HomeMy WebLinkAbout1327 MARY DUNN ROAD - Health 132low 7 MARY DUNN ROAD, BARNSTABLE
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A= 334 002.005
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TOWN OF BARN
iSTABLE
LOCATION —7 n (=eX SEWAGE c,
V LLAG L-,MM J ASSESSOR'S MAP&PARCEL J5'V--�0CV— 005
INKS NAME&PHONE NO. --n C- �(� 11r),;
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) ®®d
NO.OF BEDROOMS 3
OWNER.SE2
PERMIT DATE: DATE P
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 U ' o
r
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Water
Service !
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Mary Dunn Road a
Commonwealth of Massachusetts
s. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 1327 Mary Dunn Road
Property Address
3
Stephen &Jean.Hall
Owner Owner's Name
information is MA 02637 February 20, 2008
required for Cummaquid /�Grr
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
508-428-1779
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 main tenance;of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15-.340 ofT,
Title 5(310 CMR 15.000). The system:
r
® Passes ❑ Conditionally Passes ❑ Fails? ,'
❑ Needs Further Evaluation by the Local Approving Authority cam?
February 20, 2008
Inspe tor'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.
08-34 Hall.doc•08I06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w 1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cumma uid _MA 02637 February 20, 2008
required for q
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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:
Tank is not in need of pumping at this time, One leaching pit was empty at time of inspection and
other had 2' of standing water.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ 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
❑ obstruction is removed
08.34 Hall.cloc•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l
w 1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
t
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
08-34 Hall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page of 15
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20 2008
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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
tri co analysis must be
less than 5 ppm, provided that no other failure criteria are triggered. A PY of the anal
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
El ® 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of.times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
® tributary to a surface water supply.
08-34 Hall.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen & Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
ElAny 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 15,000 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
❑ ❑ 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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
08-34 Hall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1327 Mary Dunn Road —
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for
every page. City/Town 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
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ 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)]
08-34 Hall.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for
every page. City(rown State Zip Code Date of Inspection
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
2
Number of current residents:
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 ❑ No
Seasonal use? ❑ Yes ® No
153,000 gal. _
Water meter readings, if available (last 2 years usage (gpd)): 209 gpd.
Sump pump? ❑ Yes ® No
Currently
Last date of occupancy: Occupied
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): gallons per day(gpd)
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: — -
Last date of occupancy/use: Date
Other(describe):
08-31 Hall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
f
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen & Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Tank pumped 2004
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)
El maintenance
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:
Compliance date: 8/15/96
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-34 Hall.doc•08/06 Title 5 Official Inspection form:Subsurface sewage Disposal System-Page 8 of 15
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for
State Zip Code Date of Inspection
every page. Cityrrown
i
D. System Information (cont.) j
Building Sewer(locate on site plan):
1'
Depth below grade: 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):
1'
Depth below grade: feet
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
----------------------------------------------- --------------- ------- ----------------
8 5' long x 5.2'wide - 1000 gal.
Dimensions:
3„
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
27"
2"
Scum thickness
6„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
Measured
How were dimensions determined?
08-34 Hall.doc-08/06 Title 5 Official Inspection Farm:Subsurface Sewage Disposal system-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for State Zip Code Date of Inspection
every page. City/Town
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.):
Tees are intact and clear, liquid level was found at bottom of 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
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):
Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 15
08-34 Hall.doc•08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cu id MA 02637 February 20, 2008
required for
State Zip Code Date of Inspection
every page. Citylfown
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-34 Hall.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
f -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 1327 Mary Dunn Road
Property Address
Stephen & Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
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:
I
Type:
® leaching pits number: Two 6x6 pits
❑ leaching 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 ponding, damp soil, condition of
vegetation, etc.):
Pit#1 (rear of prop.) had no standing water with no definite high stains. Pit#2 (front) had 2'of
.standing water with clean concrete above current level.
