HomeMy WebLinkAbout0072 KEVENEY LANE - Health 72 Keveney Lane
Barnstable
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No. �� .�`� Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppYication jor Yell C u5tructiou Permit
Application is hereby made for a permit to Construct ,, Alter( ), or Repair( an individual well at:
K)e &A 5*• ���� - c-z S
Location-Address Assessors Map and Parcel
�iC V_ l�YVrLl_I
Owner Address
-Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well Capacity
Purpose of Well
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Pro ction Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of om lia ce be ssulbly the Board of Health.
Signed'
Date
Application Approved B 1 f b
Date
Application Disapproved for the following reasons:
Date
Permit No.j„)DG"►'Z— Issued
Date
--------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of �COM auce
THIS IS TO CERTIFY,that the individual well Constructe , Altered( ), or Repaired( )
by CA V-) V�Le V � �t i�n c
Installer
at
has been installed in accordance with the pro i—o s of the Town of Barnstable Board of Health Private Wel Pro ec ' n
Regulation as described in the application for Well Construction Permit No.V`�I).()D,� Dated G (V
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
No. Wv@9 17 Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
0(ppYication _for Yell Cow6tructiou Permit
Application is hereby made for a permit to Construct'(,e, Alter( ), or Repair( an individual well at:
Location-Address Assessors Map and Parcel
--
kC-llV, 1 \c1ty%r�1
l Owner ` t ` Address
Instal er-Driller Address
Type of Building V \
Dwelling
Other-Type of Building No. of Persons
Type of Well Capacity
Purpose of Well \10 r MA- C- N
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well ProtectionRegulation-The undersigned further agrees not to place the
well in operation until a Certificate of compliance s be i/issued/by the Board of Health.
Signed..® /
lei
r Date
Application Approved B / b
Date
Application Disapproved for the following reasons:
Date
Permit No. J�,)a41n ��o 'c� Issued 2s )6 1-7
Date
mm moeeeedeeemmomoemmo°omvo-o--_vo---m---emmoemevo-vova-ovo-Qemmama000eoeve-----000-eo-e----ems
BOARD OF HEALTH
cr��Q� yor., TOWN OF BARNSTABLE
Certificate of Com iartce
THIS IS TO CERTIFY,that the individual well ConstructedL( , Altered( ), or Repaired( )
by Qlcopo
e Installers
at QUQY���.l S�,(z p�
has been installed in accordance with the pro isions of the Town of Barnstable Board of Health Private Welt Protection
Regulation as described in the application for Well Construction Permit No.�'c I-) Oaa Dated (0 ~
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE
V
11 ll Yell Cotv5truction permcit
No. —d v1-a- Fee "
Permission is hereby granted to
Installer
to Construct( Alter( ), or Repair O an individual well at:
No.
V Street
as shown on.the applicati n for a Well Construction Permit No. c I ] Dated
b 6
Date �� � Approved By ��.�
DEMO W
XISTING VVALI
... NEW
WALLS
3 .
-75
Rj E --
! WOOD MASTE—
FI_p 05 Project N Icy p
I
-i
,. „ WOOD 72 K6weni
L.an
, p r I F3arrist bl-
Drawing TotJe:
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TER
L_ A 3 3 TILE '( �_` I Scale:
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wi
µ r`R ,�, ,I_ 'I / U f � eked by A
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LOORIN
MEDIA ROOM
I
E.T.R.
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----_
Commonwealth of Massachusetts
Title 5 Official Inspection, Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
/
on the computer, f/I
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
r� Company Name
P.O. Box 896
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-7608 SI 3742
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
s
U- c,,. ®-,Passes ❑ Conditionally Passes ❑'Fails
❑w.Needs Further Evaluation.by the Local Approving Authority }
11/05/10
Inspector's Signature Date
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.
****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.
VV
Commonwealth of Massachusetts
BMW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane '>
Property Address
Sanjay Palit
Owner Owner's Name
information is required for every Cummaguid MA 02637 11/04/10
page. City(rown State Zip Code Date of Inspection 5
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or /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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N °-❑ ND (Explain below):
❑ distribution box is leveled or replaced . ❑ Y ❑ N ❑ ND(Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y. ❑ N ❑ ND (Explain below):
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
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 within 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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 '/day flow
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/16
required for every q
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.,
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead.Protection
Area—IWPA)or a mapped Zone II of a public water supply well:
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z 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?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
z Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q ,
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2 '
Does residence have a garbage grinder? : ❑ Yes ® 'No.
