-T(O t`s .l Mailing Address: Y1Ar' �
LM h 0�_16 1+t PARCEL . ! E
Telephone Number: SQ 518 S-76053
. . tOT
CERTIFICATION STATEMENT '
I certify that 1 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 '
r Needs Further Evaluation by the Local Approving Authority
Fails
` Inspector's Signature: :. Date: s
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 repon to the appropriate regional office of the
DEP.The original shouid be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments' .
r .
PF .
**•**This report oniv'dek'ibes 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 6115/?000 page i '
Page 2ofII *,
OFFICIAL INSPECTION FORM-NOT FOR VULION'I-ARY ASSESSMENTS
,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address.-a, 50 (n�'
Owner: �on ����
rDate of Inspec
Inspection Summary: Check A,B,C,D or E/ALWAYS complete of s ctiaa iD <
A. System Passes:
.. .. . 3
I have not found any informationwhich 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:
C ^ .. • . µ
B.Y System Conditionally Passes
One or more"system components Vas described in the"Condition ass"section heed-to be replaced or a
repaired.The system;upon completion of the replacement or repaii, approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the -for " e following statements. If"not determined""please
explain. _
The septic tank is metal aiid over,20 years old* or the septic tank(whether.metal or not) is structurally,' "
unsound,exhibits substantial infiltration or.exfiitra 'on or tank failure is imminent. System will pass inspection,if the
existing tank is replaced with a complying septic . as approved by the Board of Health. y_
*A metal septic tank will pass inspection if it i structurally sound,not leaking and if a Certificate of Compliance +
• indicating.that the tank is less than 20 years d is available.
" ND explain:
Observation'of sewage bac or break out or high static water level in the distribution box due to.broken or r
obstructed pipe(s)or due to a bro settled or:uneven distriution box_$
approval of Board of Health): System will pass inspection if(with
broken'pepe(s)nn:rphisrd
obstruction is removed '
'distribution box is leveled or replaced
ND explain: '
The system •
y quired pumping more than4 times a.y=.due to broken.or obstructed pipe(s).The system,will.
pass inspection if ith approval of the Board of Health):
broken pipe(s)are replaced .
obstruction is removed
ND'explain: _
s
f
` r
Page 3 of 11 - r
OFFICIAL INSPECTION FORM NOT.FOk VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
a T
Property Address:• 57Z)• A— •
C t�rn�M u c y IVA
Owner
Date of Inspection:
C. Further Evaluation is Required by the Board of Health: -
Conditions exist which require furthet.evaluation,by the Board of Health fin er to determine if the sysiem is failing to protect public health, safety or the environment:
1. System will pass unless Board of.Health
dete rminesin accords with; 31
0 CMR 15.303 1 (b)that the
system is not functioning in a manner which will protect pub ' 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 v etate_d wetland or a salt marsh
12. System will fail unless the Board of He th (and Public Water Supplier,"if any)determines that the
system is functioning`in a manner that pr tects,the public health,safety and environment:
_ The system has a septic tank d soil absorption system (SAS)and the SAS is within 100'feet of a
surface water,supply or tributary a surface water supply.
_ The system'has a septic and SAS and the SAS is.within a Zone I of a public,water supply.
The system has a se is tank and SAS and the SAS is within 50 feet of"a private water supply well.
_`The system has septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply ell**. Metiaod used to determine distance
**This system p ses if the well water analysis,performed at a DEP certified laboratory, for coliform'
bacteria and v atile organic compounds indicates that the well is free from pollution from that facility and
41 t Y the presence f,ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided,that no other
failure trite ia`are triggered:A.copy of theform.-
analysis must be attached to this
3. Ot er: f
" Page 4 of 11 ,
OFFICIAL INSPECTION FOR —NOT FOR V M dL TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM Il11SPE,CTION-FORM
PART A
_ CERTIFICATION(continuedj
Property Address: i0 D InAi 1 rui 1
C d vn ato-A ui
Owner: a a_ -S
Date of inspection: S D
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for=all inspections:
,
Yes- No
_ X Backup of sewage into facility or`system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static-liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
-Liquid depth in cesspool is less than 6"below invert or available volume is less than'/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
w •j Any portion of the"SAS, cesspool or privy is below high ground water elevation.
e Any portion of cesspool or privy'is within 100 feet of a surface water supply or•tributary to a surface
'water supply,., ,
-a 'Any portion of a cesspool or privy is within a Zone 1 of a public well. „
Any,portion of a cesspool or privy is within 50 feet of a private water supply well.