08-34 Hall.doc•68106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w� 1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
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
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.):
08-34 Hall.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ICI Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.` 1327 Mary Dunn Road
Property Address
Stephen & Jean Hall
Owner Owner's Name
information is Cummaquid MA_ _02637—_ February 20 2008
required for ---"" -- State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
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.
24
N I
26
Water
Service
Mary Dunn Road
Commonwealth of Massachusetts
:
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1327 Mary Dunn Road
Property Address
Stephen &Jean Hall
Owner Owner's Name
information is Cummaquid MA 02637 February 20, 2008
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
20+
Estimated depth to ground water: 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:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el 20 and topo map shows property above el. 50.
08-34 Hall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
Regulatory Services
BARNSTABLE ; Thomas F. Geiler,Director
p,E1639- Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the,"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
4
tl�F NO.
DATE
3 sARMABLI&
NAB&
FEE
fDklD� wn of Barnstable
`� RECENE�
REC. BY
Nov 1 lsg `=� Board of Health
TADF n" 67 Main Street, Hyannis MA 02601
WoDeT
Oflke: 508-790-62 ti Susan G.Rask,R.S.
FAX: 508-775-3344 A £ Brian R.Grady,R.S.
Ralph A.Murphy,M.D.
VARIANCE REQUEST FORM
All variancc requests must be submittcd at least fifteen f 151 days prior to the scheduled Board of Health meeting.
NAME OF APPLICANT J osE pH + �-A4w IDos..ApuE TEL. NO.
ADDRESS OF APPLICANT ,f-1 :::,< , t�.,-o e ti-1 a o 1 s Zo
NAME OF OWNER OF PROPERTY li-tE
SUBDIVISION NAME DATE APPROVED ►q s t �/—
ASSESSOR'S MAP AND PARCEL NUMBER 3 5 2 / I+
LOCATION OF REQUEST w e.iv-r ,A (Z.,- c �Hr-4A. aJ I
SIZE OF LOT k o% 10-1-L s.�SQYT WETLANDS WITHIN 200 FT.YES
_,
� NO �
'd"4 . �t^.-s(6 L4- Goa-t Pt►1 ad �1c "
VARIANCE FROM REGULATION (List Regulation) l5.�'os; i a : REvae-T)o l.1 lt4
56T5-rE K SeTgA a -ra p"pE2'r� VINE (to` To 5; � 1b
1 rl Src.'�gs�-1� 't't FA I w4✓�e.-�o r.l Zo' T-o 1`4 1 I ►,. ; 2E r2.A�T1 o wl
�w1 GTPn1 -kl�M�4T�2 S�c�a.2si�lotiQ Os
REASON FOR VARIANCE(May attach if more space is needed) .5. .ar,�� p
PLAN - FOUR COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING
VARIANCE REQUEST.
VARIANCE APPROVED Susan G. Rask, R.S., Chairman
NOT APPROVED Brian R. Grady, R.S.
REASON FOR DISAPPROVAL Ralph A. Murphy, M.D.
f
t�
tel.(508)362-4541
•939 main street rt 6a fax(508)362-9880
yarmouth port
mass 02675 down cope engineering
civil engineers& land surveyors
structural design
Arm H.Oiala P.E.,P.LS.
November 16, 1998 Timothy H.Covell,P.Ls.
land court David C.Thulin,P.E.
surveys Barnstable Board of Health
367 Main Street
site planning Hyannis,MA 02601
Re: 95 Tisquantum Road,Cummaquid
sewage system
designs Dear Board Members:
inspections The enclosed represents a"Maximum Feasible Compliance" filing for a septic
upgrade from an existing cesspool septic system. No addition of habitable space is
proposed.
permits
The following variances are requested: 15.405 (1 a): Reduction in SAS setback to
property line(10' to 5');(1b): Reduction in SAS-setback to(crawlspace)foundation
(20' to 14'); and(1 i): Reduction in groundwater separation(5' to 4').