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes 2 No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail: -
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow,Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(9Pd)
Basis.of design flow(seats/persons/sq.ft., etc.):
Grease trap present? - ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
f
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is CUmma uid MA 02631 11/04/10
required for every q
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont:)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:`
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool,
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. City/Town State . ' Zip Code. Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
06/15/94 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.3
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line:. feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 0.5
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
311
Sludge depth:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is required for every Cummaquid MA. 02637 11/04/10
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle 6"
Distance from bottom of scum to bottom of outlet tee or baffle
1511
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank 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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert even '
Comments(note if box is level and distribution to outlets equal, any evidence'of solids carryover, any
evidence of leakage into or out of box, etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching,chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 @12'x44'
❑ overflow cesspool number:
innovative/alternative system
Type/name of technology-
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
This system has a 12'x44'stone field. There was no sign of ponding or failure in the stones.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration ,
Depth—top of liquid to inlet invert
Depth of solids layer . .
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 official Inspection Forma
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address -
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every G
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is required for every Cummaquid MA 02637 11/04/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
f. .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
5. Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every 4
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date_of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health explain:
❑ Checked with local excavators, installers'-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Keveney Lane
Property Address
Sanjay Palit
Owner Owner's Name
information is Cumma uid MA 02637 11/04/10
required for every q
page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
9
_ _ ONLT OF ASSACH i `R`
aS,� IS
EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
' DEPARTMENT OF ENVIRONMENTAL, PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION cm
Property Address C 59 C � �'
._SLSM YytQ�t r
Owner's Name:
Owner's Address: e LIZ cn �
Bate of Inspection: t �
Name of Inspector: leas print)
Company Name: a
Mailing Address:_ O_o ttnep-'GTC &c
•Pn11 �- *
l/
Telephone Number:
CERTIFICATION STATEMENT
i certify that I have personalty 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 fuoction 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
Needs Further Evaluation by the Local Approving Authority
_ r Fails
Inspector's Signature: Date:
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 systFem 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?Ilow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/152000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEW, AGE IjMSPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: VP n f-
Owner: t
I— __ vv�n✓yl Q�
Date of Inspection: (t (O5'
Inspection Summary: Check A,B,C,D or E/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"s n need to be replaced or
repaired.The system,upon completionof the replacement or repair,as approv y the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the f wing statements.If"not determined"please
explain.
The septic tank is metal and over;20 years old* the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltratio;i or exfi2 n or tank failure is imminent System will pass inspection if the
existing tank is replaced with a complying s `as approved by the Board of Health.
*A metal septic tank will pass inspection if' is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 ` old is available.
ND explain:
Observation of sewage ckup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to ken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Heal
broken pipe(s)amm*h red
4
obs�is.removed
distribution box is leveled or replaced
ND explain:
system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass' on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of l i
OFFICIAI.IN �SPE 1QN FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWkGE IDISPOSAI.SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fufther evaluation by the Board of Health in order to det ine 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 0 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public heal
safety and the environment:
— Cesspool or privy is within 5U feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetate etland or a salt marsh
3. System will fail unless the Board'of Health d Public Water Supplier,if any determines that the
system is functioning in a manner that protec the public health,safety and environment:
_ The system has a septic tank and s ' absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary tot a ce water supply.
____ The system has a septic d SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
i
_ The system has a s tc tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply w ".Method used to determine distance
"This system pass if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volat'a organic compounds indicates that the well is free from pollution from that facility and
the p7cnriteri
onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failuggered.A copy of the analysis must be attached to this form.
3. Othe
i
i
3
Page4ofll
OMCIAL INSPECTION FORM—NGTEGR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE UFO;SWTEM INSPECTION FORM P
PART-A
CERTMCATION{continued}
Property Address: ]Z e v�
JN i'
Owner:
Date of Inspection: t ""
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
g Static liquid level in the digtribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
0( liquid depth in cesspool is Iess than 6"below invert or available volume is less than%day flow
g 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 1 of a public well.