-Any portion of a cesspool or 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-ore of the above failure criteria exist as
'described in 310 CMR 15.303,therefore the system fails-the system owner should coirtact 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 e'a facility with a design flow of 14,000 gpd to 15,000
gpd t
You must indicate either"yes"or"no"to a of the following:
(The following criteria apply to large s ems in addition to the critzmi above)-
yes no ,
the'system is.with' 00 feet of a surface drinking water supply
_ the'system is ithin 200 feet of a tributary to a surface drinking water supply
R. ,. .--
_ — the syst is located•iti a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone of a public water supply well
If you have swered"yes"to any question in Section E the system is considered a significant threat,or answered'
"yes" in S tion D-above the large system has failed: The owner or operator of any large system considered a
" . r signific threat under Section E.or failed under Section D shall upgrade the system in accordance with.310 CMR
15.304, e system owner should contact the appropriate regional office of the Department.
_ . 4
Page 5 of I I . ..
OFFICIAL INSPECTION FORM NOT FOR
VOLU . TARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
T Gu w►r►�.a 4 u� _ _
Owner:
Date of Inspection: y
Check if the following have been done. You must`indicate` es"or"no as.to'each of the followin :
Yes No r {
3C _ Pumping information was provided by the owner, occupant,or$oard of Health
_ Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period �.
_ .Have lame volumes of water been introduced to the system recently or as art of this inspection ?
e
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility'or dwelling inspected for signs of sewage back up? r
Was the site inspected for signs of break out?
Were all system components, excludin-the SAS, located onsite?
Were the septic tank manholes uncovered, opened,and the interior:of the tank inspected fo_r the condition
of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
Was the facility owner-(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on':'
Yes no '_ r
:_k_ Existing information.f For.exampie, a plan at the Board of Health."
Determined in the field(if any of the failure criteria related toPart C is at issue approximation of distance
is unacceptable) [310 CMR.I5.302(3)(b)].��
Page 6 of 11 j
OFFICIAL INSPECTION FORM-NOT"FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYMIEM INSPECTION FORM
PART C
< SYSTEM INFORMATION
Property YAddress: " 104
a h r'k
C ` _
y nr►nn
Owner:
Dui%of Inspection: , O' _ • +.
FLOW CO
NDITIONS
RESIDENTIAL .
Number of bedrooms(design): S 'Number of bedrooms(actual): S
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd'z#of bedrooms): SSb
Number of current residents: s
Does residence have a garbage grinder(yes or no):'NO
Is laundry on a separate sewage-system(yes orno): &0 [if yes separate inspection required] '
Laundry system inspected(yes or no):NO
Seasonal use: (yes or no): ND '
Water meter readings, if available(last 2.years usage(gpd)): O p oz ' g d$ epic 4 .
Sump PAP(Yes or no): V6s i h baytwwV%*c),
Last date of 6ccupancy: CVfPG' 'P �
C O MM E R C IA L/IND U S TRIAL
Type of establishment: ,
Design
s nfl w o base don310C g MR( 15.203
gp
d
Bas
is of designflow
o seats/ er sons/s etc- .
(
P )
' Grease trap present(yes or no): F
Industrial waste holding tank pr ent(yes or no):_
Non-sanitary waste discharo to the Title S system e b s or no
Y (Y )
Water meter readings,if a ilabie:
Last date of occupancy/ se:. y
OTHER(describ r r
GENERAL INFORMATION
Pumping Records '
Source of information: L!/ �$" d )
Was system pumped as part of, a inspection(yes or no):_
If.yes;volume pumped: Qallons--How'was quantity pumped determined?
,z Reason for pumping: '.
TYPE OF SYSTEM
�C 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.Attacb:a copy of the smart operation and manuenance contract(to be '
obtained from system owner)
Tight tank 'Attach a copy of the DEP approval °
Other.(describe):',
Approximate age of 11 components,date`installed(if known)'and source of information:
yai /9y
Were sewage odors detected when arriving atthe'site.(yes or.no): AV
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
d
PART C
SYSTEM INFORMATION(continued) ..
Property Address:
y WI►NLt.�A V�
Owner: 7L>Q.S 'IrL45-6.\S
Date of Inspection: ,
BUILDING SEWER(locate on site plan) a 4
Depth below grade:
Materials of construction: X cast iron X 40 PVC other(explain):
Distance.from private water supply well or suction line:
Comments (on condition of joints,venting,evidence of leakage,'.etc.):
SEPTIC TANK: ).`(locate on.site plan)
Depth below grade:-RQ,
Material of construction:Xconcrete metal fiberglass polyethylene
other(ezplain)
If tank is metal•list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach.a copy of
certificate)
Dimensions: d'
Sludge depth:
Distance from top of sludge to bottom of outlet,tee or baffle: .