Due to site constrictions and the distance to groundwater,we have sited the system in
the highest portion of the lot. A pump is proposed. No retaining wall will be
necessary around the system if the groundwater separation is approved to be 4' from
the high groundwater adjustment. Some fill and regrading are proposed. .
The system as designed is based on the 3 existing bedrooms, with no reduction in size
of the system requested. Due to limited space in the rear yard, reductions in
separation between the SAS and property line, as well as betvveen the SAS and
crawlspace foundation are requested.
We feel that by granting the above variances, the.same-degree of environmental
protection can be attained without the need for strict adherence to Title 5 regulations.
Thank you for your consideration.
Very truly your ,
Arne H. Ojala,PE,PLS
Down Cape Engineering,Inc.
cc: Joseph and Mary Donahue
Ft"Er°w' Town of Barnstable
MUMST
AB , = Board of Health
9�A • ��� P.O. Box 534, Hyannis MA 02601
tED MA'S A
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Ralph A.Murphy,M.D.
Sumner Kaufman M.S.P.H.
December 16, 1998
Mr Arne Ojala
Down Cape Engineering
939 Main Street
Yarmouth,MA 02675
Dear Mr. Ojala:
You are granted variances on behalf of your clients,Joseph and.Mary Donahue,to construct a
replacement onsite sewage disposal system at 5 Tisquantum Road, Cummaquid,
The variances granted are as follows:
310 CMR 15.405(1) al: To construct a soil absorption system five(5)feet away from the
property line in lieu of the minimum setback requirement of ten (10)feet.
310 CMR 15.405(1)(il: To construct a soil absorption system 4.5 feet above the adjusted
groundwater table in lieu of the minimum five(5)feet vertical separation distance required.
310 CMR 15.405(1Nbl: To construct a soil absorption system fourteen feet away from a
foundation cellar wall in lieu of the minimum separation distance of twenty(20)feet required.
The variances are granted with the following conditions:
1. The engineered plan must be revised to show a minimum of 4.5 feet vertical separation
distance above the maximum adjusted groundwater table.
2. The designing engineer shall supervise the construction of the system and shall notify the
Board of Health in writing to that the system was installed in strict accordance with the revised
plan.
The variances are granted because the existing cesspool is, in all probability, sitting in the
groundwater table. Therefore, the replacement system would alleviate a source of pollution to
the groundwater table.
Sincerely yours,
usan G. .Ra"' .S.
Chairman
Board of Health
ojalar/wp/q/ls
i
3 3 ei
_ i
Comm irwecotth of Massochusetts
- - .John Grad
Office Of €rlvironrr+erff0i Aff®rs D.E.P. Title V Septic Inspector
D$ ___ P:O. Box 2119 _
Elt�rtssfetft Of - - - - _ Teaticket,MA 02536
Environmental Protection
_ (508).564-6813
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ PART A
- CERTIFICATION.
A
Property Address: 1327 Mary Dunn Rd.Barnstable Address of Owner: - _ v^
Date of Inspection:7110196 . (If different) d'
Name of Inspector:John Gracl Crockan:Box 387_Cummaquid,Ma.02637
Company Name,Address and Telephone Number: 76JJY �M7! �a5b
PARCH,NO: ?y < `e
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
Needs Fu er Ev luation By the Local Approving Authority
x Fails
Inspector's Signature: ` Date: �� to I Otto
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C, or D:
A] SYSTEM PASSES:
_ I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
Indicate yes. no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.)
_ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is .
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property-Address: 1327 Mary Dunn Rd.Barnstable
Owner: Crockan:Box 387 Cummaquid,Ma.02637 _ -Date-of Inspection:Inspection:7110/96 - -
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system'will pass inspection if(with approval of the Board of Health):-
- broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required-pumping more than four times a year due to broken or obstructed pipe(s):'The
system-will pass inspection if(with approval of the Board of Health): -
broken pipe(s)are replaced
_ obstruction is removed
C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health; safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is.within 100 feet to a
surface of water supply or tributary to a surface water supply,
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure. ~
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
gged
SAS is in hydraulic failure.