_ Any portion of a cesspool of 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.IThis system passes if the well water.analysis,
performed at a DEP certified taboratory,for cpfform 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
tt are triggered.A copy of the analysis must be attached to this form.)
N(3 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CNIR 15303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a f ' ty with a design flow of 10,000 gpd to 15,000
gpd- r
You must indicate either"yes"or"no"to each of owing:
(The following criteria apply to large systems in. dition to the criteria above)
yes no
— _ the system is within 400 fee f a surface drinking water supply
the system is within 2 feet of a tributary to a surface drinking water supply
the system is loca d in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a pu c water supply well
If you have answered es"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D ve the large system has failed.The owner or operator of any large system considered a.
significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CNM
15.304.The sy em owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (4
Owner. t!
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
No
Pumping information was provided by the owner,occupant,or Board of Health
_ Were any of the system components pumped out in the previous two weeks?
— Has the system received normal flows in the previous two week period?
R Have large volumes of water been introduced to the system recently or as part of this inspection?
— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
i Were all system components,excluding the SAS,located on site?
-�- _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
i
m1_ Was the facility owner(and occupants if different from owner)provided with information on the proper
a tenance of subsurface sewage disposal systems?
The size and location of the$oil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information.For example,a plan at the Board of Health.
Ot Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)P 10 CUR 15.302(3)(b)]
5
page 6 of I 1
OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: v p {
Owner: _
Date of Inspection: 6!It/ OS"-
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: eZ
Does residence have a garbage grinder(yes or no): tJ*
Is laundry on a separate sewage system;(yes or no):�j[if yes separate inspection required]
Laundry system inspected(yes or no): �00
Seasonal use:(yes or no):
Water meter readings,if available(last i 2 years usage(gpd)):
Sump pump(yes or no): do (�'
Last date of occupancy: Urf6V9
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): opd
Basis of design flow(seats/persons/s c.):
Grease trap present(yes or no):
Industrial waste holding tank sent(yes or no):
Non-sanitary waste disch ed to the Title 5 system(yes or no):_
Water meter readings," available:
East date of occup y/use:
OTHER(de ribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): #10
If yes,volume pumped:_gallons=How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
-1(.-Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
—ivy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate a of all components,date installed
� p e (it known)and source of mformation:
- Rog
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL,INSPECTION!FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUR_#ACE SEW OE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ) 4VCKe _
J w►wuu.C�sL
Owner: ,l
Date of Inspection: tk
BUILDING SEWER(locate on site plan) .
Depth below grade:Al K
Materials of construction _cast iron P(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: 0( (locate on site plan}
Depth below grader
Material of construction:jeconcrete 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: l000 qec
Sludge depth: �-
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: a"L"
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate to outlet invert,evidence of leakage,etc.):,
G.5
vi
GREASE TRAP:_(locate on site plan):
Depth below grade:_
Material of construction:—concrete in fiberglass_polyethylene_other
(explain): —
Dimensions:
Scum thickness:
Distance from top of sc top of outlet tie or baffle:
Distance from bottom scum to bottom of outlet tee or baffle:
Date of last pumpin
Comments(on p ping recommendations,;inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to ou t invert,evidence of leakage,etc.):
7
Page L of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Hate of Inspection:— /t�tt�0 _1
TIGHT or HOLDING TANK: (tank must be pumped at time of' tion locate on site lan
P� )( plan)
Depth below grade:
Material of construction: concrete m fiber lass
g polyethylene othe a la
r( xp m).
Dimensions:
Capacity: Ions
Design Flow: allonslday
Alarm present(yes or no):
Alarm level: arm m working order(yes or no):
Date of last pump
Comments(con ' on of alarm and float switches,etc.):
DISTRIBUTION BOX:_(Q_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:e,�Aj
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage' or out of box,etc.):
e
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):.
Alarms in working order(yes or no):
Comments(note condition of pum amber,condition of pumps and appurtenances,etc.):
I
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME!N-rs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ Fa K ve,
Owner: —
Date of Inspection: ( �-
SOIL ABSORPTION SYSTEM(SAS}: (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number._
leaching chambers,number-
leaching galleries,number:
leaching trenches,number,le ngth:
leaching fields,number,dimensions:::
overflow cesspool,number: yy'
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.):
clq` a
® r
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer.