Scum thickness: ' o
Distance from top of scum to top of outlet tee or,baffle '7
Distance from bottom of scum to bottom of outlet tee or baffle:, f S��
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, etc.):
Th fk n k Laos sovv�k c,,,4 +i
a e i VCA
« a Y'. � , - .. • -
GREASE TRAP: _(locate on site plan).
Depth below grade:
Material of construction:_concrete¢ metal, erglass •polyethylene`_other
(explain): — .
Dimensions:
Scum thickness: R
Distance from top of scum to top o outlet tee or baffle:
Distance from bottom of scum ottom of outlef tee or baffle:
Date of last pumping:
Comments(on pumping commendations, inlet,and outlet tee or baflle`condition, structural integrity,-liquid levels
as related to outlet inv ,e'vidence of leakage, etc.): .;
A-
P '
age8ofli
OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contintted)
Property Address: s0 tnd,iot,vi- (nun``
v WA
Owner: 1)-2S_t��fi'r�.�
Date of Inspection: "' y ( ty�o
TIGHT or HOLDING TANK:. (tank must be purr at time 4tinsprconr(locate on site plan)
Depth below.grade:
Material of construction: . concrete in fiberglass polyethylene other(explain):
Dimensions:
Capacity: Plarmand
all s
Design Flow: lons/day
Alarm present(yes or no
4 Alarm level:: Arking order(yes or no):
Date of last pumping: .
Comments(condition o float switches,'-etc'): f
DISTRIBUTION BOX: ,x (if present.must be opened)(locate on.site plan)
Depth of liquid level above outlet invert: a WtK
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.): cc''
PUMP CHAMBER: (locate on si an).
Pumps in working order(yes o): 4
Alarms in working order s or no):'
Comments(note coed" n of pump chamber,condition of I I andappurtenances,etc.): +
Page 9 of 11 ,. w
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)'
nQ r'
Property Address:• SD fn Ii av- Tra,;t'
- J 1M iAnoLA Vl l .4
Owner Leif iK 0 -A5
Date of Inspection: !( 11 d D a
SOIL ABSORPTION SYSTEM,(SAS): K _ (locate on site plan,excavation not required)
M
f SAS not located exp
lain•wh _ •
P Y�
i i 3
Type ..
leaching pits,number:
Ie ac- hin chambers',number:'
g c
leachinggalleries,number':`
g .-
leaching trenches, number, length:
X leaching fields,number,'dimensions: of yC SS" X ./
overflow cesspool;number: s
_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.): l 4
74: .a+*k,ers ^ Z`+� \ L '�t�E lU1 56W Rek •YLo t4:% xr%x- O r'
CESSPOOLS: (cesspool must be'pumped as of inspection)(locate on site plan) -
Number`and configuration:' `
Depth-top of liquid to inlet invert:
Depth of solids layer: t
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: `• " .
Indication of groundwater' flow(yes or no):
Comments(note conditi of soil;signs of hydraulic failure, level of ponding,condition of vegetation,etc.):`
PRIVY: (Iocate4on site pl
Materials of construction: .
Dimensions:
Depth of solids: . r
Comments(note cond• ton of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9'
Page 10 of 11`
OFFICIAL INSPECTION FORM-NOT FO R-MLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPE MON FORM
PART-C
w. SYSTEM INFORMATION'(pontinued)
Property Address:
-
Owner:
Date o,`Inspection: -
SKETCH OF SEWAGE DISPOSAIL 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•ehters the.building.
f
4
r.
• s
E
p'
4
. 6-
Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: a vim' -eer��1
Owner: -�)e4yy% .t"O.�S
Date of Inspection:- Ll 1 03. ,
SITE EXAM .
Slope -
Surface water
f
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan ieview•ed:
X Observed site(abutting prcperty/observation hole within 150'feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers- attach doc( umentatioh)- �
Accessed US -GS database explain: _
You must describe how you established the high gr and water elevation:
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AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
N' ` r SEWAGE #Li ATIO Qu
VILLAGE C m rx ua ASSESSOR'S MAP'&LOT-�39 �Q
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I SUO 9 a f -
LEACHING FACILITY: (type} 1 7f C�� (size) a 4KI( 11-5
NO.OF BEDROOMS
BUILDER OR OWNER /
PERMIT DATE: DATE: f/,fl 0 a
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 Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=336016&seq=1 3/13/2014
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Department or,Regulatory Services
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Public IIealLli< I)ivisiou .