(revised 11/15195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) - -
_Property Address: 1327 Mary Dunn Rd.Barnstable
Owner: Crockan:Box 387 Cummaquid,Ma.02637
Date of Inspection:711019B _
D] SYSTEM FAILS(continued)
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 112 day flow.
Required pumping more than.4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 l'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 1,30 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 101000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program.
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
a
(revised 11/15195)
3
wj
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B -
_ CHECLIST-
Property Address: 1327 Mary Dunn Rd.Barnstable _ -
Owner: Crockan:Box 387 cummaquld,Ma.02637
—Date of Inspection:7110196
Check if the following have been done: _.
x Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
7-flow rates during that period. Large volumes of water have not been-introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A. _
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System, have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION
Property Address: 1327 Mary Dunn Rd;Barnstable
" -
Owner: Crockan:Box 387 Cummaquld,Ma.02637 -
Date of Inspection:7110196
FLOW CONDITIONS_. -
RESIDENTIAL:
Design flow: 330 gallons -
Number of bedrooms: 3 _
Number of-current residents: 3
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes -
Seasonal use(yes or no): No - -
Water meter readings, if available: n/a
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER: (Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
none
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped: 2000 gallons
Reason for pumping: Maintenance
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool -
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1979
Sewage odors detected when arriving at the site:(yes or no) Yes
(revised 11115/95)
5
SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
9ART C
SYSTEM INFORMATION(continued)
Property Address: 1327 Mary Dunn Rd.Barnstable -
Owner:- Crockan:Box 387 WnMquid,Ma:02637
Date of Inspection:7110/96
SEPTIC TANK: X - -
(locate on site plan)
.-Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain)
_ Dimensions: LS'6'115'7'WV 10"
Sludge depth:1' _
Distance from top of sludge to bottom of outlet tee or baffle: 15'
Scum thickness:10"
Distance from top of scum to top of outlet tee or baffle:2"
Distance form bottom of scum to bottom of outlet tee or baffle: 12'
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) ,
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction:X concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:n1a A
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
nla
(revised 11115/95)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C..- _
SYSTEM-INFORMATION(continued)--
Property Address: 1327 Mary Dunn Rd.Barnstable
Owner: Crockan:Box 387 Cummaquld,Ma.02637 _
Date of Inspection:711Q/96
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla - -
Material of construction:X concrete_metal_FRP_other(explain)
- Dimensions: rda
Capacity: n1a gallons
Design.flow: n1a gallons/day
Alarm level: nla
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Na
(revised tU15195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
—SYSTEM INFORMATION(continued)
Property Address: 1327 Mary Dunn Rd.Barnstable -•i .',
Owner: Crockan:Box 387 Cu
Date Ma.02637 tll
Date of Inspection:7110196 -
SOIL ABSORPTION SYSTEM (SAS):X --
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain: ,I
n1a - -
Type: -
leaching pits, number: 11=000 gallon leach pit -
leaching chambers,number:nla
leaching galleries, number: n1a -
leaching trenches, number, length: Na
leaching fields, number, dimensions:n1a
overflow cesspool, number:n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The leach pit is in hydraulic failure.
