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HomeMy WebLinkAbout2787 MAIN ST./RTE 6A(BARN.) - Health 2-787 M—din Street/Rte�6A (Barn) FPF Barnstable P A = 258 028001 „ • r �a ;. A z a , c y4� • „ � u L J w _ TOWN OF BARNSTABLE L,�h='ATION r) � � SEWAGE # II.LAGE yC%X`ns ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I OCR 0 504- LEACHING FACILITY: (type) �� 5 (size) _ NO.OF BEDROOMS BUILDER OR PERMITDATE: COMPLIANCE DATE: 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 within300 feet of leaching facility) Feet Furnished by 1 . a ------------------ Ft, o a M fO y tJ —' (i (n r ,t G , TOWN OF,BAARNSTABLE O 'f+1i3N 'Bo /�'/` SEWAGE # 1�" .: LAGE ,C7 o �S J�b/ )-! ASSESSOR'S MAP&LOT d o/ INSTALLER'S NAME&PHONE NO. i A- SEPTIC TANK CAPAcrry Ae LEACHING FACILITY: (type) -� �s C (size) `I size NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: /I �'�oZ--S' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within,300 feet of leaching facility) Feet Furnished by - —, � _ � F -� s: j 0. ' ` .. � � _ J � � I c, i � .� .� , � �,�,. •� .. r �. -. � �^• � No. " Fee$5 0 .0 0 THE COMMONWEALTH OF MASSACH TTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNS T ES MASSACHUSETTS ZippYication for �iopo�ar *potem Co gtruction Permit Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. main St Owner's Name,Address and Tel.No. — Barnstable Ellen Nicholson Assessor's Map/Parcel 2787 Main St - PO Box 433 Barnstable Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service PO Box 1089 Centerville 02632 Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder(n4 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil gravel Nature of Repairs or Alterations(Answer when applicable) Install Title 5 leaching consisting of D-box, and. three H-20 precast leach chambers . Z p i2EE7� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by tuis B and of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. - Date Issued - � , - ——————— \0 TOWN OF BARNSTABLE LOCATION 2- //'� : r SEWAGE # VILLAGE ' 5 rb /Zi ASSESSOR'S MAP& LOT IU•D 18-Oa f INSTALLER'S NAME&PHONE NO. a i ram- •�— ? 2 SEPTIC TANK CAPACITY 6a' dx- LEACHING FACILITY: (type) —��'U (size) T`'S`// , NO.OF BEDROOMS BUII.DER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by a 4t No. aI ,� �f //JJ §Fee 5 .00 THE COMMONWEALTH OF MASSACH S TTS Entered in compute{: '• Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTA E., MASSACHUSETTS 0(pprication for Mizpooar bpetemi Co otruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2787 a ii1 St Owner's Name,Address and Tel.No. 3 — Barnstable Ellen Nicholson Assessor'sMap/Parcel ..� 2787 Main St - PO Box 4-33 Barnstable rr,, 3 Installer's Name,Address,and Tel.No. 7 7 5—O 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service PO Box 1089 Centerville 02632 Type of Building: .i a Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder(ng Other Type of Building' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow C� gallons. Plan Date S, Number of sheets Revision Date Title (=' .Size of Septic Tank Type,of S:A.S. Description of Soil gravel NaturefofRepairsor Alterations<Answer when applicable) riS all 'Title 5 leachingconsisting of, D-box, and three H-20 precast leach c am ers $ Y Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is B and of Health. p Signed c Y Date Application Approved by '° r Date Application Disapproved for the following reasons Y l_ Permit No. A opA Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Nicholson (tertificate of QCompliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired(XX)Upgraded( ) Abandn� b at (( a n St Barnstable has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - `s °'' ,�dated �', � Installer W E Robinson S e pt ie Service Designer The issuance of this permit shall not`b • onstrued as a guarantee that the system will function as designed. Date 11 �� - l Inspector --------------------------------------- No. ot THE COMMONWEALTH OF MASSACHUSETTS Nicholson PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Xi5poal 6potem Conotruction Permit Permission is hereby granted to Construct )Repair( X)Upgrade( )Abandon( ) System located at 2787 Main Street Barnstable nsta ens w 1, Kobinson Septic e e and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this mut. Date: Approved by ;ell�� - J r - NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated ,//—c?