RNareeLL i I.' .: 1
"MAIM, $ 100 Main Stteet llyannis MA 0?G01
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!Time
Date Scliedulcd
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,�oil ►�uitd bi�lify Ass�essipe� ` � �,�
Witnessed Ily:
performed By: i
LOCATION & GENERAL INTOINZMATION
P
ame
Location Address t� ! a D
_ �v , s _
A / ( i! Addres
!i Gil ineer's Name ST
Assessor's Map/parcel:
1 ' SDI` iJ�doZ- l 7 •�•
REPAIR Telephone# ,
NLW CONSMIiill-,rION r ! Y
Slopes M.
�Surfsce Stones {
Land Use St , - (If
assiblc Wet Areaft Dunking Water
a r
Distances from: Open Water Ea1y j ft
7 ft _other -
Urainagc Way ft property Line —
I
j z
' ere t Its,locale wetlands in proms itY tO holes)
SI TCII:(Street name,dime Ansions of lot,exact locations of test 6olcs&V p
�
Lq
I (S •po eo J '�
L
' '2sW466
t i gtl.,G
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/ Gf PREPARED UNDER.THE DIREC "THE
aeS'j9� y BARNSTABLE BOARD SSESSORS�
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parent material(gedlogic) _ �l.� �I + �3
I Weeping from pit race
Water in I101e
a dr. Standing
' Depth to Grouudw � - I
Estimated Seasonal;Itigh Groundwater {' 1 t
c ION TOR SEASONAL'IIIGH WATER'T"LJ�
D •CI;RMINIT In.
Method Used: C� -ice Vice.'14 �3 t(4 �_in. Depth to Sall mottles
t7enth Obaervcd standing in obs.6olc _in D;)undW !er Adjustment liv�untlwnter Level - _
Dcpth tolweeping from sn(c of obs uv, At
Lute%Well level..,1,.._......--�. K
Index Well tl Reading Datc: � ! /.!
TI'SrI' Dille 'tlnt�_li r x '.
PLRCOLA'1'1UN > 1si C
t !M C. t
Time at
Obscrvalion
Hole# ,.t', eat 6"
Depth of Perc r 7S 0 J. a g„-b,,)
Start Pre-soak
Endrrc-soak
Rate Min./brch �"—'J , lr Additional Ibsting Needed(YIN)
' Silc Failed; ` 1
Site Suitability AsscasmcnC, Site Passed 1 to .o J3e Completed on Back
bservatioti Hole Da
Original: Public He�1Ut Divisiio f/Q y a�v rt- �.p "an S,,t'
0u must first 110tify the
**If oeicola0l, test is to be couclucted within werk prior to�begin�ug•'
13arustable Cdt)scrvatioit Division at least oOtte (1).)
0 3
--— 'DEEP OBSERVA` ION HOLE' LOG Hole# _
Depth from Soil Horizon Soil Texture Soil Cola Soil I Other
't1 A) I'Auitiiug (StrucJture.Stones,Boulders.
(: St (e, O('dYGI)
C S,•��- s. d C bb F s
DEEP OBSERVATION IIOLE LOG Hole#
Depth from Soil Ilorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
consistency.%Gra e
36 .I-T
90-L3! LZ
CSri r
!3
;DEEP OBSERVATION IIOLT LOG Hole#
Depth front; Soil Horizon. Soil Texture Soil Color Soil Other
Surface(in.)
F (USDA) (Munsell) Mottling "(Structure,Stones,Boulders.
Co si51 licy, Ora
,-/
1 '
_ t
Ffi-
BSERVATION HOLE LOG hole#
Horizon Soil Texture Soil L'olor 5a11 4—otlmr
(USDA) (Munsell) Mottling (Structure.Stones,Boulders.
o s' n 41L-
L r /I
`
Flood Insuranje Rate Man:
Above Spo year flood boundary No Yes
Within 100 year boundary No K Yes
-c
Within 100 year flood boundary NoJ—< Yes
De th of Natuttali Oceurrhi •Pervlmis Material
Does at least fo rNfeet of naturally occurring pervidoru's matzo �e �it /are�J �iervUd���o out then
area proposed f r the soil absorptTton system? ry. �b(Lj -- C�*t
If not,what is the depth of naturally occurring pervious material?
Certifleation
I certify that on. �1 2' (date)I havelp ti el ulbove�analysise soil lor exitminaflon was performed by aliproved
consistent will,
Department of Vnvi onmental Protection and t
the required-t ing,.expertis a experience described in MO CMR 15.017.
Date 3 _
Signature
QaSeFnC%PBRCI-ORM.DOC.
+� DEEP OBSERVATION HOLE LOG hole IF
Depth frog" Solt Horizon Sail Texture Soil Color Soil Other
. ;, (i:a,tsclij ;vioitiiug (Structure,Stones,Houlders.