CESSPOOLS:_
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nla
Depth of solids layer: n/a
Depth of scum layer: n1a
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n1a
PRIVY:_
(locate on site plan)
Materials of construction. n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
nla
(revised 11115195)
41
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1327 Mary Dunn Rd.Barnstable -
Owherr -Crockan:Box,387 Cummaquld,Ma.02537 -
Date of Inspection:7110190 -
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' -
Q
r0!l�
A4 1�
Ab (�
�c
DEPTH TO GROUNDWATER
` Depth to groundwater:12 feet
method of determination or approximation:
USGS MAPS AND CHARTS
(revised 11115195)
• 9
`= TOWN OF BARNSTABLE
LOCt:-.TION 32-� v, aA141 SEWAGE # b"
VIVAGE C u12�/N'1.�-�; �/ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. .T'"do
SEPTIC TANK CAPACITY
LEACHING FACILM: (type) (size) ,
NO.OF BEDROOMS
3 �
BUILDER OR OWNER �L,ItM COQQ('_ kAA1
PERMT'DATE: �'C � � 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) Th/ Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fee leac 'ng f ility)� Feet:
Furnished by �/''
t' r
-
s IF
d.
tq
No: !• /� / ✓ ®� r* Fee T
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0pprication for Mf!9pool *pgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address-orLot No. Owner's Name,Address and Tel.No.
132� qRY s UAM/ Cc 3_i' 4 ��v 64 M)
Assessor's Map/Parcel
Installer's ame,Address,and Ted.No. Designer's Name,Address and Tel.No.
--y �2
l s I k Q Ron),--
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow -200 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations Answer when applicable)
/v 66
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 o 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i u d ss by s oard He o
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 96 Date Issued `7 9�
No. _3 �-r 1% 33
/ 00 oO o 3 ` Fee
44
THE COMMONWEALTH OF MASSACHUSETTS
r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYtcation for 30t5po5ar *pgtent Con!6tructioif'Permit
' Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System:at:
Location Address or Lot No. Owner's Name,Address and Tel'.
13* � MAC y Cam. c 'iq nl
Assessor's Map/Parcel
�h
Initall er'sname,Address,and Tel.No. Designer's Name,Address and Tel.No.
i
t
;--1 5,4 ( rr Ac.e-� �i�(1 . Rou.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
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
Description of Soil 4t 1
X � 1
8 y
Nature of Repairs or Alterations Answer henapplicable)
Date last inspected:
Agreement:
The undersigned agrees to ens'ure the donstruAZn and maintenance of the afore described on-site sewage disposal system #
in accordance with the provisions �`I� m�'rtl 5 of the Environmental Code and not to place the system in operation until a Certifi-}
Cate of Compliance has been issueii by s oard of He
Signed 1 A Date —c1919,
Application Approved by Date P -
Application Disapproved for the following reasons
Permit No'. 96 F, Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(C--'on
by 1' M o 2 Installe
at t ( a i has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Constructio rmit N . to - 2 dated
Date '/ g Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
---Q----- ------- ---- ----- -------
No. /G /.� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS'
Miopogaf *p2lem, Conotruction Permit
Permission is hereby granted to � (� / "/n /P iyL)
to construct( )repair( t).awOn-site Sewage System located at No.# / Z? V
04,.fj Q g G%L/
Street
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
p. " e �C l/i'�-
Date: � � Approved by �����/
Board of Health e�
i
f
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, , hereby certify that the application for disposal works
construction permit signed by me dated concen the
cl u
property located at meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in now and/or change in use proposed
a There are no variances requested or needed.
SIGNED : / " DATE:
LICENSED SE C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
� s�
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No� - �ZEY.4ljo.c/S BAs E"D d�J
Ass e-D 2)/fin,,y
CERTIFIED PLOT PLAN
E.
LOCATION .?T9j'-'�
SCALE . ��=. . . . DATE
PLAN REFERENCE
1 CERTIFY THAT THEX�ST!NC !n�,voATla✓
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETPACK REQUIREMENTS OF THE TOWN OF
WHEN OONSTRUCTED.
DATE '47AY.
PETITIONER: 13'A;�--"z7;-le44- 19,Ass,
REGISTERED LAND SURVE
N59 1
7AL- CE Al7Z_)_
TOP OF FOUNDATION • qc 7ty�^ !Ei►ci/ P17-
i9�D•'
jW �� 'S'�"'D•CONCRETE COVERS CONCRETE COVER
•-•
4"CAST IRONr
PIPE (OR 12"MAX.