Dimensions of cesspool:
Materials of constructio .
Indication of ground ter inflow(yes or no):
Comments(note co dition of soil,signs ofhydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note con ion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued,,
Property Address:_��✓py�
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.
7� 7
zn
Pain I I of l I
OFFICIAL INSPECTION VORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: eycvx 'La
Owner:
�—f
Date of Inspection
SITE EXAM
Slope
Surface waterfJ1
Check cellar
Shallow wells 0
Estimated depth to ground water 0 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 reviewed:
Observed site(abutting propetry/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: .
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established thehigh ground water elevation:
II
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Q N
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74
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It' d
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,:f G 4TOWN OF BARNSTABLE
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LOCAi'ION .G � ��j��'e:✓ SEWAGE #
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VILLAGE ASSESSOR'S MAP & LOT '' I
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INSTALLER'S NAME 6i PHONE NO. ME LAMPI
ble,MA I1%''
SEPTIC TANK CAPACITY. C�c���.
LEACHING FACILITY:(type) "� -�i _ (size) 1.
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER Y'ia;
BUILDER OR OWNER
DATE PERMIT ISSUED: ya
DATE COMPLIANCE ISSUED
VARIANCE GRANTED: Yesi No
F
_ 1
�o P
N M ) fr
No........................ FIER................. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
W.A.....:...............OF......... q f i ................................................
Applirafian fur Vor'kg TnnBtrurtion Famit
Application is hereby made for a -Permit to Construct or Repair (>eQan Individual Sewage Disposal
System at:
....................... 4.......................... ..........� ......... ..........................................
L'o,*ajio 'Address or Lot No.
Owner ........... .........."........ ......*........*.........Address
Installer Address
Type of Building Size Lot.......5.. ...).0....C.5 I_:.:...Sq. feet
U
Dwelling—No. of Bedrooms........... .............................Expansion Attic Garbage Grinder (0):-,
Other—Type of Building ..........1%4.A........ No. of persons............................ Showers Cafeteria
Other fixtures ..........................
Design Flow.................. ................gallons per person per day. Total daily flow........_53 ..........................gallons.
Width..t.:�.. .... DiameterA. A....... Depth....+I.:i5?"
�4 Septic Tank—Liquid capacity.I.Q0Q.gallons Length..e�
Disposal Trench—No..................... Width.................... Total Length................... Total leaching area......-....... $a. ft.
Seepage Pit No ...- -7. q. ft.
.............Z..... Diameter... I .... Depth below inlet.........j:-.d.... Total leaching area...... tf
Other Distribution box ( ) Dosing tank ( ) I-) ft.k �� pe'a—
Percolation Test Results Performed by.......................................:.................................. Date....----....:....... _•--•-.........
Test Pit No. I.............minutesperinch Depth of Test Pit...""*.......... Depth to ground water....!K................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...._...................
0 0 ......................
.................*--**'*'*'**............*....... ........... ------..............................
Descriptionof Soil........ .......... ...... an.1.....................•---......--------••----................._.............................
U .........................................................................................................................................................................................................
W
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.......................I........................................................................
........................................................................................................................................................................................................
Agreement:
. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T!Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeil,issuledby the boiird of health.
Signed:. Z�e .....
............
_Da t e
...................... .............................. ........................ ............
Application Approved By. .....'kt
Date
Application Disapproved for the following reasons:............ ..................................................................................................
.........................................................................................................I...............................................................................................
Date
PermitNo.......... ........................................ Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OL-"'Aj....................I.............OF........ ...... ...T
aa.C.E..................
(9rdifiratr of Toutplittnirr
THIS IS TO CERTIFY, That the.-IndMdual Sewage Disposal System constructed or Repaired
by....................................................................................................................................................................................................
Installer
at..................... -----------I<-P_�r-"�_,--- ",
...................... ................... ......................................................... ............................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary :Code as described in the
application for Disposal Works Construction Permit No..........................:................ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED,AS`A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........