Surlacc(ho.) ( ('
/f) nsistenc irav I
2-� z
DEEP OBSERVATION HOLE LOG., hole
Depth from Soil Horizon Soil Texture Soil Color Soil # Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consiste is a e
30 -Iota C
a,q /KL -
;DEEP OBSERVATION HOLE LOG Hole#
Depth fronr Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
6i.is c y. Orave
;DEEP OBSERVATION HOLE LOG hole# —'
Depth from Soil Horizon Soil Texture Soil Color Soil
he'
Surface(ill.) (USDA) (Munsell) M9111ing ctuCe,Stones,Boulders.
ons' ten
-------------
Flood IllSilranLe Rate Man:
Above 5po ycar flood boundary No Yes ;
Within 100 year'boundary No x Yes,._
s _,
...,.:.,..,- • _----- -- - Yes.. .....
Within t00 Year flood boundary No�
,
r
� 3 3
- TOWN OF BARNSTABLE
Lc notN ' Jl7 ]Aa r c�yx Trroct\ SEWAGE #
y V-A moL_Gr ut& ASSESSOR'S MAP & LOT-)
"INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1,:!rVO 9 a
LEACHING FACILITY: (type) /'i (size)
NO. OF BEDROOMS S a
BUILDER OR OWNER /
PERMITDATE: C'6 fehWE DATE: olllr o.-a
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
4
a�: S.r
35.;
-, '�
-,
_ r a�.
E.. � � j
,a a
TOWN OF BARNSTABLE
LOCATIJ6& 50 ,IN`b1AN TRAIL SEWAGE # . 1)
VI'`IAGE C UMMAQU I D ASSESSOR'S MAP & LOTe7, , &
INSTALLER'S NAME & PHONE NO.FI I TS RRnTHFRC CnNST ran 162-6 3I
SEPTIC TANK CAPACITY 1,5'00
LEACHING' FACILITY:(type) (size)
NO. OF' BEDROOMS PRIVATE WELL OR PUBLIC WATER Ajtr Lic..,
BUILDER O OWNER 1, SMr4i2 }S
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: f`�
VARIANCE GRANTED:'-Yes No �/'
- r
-o
3iU r
i
No.._ .._. Fas..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
9 SOWN OF BARNSTABLE
ppliratinn for Diripwml Onr1w Tnntrnrtinn frrufit
Application is hereby made for a Permit to Construct ( ) or Rcpair '(' an Individual Sewage Disposal .�
System
....... 7.. ................ � �. d G ..----••---•--•-----. -----•--- . ------•. ---- .....
Location Ad ress or Lot
................ ....�5
tot%+-ner Address '
Installer , Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms-----------------------------_---.---.._..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ..............................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............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 ( ) t, Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit--.................. Depth to ground water........................
LXo Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.................................................•------•-•---•---•--•---------•---.........................................................................
0 Description of Soil..............................................................•-•-----••-•--•...........---•••-----•-••-...-----•-----...--•--•----•----••-••-••-••-•-•..........._....
x
...............•--------•-•---------..................----------------------------------------------•---------------------------------------------------•---------------------------........------......
x -.... ;
U Nature of Repairs or Alterations—Answer when applicable.-- `?�T �
••---•--•.....•----------------•---•-----•---•--•-•-•----•-•-----------•-------••---.....--•-••••-••-.....-••-•-•--------•--....•----- ----••• .......
The undersigned agrees to install the aforedescribed d' idual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental o —The undersi ned further agrees not,to place the
system in operation until a Certificate of Compliance s en issued by th o f health..
� .
Signed .. .. ......... . -------- - ... ..... ................. ............. ..............................
Dare
Application Approved By I_ ....... ... .....
Application Disapproved for the following r ons: ................................................................................................................Date.................
........................................................ ............_................._................................................................-........._........................................ ........................................
Permit No. . ........® .��
Issued
-.....................Dare...-..................................
.•.�,....•-»....�...a.crv-....••+..vy...�;r•..•....-....—....-�-.'+^"y,r.�v--r-..+-ti ��.. ,. �:v.:`._ -�....• `my�.. ��. r,; .d- ✓v �..�.... ,;.r:. ..-._ -� .. .... ,,,,.. ., .. _. _ -....
at
Z1 (JOO
Nr . . Fps....: ............ ....
' THE COMMONWEALTH OF MASSACHUSETTS J
BOARD OF HEALTH
r �/ /TOWN OF BARNSTABLE
i
Apphratiun fur Diripwial Works Tomitrnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (V�an Individual Sewage Disposal
System at• _
Location-Address or L o o
----------- ---
,✓- Address /�
------•--..... --- ........../1!✓ " �r� ..........................'' ' Q�:
a .