. ' EQUIV.)— MIN. 4"ORANGEBURG(OR EOUIV.) 12"MAX. 70mv � i�aen+•
• ••, PITCH I/4"PER, PIPE- MIN. I
e • PITCH 1/4"PER.FT LEACH
e' NVER�T PIT PRECAST
EL.6B
J LEACHING
.. . 7...
INVERT "::
e SEPTIC TANK Z DIST. INVERT • . t PIT OR
INVERT EL..�". . 1 . W �',
e; EL.GB.44. . /o q.o.. .. GAL. INVERT BOX EL.6.7.9�. :.; EQUIV.
� a ;,:;
ELF.6. INVERT w W O �, 3/4 TO I V2
EL67
e, , WASHED
/o 6 %; W STONE
':;'' '•' —' ��' DIAL--�-� .vo
PROR LE OF �_
GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE PRELIMINARY
SOIL LOG WITNESSED BY :
DATE APR-6.1.7./979 TIME.io'3o A4'1
TEST HOLE I TEST HOLE 2 BOARD OF HEALTH
ELEV. 408 494. . . �8 Ao 7f sA� `� / P�.'. ENGINEER
�l SASS DESIGN DATA :
S�8 So�C.
N
OF BEDROOMS
� E
NUMBER
s�D F,^�E TOTAL ESTIMATED FLOW 330
h S.4�vD • • • . . . GALLONS/DAY
Fl"4 BOTTOM LEACHING AREA !�
µ°xc . S0.FT. /PIT
F,N� S,q�,D ie„ /7.�� 9 3
0 CL4y Awe" SIDE LEACHING AREA . .
/101 Fy v� SA+.D . . . . . . . SQ.FT./ PIT
GARBAGE DISPOSAL eyq!' t,' . .(50% AREA INCREASE)
�c44 si+,.n d OF C41*y TOTAL LEACHING AREA j?cJ.•,87 . SO.FT
ot.dy Hxc-fl ;
/80,i_ PERCOLATION RATE . . . . . . FlVdc- . , , MIN/INCH
!�o. . .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE' .3, SOFT.
NUMBER OF LEACHING PITS
. .
APPROVED . . . . . . . BOARD OF HEALTH ��`M• ��`. �?�?��, s v Si 71./ ra,vs f
DATE. . . . . . QFSrp.vE-. �•x• PiT . . . . . . .
THOMAS E.ICELL$'�CO:
AGENT OR INSPECTOR ENGINEERS—SURVEYORS
346 LONG POND DRIVE
TH YARMOUTH,MASS. ASH OFM
AS: 026"
THO
E.
�L►1zy D `_. .• LEY
No.242611
1�!�GG/Aro F. G�sTER�`
PETITIONER ' ,C•ryjp," FSs�ONALENb�
' ,YA�zvsr/-��?LE /`piss `�A-.
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UG' CAT A SE G E PERMIT NO.
VIaLLAGE
1 TA LLER'S NAME i' ADDRESS
e UILDE OR OWNS,
DA T E P ERMIT ISSU E D
DAT E COMPLIANCE ISSUED � ,
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THE COMMONWEALTH OF MASS ACHUSETTS
BOARD OF HEALTH
................OF........
............................
Appliration for Disposal Works Tonstrurtion JIrrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Location-Address or Lot No.
00r_
........................................... ete,
Owner Adaress
............................... .......... ........................................
Installer Address
Type of Building Size Lot..--------------------------Sq. feet
U
Dwelling—No. of Bedro oms........NS..............................Expansion Attic Garbage Grinder 4
04 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria
PaOther fixtures ......................................................................................................................................................
Design Flow............. 33.0.................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid*capacitye.4209.gallons Length................ Width........_._..... Diameter.______..._..... Depth................
Disposal Trench—No..................... Width...-........._...... Total Length__........_._._..... Total leaching area.....................sq. ft.