................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................
............7 OF..............
NO.. ............... FEE............£:.........
Permissionis hereby granted..............................................................................................................................................
to Construct or Repair (—`9:an Individual Sewage Disposal Sys
tem
at No..........Z"!Z�%,-471.a...... 4fl,�Z&Vr
.......... ...tl..&............(.......... ...... ............................................................
Street - , r)
as shown on the application for Disposal Works Construction' Permit No......................Dated..........................................
...............................
......... b-ard-o-i-H-eaith........................................
DATE...................... V
.........................................
FORM 1255 H0138S & WARREN. INC., PUBLISHERS
No...... APPROVED
0 R
r Consent . nD8 THE COMMONWEALTH OF MASSACHUSETTS
s�6 ; BOARD OF HEALTH
i9 OF JM� f
...........................
Avulp iratiou flax Dhip t ial Marko Tmitrurtiun Prrutit
Application is hereby made for.all Permit to Construct ( ) or Repair (>4'an Individual Sewage Disposal
System�./yat: 1 //\
. t:�� !'.1 '!.........i.�1��.............................. Y.. ........ )161:::r'... 1 5..........................................
Locajion-Address or Lot No.
fluoeM►u tZ.. ..........................•---............ .......---•---•--..........................
®..../jam . •--- ........
W ' C77 �F Owner
Address .....................................
In ller Address
Type of Building Size Lot.._.g5..)............... feet
U Dwelling— No. of Bedrooms........... ................. . . .....Expansion Attic Garbage Grinder
aOther—Type of Building ..........1,A.�t.......... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------•-----------------.••.....-•••--.....................•-•••...••-•••-•••-•.........................................
W Design Flow................. ....................gallons per person per day. Total daily flow.._.:...3�.....0 ..........-.........:..gallons.
P4 Septic Tank—Liquid capacity..lOUo?-gallons Length._-!�:' Width. :: `... Diameter.q.�.P....... Depth.....`i-.-.5n
xDisposal Trench—No. .................... Width.................... Total Length............ Total leaching area............_. q. ft.
j Seepage Pit No.. Diameter......T�_ ��..... Depth below inlet.......-n'... Total leaching area.....Z�.•4..-. q. ft.
z Other Distribution box ( ) Dosing tank ( ) kA Prr f 1T.
Percolation Test Results Performed by.......................................:......................•-•••....... Date.........................................
,.�
minutes er inch Depth of Test Pit..... .Test Pit No. 1....._�`.:....._. p p ��..........:. Depth to ground water....................
c� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O �... -------------•--------••--••••-•-••••••••...a.......................................... -------
Description
oo ........i ;—')..........e-t1
x ^� .......
`
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 L IM E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b iss y e b rd of health. `
Signe .... .... . ......................... ................................
` Date
Application Approved By........... ="r-,�, .°`1u........... ................ ........ .:" .(o �:�
Date
Application Disapproved for the following reasons:------...... ..................................................................................................
..................•••-••---:......................::......................-----------....................•-•--•••..........-•••-
Date
Permit No...... _.'. %7... ........... Issued
Date ...
AL
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DRIT�E'T Y 16 No.351m N0.
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BENCHMARK �— — E
ELEV.=28.92' (N.G. V.D. o \ LOT 4A ; 18 '�
TOP OF TAG BOLT #115 co , 2 }°j
(OLD) —
�/ SEPTIC O p LOT 4
DEC �-- s-
9 20— — PLAN REF. 135/155 -
y
04 \ 78' \I ZONING: "RF--1"
w :..
32
•� \ " '4' �? Q --�D '24 ` PROJECT L OCA TION•
i .26• SPRUCE - SHED
TREES ya _ a - 72 KE'YE'NEY LANE
34 DECK 26 CUMMAQUID, BARN.
/ \ RIMARY AREEA�� \ AREA
28 —
6�� APPLICANT
•
L 806E= STA UFFE'R & ELINOR MILLER
30
�0 YANKEE SUR VEY CONSUL TANTS
32_ P. O. BOX 265
`l UNIT 5, 40B INDUSTRY ROAD
��o _ 0�� •��1 MARSTONS MILLS, MA. 02648
PH.(508)428-0055 - FAX(508)420-555J
ASSESSORS MAP : 351-25 SCALE 1."=40' [DA TE.• 5105194
REV. LRE V• 5115194
JOB NO. 50473NEW SHEET 1 OF 2
,y N
CO
LAYVE
wv
.1 e 48" y ��N?' L=33 3
4- No59'00�,
to 9t —�
�. ♦ .
y —Jm
4�1
1000
l
ems, I I b
i
Z Z y co��yo
% `
ti
o p coM
o 00
sl
EL. _ 29.2_4'
TOP OF FOUNDATION 'J
- 20' MIN.