-�9 v concerning the property located at 2787 Main Street, Barnstable, meets all of the following criteria: T ere are no wetlands within 100 feet of the proposed leaching facility. There are no private wells within 150 feet of the proposed septic system. A - re is no increase inflow and/or change in use proposed. There are no variances requested or needed. r If4he proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the roposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: DATE 9 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). O ' J � ly COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION kiwi RECDVED �a k-, JAR 1 2 2005 TITLE 5 TOWN.Or BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNT_ARY=ASSE SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A - CERTIFICATION Property Address: 2787 Main _Street Barnstable PARCEL" # � Owner's Name: Ellen Nicholson F" 7, Owner's Address: Date of Inspection: Name of Inspector:(please print) Wi 1 1 i am _ Robinson Sr. Company Name: William E. Robinson Septic Service ` Mailing Address: P O Box 1089 Centerville, MA Telephone Number. ( 5081 775-8776 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: Z fA"©. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Neanh 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 approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that ion does not address how the system will perform in the future under the same or different time.This inspect conditions of use. Title 5 Inspection Form n p 6/15/2000 page 1 � 4 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2787 Main Street Barnstable Owner: Ellen Nicholson Date of Inspections Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst in Passes: t/ i have not found an information which indicates that an of the failure criteria y y n described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: i B. System onditionally Passes: One or ore system components as described in the"Conditional Pass"section need to be replaced or repaired.The s tem,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or of determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits su stantial infiltration or exfilration or tank failure is imminent System will pass inspection if the - existing tank is replac d with a complying septic tank as approved by the Board of Health. •A metal septic tank ill pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the is less than 20 years old is available. ND explain: Observation of s wage backup or break out or high static water level in the distribution box due torbroken or _ obstructed pipe(s)or du to a broken,settled or uneven distribution box.System will pass inspection if(with approval pp of Board o[H lth broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system re fired pumping more than 4 times a year due..to broken or obstructed pipe(s).The system will pass inspection if(wi approval of the Board of Health): broken pipes)are replaced obstruction is rcmotrod ND explain: Page 3 of l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION(continued) Property Address: 2787 Main Street Barnstable w Owner: Ellen . Date of Inspection: . C. Further Evaluation is Required by the Board of Health: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing protect public health,safety or the environment. I. Sy em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the Sys m is not functioning in a manner which will protect public health,safety.and the environment: — esspool or privy is within 50 feet of a surface water esspool or privy is within 50 feet of a bordering vegetated.wetland or a salt.marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fu clioning in a manner that protects the public health,safety and environment: _ Th system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface . ater supply or tributary to a surface water supply. — Th system has a septic tank and SAS and the SAS is within a Zone I of a public water supply., _ T system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. e system has a septic tank and SAS and the SAS is less than.100 feet bui 50 feet or mote front a privat water supply well*•' Method used to determine distance *'Th* system passes if the well water analysis,performed at a DEP certified laboratory,for coliforin bact 'a and volatile organic compounds indicates that the well is Gee from pollution from that facility and the esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fail a criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: VN 3 , Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2787 Main Street Barnstable Owner: Ellen Nicholson Date of Inspection: s D. Sys m Failure Criteria applicable to all systems: You mu t tndicate')- res".or"no"to each of the following for all inspections: Yes N _ 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 iquid depth in cesspool is less than 6"below invert or available volume is less than IA day flow equired 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. y portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone I of a.public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private%a= 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.) eslNo)The system fails.I have determined that one or more ofthe 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. arge Systems:To a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 Yo .must indicate either"yes"or"no"to each of the following: (17ie ollowing criteria apply to large systems in addition to the criteria above) yes n the system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zo a 11 of a public water supply well If you have an wered"yes"to any question in Section E dte system is considered a significant threat,or answered y..yes"in Sectio� D above the large s stem has failed.The owner or operator of wry large system considered a significant thre under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The sys em owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST q ' Property Address: 27.87 Main Street Barnstable Owner: Ellen Nicholson Date of Inspection: a S i Check if the following have been done.You must indicate'yes"or"no"as to each of the following: Yes No/Pumping Vwcre information was provided by the owner,occupant,or Board of Health any of the system components pumped out in the previous two weeks 7 Ha a system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection?. I//_ 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 7 r/ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site 11 Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bafflees ortees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ` _V 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 _ Existing information.For example,a plan at the Board of Health. t _ _ Deterrttined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)13 10 CMR 15.302(3)(b)j A. 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2787 Main Street Barnstable Owner: Ellen Nicholson Date of Inspection: ' —0 ET FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based on 310 C 15.203(for example: 110 gpd x#of bedrooms): ,!rS,0 Number of current residents: ^� Does residence have a garbage grinder(yes or nod Is laundry on a separate sewage system(yes or no):,C���[if yes separate inspection required] Laundry system inspectePailable or no): Seasonal use:(yes or no) Water meter readings,if (last 2 years usage(gpd)): 4/0 3 to 4/0 4 36, 000 Sump pump(yes or no):� 4104 to 0 4 1 1 ,000. Last date of occupancy: COMME[sent USTRIAL Type of ent: Design flon 310 CMR 15.203): gpd Basis of (seats/persons/sgft,etc.): Grease tr (yes or no):Industrialding tank present(yes or no):Non-sanidischarged to the Title 5 system(yes or no):Water mgs,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: y A,►;Lt./ V � Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: _ TYOF 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank Attach a copy of the DEP approval _Other(describe): ...... . .. . .. .... Approximate age of all components,date installed(if known)and source of information: 73 6 '? � Were sewage odors detected when arriving at the site(yes or no):.�iU 6 I'agc 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORt1'1 PART C SYSTEM INFORMATION(continued) Property Address:2787 Main Street Barnstable Owner: Eiien Nicholson Date of Inspectlon: UUILUING SEW (locate on site plan) a Depth below gra Materials of co traction:_cast iron _40 PVC other(explain): Distance Gom rivate water supply well or suction lute: Comments( condition of juutls,venting,cvidcncc of leakage,etc.): SEPTIC TANK:_ locate on site plan). Depth below grade: Material of construction:_,/cuncrcle metal fiberglass_polyethylene _oUur(cxplain) _ If tank is metal list age:_ Is age confinned•by a Certificate of Compliance(yes or no):—(allach a copy of certificate) Dimensions: �, Cs �; a ► r Sludge depth: e� , Distance from top of slud�c to bottom of outlet Icc.or battle: SCUM thickness: Distance from top of scum to lop of outlet Ice or baffle: i t Distance from bo►Iom of scum to bottom of outlet tee or battle: L f low A crc dimensions determined: G FL;..