I
Seepage Pit No..................... Diameter.............__..... Depth below inlet........._.......... Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
aPercolation Test Results Performed ...................... Date... ............,_-aTest Pit No. I......%�----minutes per inch Depth of Test Pit..,./3-"' - Depth to ground water........................
P.-I
44 Test Pit No. 2................minutes per inch Depth of Test Pit..............._._.. Depth to ground water.._.................___.
................................................................"------------- ....................-----------------*.................
0 Description of Soil.......efg�� S.,!9-nV ....... Q. ....�_5AI.,.V ..4.... 16.,.��.Z.;.o.V_----
W a ............................
.........................................................................................................................................................................................................
U
.........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with
the provisions of'LITiZ 5 of the State Sanitary Code—The underygned further agrees not to place the system in
operation until a Certificate of Compliance has been by/
"phe It ealth.....S e
Signed. . ....................... .. ................................
..... ............
Date
ez_eol
Application Approved By...."'---- 71.......................... ............... Date..............
Application Disapproved for"the following reasons:................................................................................................................
........................................................................................................................................................................................................
Date
Permit No....................................................... Issued_... —7
--------- ........................
Date
7 ;:z
No........... FEB..........`.................
THE COMMONWEALTH OF MASSACHUSETTS
4-BOARD OF H.EALTH,
............OF...... z -------------------------_--
Appliration for Disposal IVorkfi Toustrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System-at:
................... ....a/...to.................................
Location-Address or�t No.
e—
./.V* J&.. .......................................... .....ZOA045
Owner Ad---1-s-s-
ilAejoc................................ e
........................................
Installer Address
U Type of Building Si2e Lot............................Sq. feet
Dwelling—No. of Bedrooms....:.................................Expansion Attic Garbage Grinder
04 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria
P4Other fixtures ......................................................................................................................................................
Design Flow.............j331C>.................gallonsper person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid'capacit .gallons Length.__'..:::_.::... Width................. Diameter................ Depth................
Disposal Trench—No..................... Width.._.._.............. Total Length......._._....._.... Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter_........__..._..... Depth below inlet.._..._._........... Total leaching area..................sq. ft.
Other Distribution box Dosing tank
Percolation Test Results, Performed by.,&WeZd19.�,... k .................. Date.._.e�.2P............
Test Pit No. 1...... r-___minutes perinch Depth of Test Pit—.43._4..... Depth to ground water........................
fiq Test Pit No. 2................minutes per inch Depth of Test Pit.._........._....... Depth to ground water..__._......._..........
.............................................................................................................................................................
0 Description of,.Soil......=e��.....S4,V?v27.....— . ............................
....................
.........................................................................................................................................................................................................
U
................. ................................................................................................................................ .....................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual, Sewage Disposal System in accordance with
the provisions of'T'LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
-
operation until a Certificate of Compliance has been issued by the board of health.
Signed Date
Application Approved By.... ........................ .1�r-11...............
7.. ................ ...
-------------- ------"...........*----------------------------------------- -------------*......
Date
Application Disapproved for the following reasons:..............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF............6.:Z-044
(Infifiratr of Toutpliatme
TH S.TO CE)?TIFY, That the Individual Sewage Disposal System constructed �or Repaired
by ........
..........t. ...........................................
... .................. ---i
-- ------- ..........-------
at__ .__..._ Install .
.t n
Z-0
acco;�daince with the provisions off PLE 5 of The State Sanitary Code as described in the
has been installed in
application for Disposal Works Construction ...................... dated---P-----------------1�------------ ----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A-GUARANTEE THAT THE
SYSTEM WILL JFUNCTION SATISFACTORY.
DATE................e.......................... .... ........................
Inspector... ..........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O/F HEALTH
..........................................
........... . .....�OF...........