2'LAYRR OF
10' min CONCRETE COVERS ALL SEWERAGE PIPES SHALL
ELEVATION VARIES lA VE A MINIMUM OF 2.5'. OF CO VER. WAS ED STONE
25.5E CONCRETE CO VERS
-7-7-7 24.5E //
' 4"' CAST IRON 12"MAX i i 3WA4 S711NE
OR P. V.C. PE "
�) SCHEDULE P 40 25. Of
4"' SCHEDULE 40 P. V.C. DIST.
BOX
S=0.13, D=12' FLOW LINE 12"
INVERT 110"' 19" S'=0. 0� D=78' MIN. O
MIN.
73_ INVERT 2' 000 12" OF STONE BENEATH THE °o 0
INVERT EL.=24 1 LEVEL °oo PERFORATED PIPES °000
0 0
EL.= 24. 45 -- —oo —
INVER INVERT EL. =20.8 o o 00 6-4"DIA PIPES 8' LONG o 0 00
1000 GALLON EL._ 2252 EL.= 22. 45 EL = 19.8
THE FIELD SHALL BE A MINIMUM --
SEPTIC TANK OF 36' LONG BY 12' WIDE.
PROFILE OF
SEWAGE DISPOSAL SYSTEM
NOT TO SCALE BOTTOM OF TEST HOLE OR VSGS PROBABLE WATER TABLE EL= 12. 0***
ALL ELEVATIONS ARE ON NGVD *** ELEVATION OF WETLANDS BY THE LOT.
THE CONTRACTOR EXCA VATED TO A DEPTH OF
13' DIRECTLY BELOW THE PROPOSED LEACHING FIELD.
NO WATER WAS ENCOUNTERED. THE SOIL WAS A
'' COMPOSITION OF SILTY-SANDY SOUS
GENERAL NOTES
1. THIS PLAN IS FOR REPAIR OF SEWERAGE DISPOSAL SYSTEM. DESIGN DA TA:2. PLAN REFERENCE BOOK 135 PAGE 155, LOT 3 and 4A, BARN. REG. DEEDS.
3THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM `N OF ,ya
AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. NUMBER OF BEDROOMS THREE �� JOHN ti�
4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO DER LANDERSCAUI.EY r^4
TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS GARBAGE DISPOSAL NONE `� �1V1L
No.35101
FOR THE SUBSURFACE DISPOSAL OF SEWAGE. TOTAL ESTIMATED FLOW 330
5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN
12" OF.FINISHED GRADE. ( 110__GAL/BR./DAY x -3__ BR.) �DIfIA
6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE
SAME, UNLESS NOTED BY FINAL CONTOURS. SEPTIC TANK CAPACITY _1000 GPD
7. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE LEACHING AREA REQUIREMENTS
OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER
OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SIDEWALL AREA 0* _ GALS.F.
SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING.
' UNLESS NOTED. BOTTOM AREA 440 GAL/S/F
8. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL LEACHING CAPACITY (BOTTOM & SIDEWALL)-330-**GAL
BE MORTARED IN PLACE.
9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
I DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO RESERVE LEACHING CAPACITY 330**_ GAL.
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. * NO SIDEWALL AREA VALUES WERE ASSIGNED.
10. THE EXCA VA TOR\CONTRACTOR SHALL VERIFY THE LOCATION OF ALL **FLOW RATE BASED ON RATE
UNDERGROUND UTILITIES PRIOR TO ANY EXCAVATION. CALCULATED BY THE TOWN OF
- ----- - - - - --- - - --- - -- BARNSTABLE. - - -
504 73NEW