— Td H-X ' Comments(on pumping recommendations,inlet and outlet Iee or baflle condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc. : T - GREASE TRAP:_(I catc on site plan) - Dcpth below grade: Material of construct' It:_concrete_metal fiberglass_poi}'ethylene _other (explain): — Dimensions: Scull)Iltickncss: Distance Gom to of scum 10 top of outlet tee or baffle: . Distance Gom b Itom of scum to bottom of outlet Ice or baMc: Date of last pu ping: Continents(o pumping recommendations,inlet and Outlet Ice or battle conditiO:t,structural integrity, liquid levels as related to Ilcl invert,evidence of leakage,cic.): 7 „ Page 8 of 1 OFFICIAL INSPECTION FOR11I —NOT I101t VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR AI PART C SYSTEM 1NFORA'IATION(continued) Property Address: 2787Main Street . Barnstable Owner: F1 1 an Ni rhnl Gnn Dole or Inspection:_1` ,5= D . TIGHT or 11OLdiG TANK: (►milt must be pumped at time of inspection)(locate on site plan) Depth below grade: - Material of construe ion:—concrete_metal fiberglass_polyelhylerte otlter(explaut): Dimensions: Capacity: gallons Design Flow:rof gallons/day Alann presen Alarm level: orking order(yes or no): Date of last p Comments(cd float switches,cic.): DISTIUBUTION BOX: (W if present must be o mieJ locale on site Ian 1 )( plan) Depth of liquid level above outlet invert: 0) Conunents(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.): LO 1? 6 PUMP CHAMBER: (locate on site plan) Pumps in working or r(yes or no): Alarnis in working der(yes or no): Comments(note a ndition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM—' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2787 Main Street Barnstable Owner: Ellen Nicholson Date of Inspection: .j— ,52—G S� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required),L If SAS not located explain why: Type aching pits,number:_ - icaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pondin„damp soil,condition of vegetation, etc.): � � CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and c figuration: « _ � 1 Depth—top o liquid to inlet invert: Depth of sol' slayer. ` Depth of sc m layer: Dimension of cesspool: t Materials f construction: Indicatio of groundwater inflow(yes or no): r Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate n site plan), Materials of cons ction: . t Dimensions: Depth of solids Comments(n a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2787 Main Street Barnstable Owner: Ellen Nicholson Date of Inspection: ,$r . 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. 0 4 0 lip A - 10 Page,l 1 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) f Property Address: 2787 Main Street Barnstable Owner. Ellen Nicholson Date.of Inspection: 6�—G 6- 1 , SITE EXAM Slope Surface water Check cellar , Shallow wells Estimated depth to ground water zF,6 feet Please indicate(check)all methods used to determine_ the high ground water elevation:' - 3 . Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) CSZhecked with local Board of Health-explain: hecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: i 5e10S vacs b --.;?— 1146& s i 11 oT / GovoRA-) r w19y 9' I ` CATION 2T - ' SEWAGE PERMIT NO. ter, �.A 2 N.3T O a C.s— — ViLLAGE `Z MfFpN INS ER'S NAME i ADDRESS 10, m A c o v4 R v-- 4-s o dJ -T`-)C- BUILDER OR OWNER o r' 6 A 'c� ct-f Ej' �rrEy DATE PERMIT ISSUED �2 _ 2S_�� DATE COMPLIANCE ISSUED , Ej 1' 0 4 THE COMMONWEALTH OF MASSACHUSETTS , BOAR® OF HEALTH -•................ ......................OF..........................................---------.......---------------................. luation fnr Did vii al Workii Tome rurtion Vanfit Application is hereby made for a Permit to Construct (l,<or Repair ( ) an Individual Sewage Disposal System at Rt- LA.. _� G(IV--_ 6� 1, ............................................... // Locatio -Add re s or Lot No: er Address W Installer Address UType of Building Size Lot; ,__ ___ _. ...Sq. feet Dwelling—No. of Bedrooms.__.....`'...................................Expansion Attic ( ) Garbage Grinder 06.17). `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --------------- ----------- W Design Flow ..... ........................gallons per person per day. Total daily flow------ ._(,�...._-----.-----gallons. WSeptic Tank-f-Liquid capacit','ih_�gallons Length-------------_ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------- --------- Total leaching area....................sq. ft. Seepage Pit No---------/----_-_. Diameter-------/Q------- Depth below inlet...... .......... Total leaching area... _ ld._sq. ft. Other Distribution box ( ) Dosin nk ( ) Z Percolation Test Results Performed by."V a-k ��.._. .....................................Date... -fir' .1.............. aTest Pit No. I...... 2:_minutes per inch Depth of Test Pit.................... Depth to ground water-.___.--________--_--_. G Test Pit No. 2................minutes per inch Depth of Test Pit---_................ Depth to ground water........................ O Description of Soil------ ` " L'.: = ►�1 x U ------•--••••••--------•-•--•----•-•--------••-----------------•••--•---------•-----•-------------•---------------•-------------------------.....