Disposal ]Vvrkg Tizotration "pamit
Permission i� .......,�s . reby granted... !V_�.40% ....................... ...... .........................
to Construct or epajr anmividualswag6 Dipssa-1 System
at No.. ...... � a �
. -
Street
as shown on the application for Disposal Works Construction Pe a IVo. Dated:.: 7�................
DATE. .......... Board of HeaV
---------------------
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i FORM 1255- HOBBS & WARREN, INC.. PUBLISHERS
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CERTIFIED PLOT PLAN
EDWARD E, KELLEY LOCATION .� ST
adl1WV-.QUID, MASS- 026K . . .!9 � !%Ass,
SCALE . �� .' '. . . DATE !?�
PLAN REFERENCE
0v "
131,
1 CERTIFY THAT THE 1G:olA!P,4170A
No 510c SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
W.,LG/.A7A7 A, SW//=j! DATE
PETITIONER:
REGISTERED LAND SURVEYOR
N59345
' - NoT�-- �t.L �/dp�e.vious /sr��'/.gc.• .S/-/i�"�?` Z ate` Z •S/-/6�'7�
TOP OF FOUNDATION OF 77-le LEA~/ P/7 fY�D
)e&?4,}cL-n W"7w coo Av✓ Si' n. CONCRETE COVER
CONCRETE COVERS
0 4 CAST IRON }��r �n�Jr
PIPE (OR 12"MAX. 12"MAX.
4 ORANGEBURG(OR EQUIV.)
EQUIV.)- MIN. PIPE- MIN. LEACH
PITCH 1/4"PER, PITCH 1/4"PER.FT. PIT
PRECAST
o' INVERT . Q ;�,:: LEACHING
`.e EL. %67... INVERT INVERT a - W 0 PIT OR
SEPTIC TANK EL•• z9 DI ST. EL G79 Jam.. :; ;;; EQUIV.
,•o INVERT BOX
44.0. GAL. INVERT �: 3 e; EL....'....... INVERT o a ::. /4"TO I I/2
EL... /6. w o
EL 47.7p ;. u- v: WASHED
w STONE
PROFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE mlIU���
SOIL LOG WITNESSED BY :
DATE TIME.!o'30 ?iZt/G u*�2, / BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 7/tibhAS Y/ ENGINEER
ELEV. .G8<84. . . ELEV-48-Co
�r S$ DESIGN DATA
I/ S�8 SaG►
3O„ 7l34,1 NUMBER OF BEDROOMS
r�,vE
Sf�✓D /C/,vc TOTAL ESTIMATED FLOW 330 GALLONS/DAY
7Z SAD BOTTOM LEACHING AREA SO.FT. /PIT
pe". `\v *'4 SAD /08" SIDE LEACHING AREA 3. . . SQ.FT./ PIT
/Lo'/ ;' �'�� 'S�'D GARBAGE DISPOSAL (50% AREA INCREASE)
SAVO � //rN TItAdZ
144" of C4Ay TOTAL LEACHING AREA SQ.FT
,/
/f a r►�xc-D /80// PERCOLATION RATE . . . . . . /�E. . . MIN/INCH
LEACHING AREA PER PERCOLATION RATE .�. SQ.FT.
No. WATER ENCOUNTERED
NUMBER OF LEACHING PITS ��T w/ . �?��.
APPROVED . . . . . BOARD OF HEALTH F27'7" 0,t . S7o4vE, aokJ A'.(. SiDEs, = u-/ 7VtiS
of S7VAd A-Z T
. . . . . . . . . . .
DATE . . . . . . . THOMAS E.KBLLEl�CO: '
AGENT OR INSPECTOR ENGINEERS—SURVEYORS
346 LONG POND DRIVE
SOUTH YARMOUTH,MASS, �a�'fH OFlyAss
Ltd DF Amcq 02664
� THOE E.
L Ep;NAR DLo'
LEY
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PETITIONER �D s�
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B�iX?.•e/sTGYBI.E' /'�A-Ss. <.