Installer ✓ Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.-............
�1 ........................-------
Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures ------------------1...................................................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity-__.-__--.-gallons' a 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.........................................
14
Test Pit No. I................mtnutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 /I -----------------------------------•--•------------------.....----------..._.....-•----------................................................................
0 Description of Soil........................................................................................................................................................................
W ••••• •------------------- .................................--------••-- ._.......... .-......._.....:...
x Nature of Repairs or Alterations—Answer when a �licalile... .. � �� 4�1 � f��'1!
U P fit. f. PP, •
............................................................-•----•a••••........................
Agreement: '
The undersigned agrees to install the aforedescribe�Wod/—
iidifiidual Sewage Disposal System in accordance with
theprovisions of TITLE of the State Environmental The undersi ned further a r n
5ees of to lace the
Pg g P
system in operation until a Certificate of Compliance h� n issued by th ,oa- d- f health.
Y P
Signed ..;�. .:...... `..�1 - ` ' `-
�/ �. ........Dare
Application Approved BY --�''' °- r:, .. -:................................ _e-...... .......
Application Disapproved for the following re'aZns- ------------------`------------....................:............................................
........................
�y�/ ///J�} -- ..... .....
Dace
Permit No. ....�.......1............ _. _ Issued .............�....
• Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Cgompliance
THIS` IS 0 CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
b ---........ =.: ��- '. .�n� .s.....,-------.....-------
y _ ..> - hs�Irr - _...................................................................................................
at .. a ...C%...._ L t - t?--ri ... /t�l3 Vic,• (�.., U ....{ .. . .................. ......._........ _...... ......
has been installed in accordance with the provisions of TITLE�5�o�f/Xb,e State Environmental Code as described in
the application for Disposal Works Construction Permit No. _...�1... '.. � ..... _- dated .......... _...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... ........ - ....... ._................... InspectC-r ..� �'' ......:.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"
(V)
TOWN OF BARNSTABLE
No.q. FEE......`-.._--��J J
Rspviial �nvrk� 1Tomitrnrttion rrmit
Permission is hereby granted_- -t��;-R/�'�------� ----------------------------•-•-----•----------•...-----......--.......
to Construct ( ) or Repair (�i/�an Inclipidual Sev�a ge Disposal System
at No.......... �� _2•... o�'_'�1�l �l y� a/ .._. �a jJ]���p�� /-�- %I
�.� rev .-_'_�.,.t ✓ , L -•
Street / ��,/i-/
as shown on the application for Disposal Works Construction �Pe mr it No...-_-`--t_i-._....___,_. Daytejd..-.a..................... ..+�...
J Board of Health
DATE...............
1 T. %
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
APIPILICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION JfJOIAN T►ZA)L NO. oOg3
VILLAGE Curyn/(1 AQU Its _ DATE 7-ZI- 13
,APPLICANT CHAIZUES Da✓5MAZIA5. FEE.. I60•.00 .
ADDRESS 50 T NbIAYv T►2q 1>✓ TELEPHONE. NO. R1-2,U 8 . (Non-refundable
ENGINEER DEM' A ZEf-- M OI.Et-L 4o -j ENGIt✓E£TZ116 _TELEP ONE NO. ?Q13, 71 10
DATE SCHEDULED -ZL-g'�
A lica t1s signature
ASSES�OR'S�b�� ' dt LOOT NO. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . n,. . . e • • . . . . . • .
MAQ 336
LoT 46 SOIL LOG -
SUB-DIVISION NAME DATE_ 7"ZI -12 _ TIME II: 30
EXPANSION AREA: YES NO -THomAS MCC.EuLAry ENGINEER N .
TOWN WATER "PRIVATE WELL Jen2,4 I)umv►nr(r-- BOARD OF HEALTH
ToP-t DacSmon,b EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes )
NOTES: 3FE StrE PLALv
P-X1SPNG bM q3-ob0/7-2�} q3.
O
J °
L11 N ,
TH-
. r11-,
+DM-3 N
THOMAU cyG
I&LELLAN m
o CIVIL y
No.36471 p L
PERCOLATION RATE: Z m►N l^�
TEST HOLE NO: I ELEVATION: TEST HOLE NO: Z ELEVATION: 3
2 l-oflM G" i LeAM LDAM
H
2 1 (-LAY Z¢'' 7t(,I{(' KtNE-MI;r7 2 T,v�-r 010 Mrn *,6,ffT F8a6-
3 SI UN 5.4-D 3 51L Y'1 SAN#o z AMD SlcyY
"
4 . F,N&- 36 4 gg 3o"
' �'V A Flnl���.