--------------------•----•-•-----•-'•---•---•----•----- W -----•-----•--------------------•------••----••-•-•-----------------•-•-•.._..._....--••---•••--•••-------.....----------------------------•-•-•----------------------•----......----••------'-•--.--•-- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------••--•--•----••-•----------....--•---•-•----•••-••--------•----------•-•-----••----••........_......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTL p S of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued y the D d of , alth. Signe -•-- . --•----•----------------- Date Application Approved B r� �i` YL k ` PP PP y--•-•--- '----s Dates / Application Disapproved for the following reasons:---•---------------------------------------•-----------------------------------•----------..................... -•-----------------------------------------------------------------------------------------•----------...------------....--------------------•--------------------------------------- ................. Date PermitNo................................... Issued....................................................... Date A.-III - No............ -Fy,B...S.V.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --------- - - - ----------------­OF........................................................................................ Appliraffou for Uhipotial V,ark, Tomitrurtion ramit ;Application is hereby made for a Permit,to Construct ( L--)-"or Repair an Individual Sewage Disposal SysiiNn at: .......................... ..........................................................................•....................... • t Loca i ess-Add or.I,&No. M. . ......... Address ............ ................................................................... ................................................................................................. Installer Address ? Q '7 Size Lot........ -Sq., -.4 Type of Building eet U Dwelling No. of Bedrooms............................................Expansion Attic Garbage Grinder 1fV 04 Other—Type of'Building ............................ No. of persons............................ Showers Cafeteria Othreg-------------------------------------------------------------------------------------------------- ...... --------------------- u Design Flo ..lk...... ----gallops per person per day. Total daily flow............................................gallons. :W/...................- - 11 P4 Septic Tank—Liquid capacity............gallons Length...... ......... Width_____._._....... Diameter............_._. Depth................. Disposal Trench— To.......................Wid . Total,Length----i� _------ --- Total leaching are�`i;-.................sq. f t. ......... ...... Seepage Pit No_____________________ Diameter----_-------------- -Depth below inlet..__......_......... Total leaching area;.'4.i __,sq. ft. Z Other Distribution box D;oOsi tank" Percolation Test Resu)t.,% Performed -01 ` —� .... ... ....... --------------­ . Irm... .............................!� -. batA­ y.................. Test Pit�Nuor!o I-—----------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Test Pit No. 2.... ......minutes per inch Depth of Test Pit___________________ Depth to ground waf&...................... ................................... .. �............ 0 ------ .............Description of Soil.................. .......... ....! . ----------------------------------------------------------------- -------------.......... U .................................... ........................................................... ............................................................................................�!................................................................................ .......................... U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- .........................................7............................................................................................................................................................... Agreement: The undersigned agrees V9" install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 'if.e State S,�nitdry Code TI 5 of TLE �; — he"undersigned further agrees not to place the system in operation until a trtincate of Compliance has issue y the rd of Aalth. fie�A Si��6,e ....... . ....... ... ................................. Date Approved .. -------------X�--------------------­...... ApplicationAppr d B ..................................................../........................... Date Application Disapproved for the following reasons:!.............................................................................................................. ........................................ ............................................................................................................................................................... Date PermitNo......................................................... Issued.................... ---------------------Date-------- 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTI-1— .......... ...........OF........ & -p ...................... (9rdifiratr of UtUrr ,THIS at the (qvidual SewXS Disposal System constructed dS TO RTIFK,, Th or Repaired by....... ............. .......... ........ T,................... ..... .......... ----------------------------- I s t ayey W4--------------- at........ . ....... ....... . .... .. 01>111.f..........................--- --------- ------------------------------------z-------------- . , — I The State S-7 �jbed in-tbe. has been installed in accordance with Itz"r-r--ovisions of ;,ait,,,, c * applicition for Disposal Works Construction Permit.No P............t ................... dated__..-:----------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA TORY. DATE....................................... ....... Inspec ..........................•................. Z�l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ........OF...................Q�............................................................. NJO.�---71 FEE........................ I.......... Permission is by granted........... .......V. .........;g 14---. to Const®rttl( Re i a I S ispospf. �ystem Individual p �n ivi.uaem,5g( .�w , �e...*............. at . . ..... ...... ......... ............................ /treet as shown on the application for Disposal Works Construction Pe slit 0.__ --- ated- V df ------ ......................................... .......... -...- ...... . = 4 ------ - -- ----- ................. DATE.__..__.... 712 a_ Boar&of Health ....................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r-� SECTION - SEWAGE jr to - SEPTIC TANK - _ „D" BOX -" - LEACH 1 i �, je%'�``' � k/4�/.'.�' ?{ ` '74;g �"�•�.AS TOP O FDN V G - (1 I / `r ' `� �,• a 4 6^.i. 4 7¢ O . 'o rno e n 1 i4�l r a (MSL)x � v 0 kA l! S,Ac661 y✓16� r- 79 "2..OF 1;aTO 1/2' di9fanc�° Of �O c��pUn�etnflrL° I$Y1C� fx� WASHED STONE iI �� Jul G{ `k- �aiY p� a ref5lC ce wHjh c e4n Cionr-9 sa.r �o r,y ! �.'' � 4,�,� ��kg � �- A�`E• . fj • IN, OUT - - � .,;•j 5"�/� F y i .-Ty ' 't 7�, ! .. Y. l i I / / loop IN ' ouT- IN . Tf / /� �+ o �� o�o��C f �d� 1'µ , SEPTICGr r �!{{ �) -TS.4jU, r 1SZ TANK 15.00 �4LIGI J t _fie I� ` r /p ELEV. ELEV. ELEV. -�./ !G ! �! r + �-. 0 ELEV. 14.E 1 tELEV. ELEV. C-8.40 F ter/ r • �r�o gc cf i77 .�-- OFF *4'°..1112" .fu J t ,t•.. lj•a - WASHE D STONE f ` ..�0 37.8 TEST HOLE LOG �� d_ 9a� _ _ _-.- _ s /U TEST BY IZ.t=a�2t3Aax.t1C 73 F-E. 74 . C •/ .. .� / L -r� w1T(vEss _ __BEDROOM HOlJ5� K 1 to / / ��` F3Z TEST DATE �j ` DESIGN -- t — _7-3 T.H. � 1 T.H. # 2 ter(• -- 00----u. ELEV. OD" .ELEV. NO t< .� f ^,.•-- '--'`- DISPOSER— DISPOSER o•� / 1� _ Lvearn +Y u>asvi� s�bso41 PERC RATE L�_;___MIN/IN. L- 3 0 ��- -74.9 FLOW RATE 33o (GAL./DAY ) 3 _. . -L N -� 4Z '14.3 SEPTIC TANK 330 (I. )= _4' )G _ - ,. `- - REO'D SEPTIC TANK SIZE ��1 o 2 'n r {- --- r' r E O IfyNedl tt (V rn4?ai L,.v.\ --x. L I LEACH FACILITY _ Some .,cs { SIDE WALL r1"u)cc'} _..__( -•� ) -_4� 1-_ G/D. � _ n Goa G r cxr.t� BOTT07VI -- C'T___._�_�_.( I. a ) r �_�8 G/D. -v17 �� - Q TOTAL - - �'4 w/ av PIT, 7 — ---I — - I� ^ USE: __ - --LEACNING `_ / Z-7 ISM �o4.fi t5� �4.4 /1 .. - .. �o � �c� /;��-//, •+�---v�.. ! WATER ENCOUNTERED _ "r`-_ " i' -�` I r +• V NOTES: (UNLESS OTHERWISE NOkED) 1. DATUM (MSL) + TAKEN FROM A!2u F±.� -__QUADRANGLE MAP 2.MUNICIPAL WATER....-,__--_� _____-__•_____________AVAILABLE r� ' /37 4 3. PIPE PITCH: 44"PER FOOTAtN QF r. S' 4.DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO - •44 •� �� � JA G fa 5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. � JAMIES , s\ *'' —Q-- DISTANCE AS CERTIFIED 6.PIPE JOINTS SHALL BE MADE WATERTIGHT O T _ 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. STATE ENVIRONMENTAL CODE TITLE 5 ,1. ' i40,1 I HEREBY CERTIFY THAT THE BUILDING 0 .�� � � � '�'�— SITE PLAN . SHOWN ON THIS PLAN IS LOCATED ON THE STREET AN D •'A GROUND AS SHOWN HEREON&THAT IT-- LOCUS: RT 6A __Aily. S CONFORM TO THE ZONING BY LAWS OF THE GpVRNOR'S WAY 3ARNSTABLE -`------- TOWN OF ) ritir��a REG.PROFESSIONAL ENGINEER' WHEN CONSTRUCTED. DATE REF: f=L BK. IGO PG- i3 dOWO C&DO engineefinf PREPARED FOR: CHA RL E 5 DUC H P- 1N EY_ CIVIL ENGINEERS --------_-- BOARD OF HEALTH LAND SURVEYORS ^REG. LAND SURVEYOR ,t CONTOURS (EXISTING)- SCALE.. I 301 — Z/2. 81 (PROPOSED)-O-0-O---O APPROVED DATE MA YarrYlOUth&Orleans,MA8 _OOP DATE