5 SA t4v cou �fua 5
6 6 SA NO,T-FA tf5 -
,c��-mflb 7 .F t.¢..,avec- 6
� SAND i
• 8 � w
9 S/ewb g T"tbH-f Flt�E
108^ � -
10 pu,*-a,eg - 10 (06" s l L'jy SAwp 4 _'
FINE
11 SIt7ANn 11 i2 OAoWmeD-
`f 60A¢Se SAw4
12 Kal Flare 12 MED, .Pa SILT
13 $X 1SAW,) 13 COAQJE
14o 14 SAwo j
15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: _ LEACHING FIELD jC LEACHING PIT5 � .
LEACHING TRENCHES
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEEtRING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF HEALTH
COrlY-, Pf"T71TP1('Tl nV APPT.Ir AtTIr
55 E550V_5 M AP: 3
GAPS. COP f3A
pA;°Ui i TES D 1 a
Nor E s T H L �5 � Cue-�To ��«� p��o�� � �
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-t 'a T'I<,AL r>AtuM Q o
wINC7 5eT 1TNESS JA Y Jtv�-lmiu+!-r- ----,
2•` MUN!c l PAIL WAT ETZ 15 AYA1 LABt
F,
N b,b;TE 3. 5 CH ELwt_•E 40 `- 4" PVC PI TpE: To Bar USED
P E lZr- RATE ; T to U Z MIN i N H a�.H -OUT SEPTIC- S`( 5T�N(.
� L��� �L-mt7 �OLI�•• ..
I q-• ALL- PM(::AST (jNtI7s To :COW-F07-.M W ITH
AfASHT 4-10
T•H- TH' 2 Tip-- 3 o LoAV I►.I Cam- Sfir~c I� !CAT l a�.i S
s F1 PEPITc. + - f • r- 07 UK sZy 30.a
ca LoaM Lev LOAL,t LoA� EL OTHE1zl-.11SE> (�IOTE.D.
go.3.
-Mtn T16rHT 6, FIF-ST Z' OF- PIPE OAT OP D- EOX TO BE L�-vcL,
24" GL- Y Z7.7 4g Stt,�r sas�r Lc..$ r-lk�E-NlEn 7. THE sEPT I C- `SYSTG" AS H01 13&Z., , bESI Gf�IEl�
LOCAT'(oti4 MAP TLUH�-
Fiit�- 3o SLATY sAN 28:`I To Acc.oM M0r>AlE Tt-i USE c�F fl Ga2gA�E GjZIUt*-
L►�� -
5 Y, Metz 4$" SA D zG 6 8, ALL_ CAN ST2Uc-T 1OtJ i�TAJ L_S AZIE To Ze I ki
M� Ft t GO►J F o 2M A taC E WITH "T}f ty ST/LTE Dl= MASS .
FINE- bR�4%Ei✓ q6u SAND zz.G Et�lVfPDtJMEiJTNL GORE '�TtTt�. v, ,
M� g`� St�T z3.o q CptJTrz�tCTo>z- To v'�IF.Y Loc.".TlO-l5 of ALL�Ii-tE SANo ;
TIUH
nG NT Ftt SitT 102° T cc dF izz.l L/TI L-1 TtE5 �fZ,I om -re) eoN5rrwcTLo#-4
VEey FiliE Hzv Al IA6" 5AND ZZ.o
-MEP 6L.Z6,7 a�17 IQ. ALL U4501TASLZ 501L Tv BE MHoVV_:n AWD E_EPt_AC_C0 WLTl+
8" SILT SdY I t.l , .5Aali_ 2 t1.1
. tif:La-Gaerzf GL-EAnt MAD SANp ►�it71k1►-I 10 C1F L�AC.fi �tE.i.D. ApPEax,MATE
yob 5tL IZ1+ Zo•5 ►20" SAND Zb.G, DEPT-4S Or- Et✓VI' IVal. AC AS �-Ok-L..ot�LS - t3Y TEST ROLE:.*1
I32" S,n 18 7 Pt-_06YAL JI*Pr = 36 MY TEST HOLC a Z, P-E'VIoVAL D_P`Th+= +16"
L� VGVY FIkK
E).f TEST H4 E " 3 "RE_MOVNL DE=rrf+x 3o".
51L_1YU140 WATE2 ELEVNTtoty IN QBSER.VATtcW WFL.r_
Yr
180" 'Ir--aY� 14:7 oN 7-z7-°I3 ZI.OS. (Sara wore IZ) 11, ALL tr157RIBvTLaN Boxa_,,5 (+) AVE To se J,4ATEV. TESTE-D
cF ti�TLN Ti) E445ulLti AND E'AVAL- FL.o►l, ALL
f� oP Pit;T-LAND " �EPTIG. SYSTEt�'1 �ESI�sN p-.t3Ox 5 Ta l 5eT OW �" of
-- -'� 12- THE OSSEEvep G vlovWC)WATEC_ APPFlLeS TO Bt PE.PG4eD
t3�f' FWH WETLAwV F'-LOki ESTIMATE '
BA5E.L7 uP4ti1 THE f"OLLO4JIt`!!s DATA
' Tv L4 1►A_H F►EL-D, 5 E,4 DtzLbF-lf',- AT 110 GAL/rAY/BV__ GAL/DAY
! A. f�U� �L.�-VitTl4�t oN aPPOsiT+✓ SIvV- of INDIAN
1 C12 3' To SC.PT,G TAµK)
5E PTI C. TAN K 7P_A IL 15 L 55 THAN i;LEVATrD1�c I c.o'
�5o GAL�DAY x 1.5 r)^Y`5 = 8Z5 L, L• S. JvLrY Ig93 Lt vVIEL IFj
USE 1500 GALt�N ,iEr" TIc_ -TA14K US6- WELL_ tAILI-7.4-7 44A5 F_J_r_ aTio,.t ZI 0Z
krSrr Tr=N^,,5 BENu+MAFx AT Pk NAIL LEAGHl1QG ^R_EA THE 5OUTN n-THe L�� Tr+�Fc k T"HG"
. Gewuo-
._---GaVQT F_ v= z9.z V5e ONE LEACH TIC Z-t x 35
WAree EL�1rArtop AT LOGLS 'SHOL)LV FF C.otlStt�r�9t�?
�. 3O ��4a-'t�KTAti�t�: �PfEc.'1"It�� SIDE 25'X 3�'
L-55 TWA�4 3t \ ` 1 SIDE ACf�_A, 1 NA \\ iJf� GAL DAY z9 1✓X,SjI�IG+ ono G,AL S�fttc (�Nst J G. THE SnLs o� T•I,FE_ JM-4"DIAT'c 'AEA AR-E k►sa \Jt-L
To B� PUMPA.D AND FILL_Et, WITH SAND 130TTOM AF-EA. Z7' x 3';= gCaSF (o.7j) = �o7rj C?ALl1A� 1-0 Got,LSIST oP CL4Y AS RouF- D 1r4 T"t+-1 _
';; \\`�•'.-, \r�^��:-. AP?2nxsHATE- L04AT,ot-t of TOTAL. cAPA+GIT-t- C'aAL_/DAY 1?,AS�p UPoy� THE At3ovE INFvrcMAno►y, I1 t�lovL a
E1cESTE►Jc LEACH FEELD AP A2 TI+/0.? rNt VSGs 6 _0u DWATE,z Ac jvsrMeNT,
A" ra. � /^ TO 5e ABAWJ>_lMEo CAS "OT APPLY.
N
N -lPp�X � G T L
� `'ors � Fl�sr J�PT 1 Cr. �JYS E EG O
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pP'OvTLET PIPE_ 3o.`F INLET Co' UP/ 10.1 GYol� t j (5a r PIPtLJCT MTfaI� THtS SFi�T)
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10' P-EMoVNL of u",suiTAgL <r�t,* hf3S YEt7 GPrusJDW.AT£2
SDiI SEE lleTE IO• EL-FYATLpt4 = Z t,C3
,
ZL5 FPdM L�1t'L 1 iELD Z,
10 I T� �E_ ,j AG F p L A r_4
x
W E'T LAW I�
!'CEY L,,OGATION
!<.X I.STI Plr„�•- CO►.iTOvEL` �-�--_._� SO rNa�1 At`.f Ti?AI l_..
PP•.-olx�s�t7 �uT-ovtL" c.t�MMAQvLD MA-
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PcPr05ern SPOT Y• 30 1 ( PIZEPAI'EL7 nor`:
GHh�Les pis Mne.��s . .
li �1 1 •, SCALE 1"-9a` DATE 7-2A--q
-, = �EFE2Et.(G E F'f3 18I P'15
1 �: -
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of
<, Lt%./1cN Fta��-•U P1�'t�- �.�C.TtoN �fl,, ta'�
0
T♦-fOMaIS J. MGLELLAW I'.'E. JOHN 7.bE►rARF15T, JiZ,PLS PEMARESTMGLELLAN ENCiINEERIN6
r<.x -