HomeMy WebLinkAbout0121 PALOMINO DRIVE - Health 121 PALOMINO DRIVE, BARNSTABLE
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54 Acorn Drive, W. Barnstable
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Z TOWN OF BARNSTABLE C/
LOCAi ION PC"(® m-k► _0 Or v\Fv-- SEWAGE # 66 Z
VILLAGE 1 k-�`�� ASSESSOR'S MAP & LOT OZa�-0 _
INSTALLER'S NAME&PHONE NO.�
SEPTIC TANK CAPACITY C-7K/ f CIlo
LEACHING FACILITY: (type) -Ike (size)
NO. OF BEDROOMS 0
BUILDER OR OWNER � �
PERMIT DATE: 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
N
I '
��'�p --
6
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2 s ild-
�l e L w o
No. O�� 5 l .�. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _es
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Z(ppliration for ;Dioogat *proem Conelruction Permit
Application for a Permit to Construct( . )Repair X)Upgrade( )Abandon( ) ❑Complete System irtdividual Components
Location Address or Lot No. �
� a t,d Owner's Name,Address and Tel.No.�1 `nn, R-
Assessor's Map/Parcel _bOCrIS�b`C I Pit&_ B'TCA EtAC?.
OSA spnMG
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-0�5 5v k-+C- SQ-N owe.. ISO,-Ay Clio. v\1 CS
co�t3.63,� 539-39&4,
Type of Building: l -7��
Dwelling No.of Bedrooms Lot Size=L '9.ft. Garbage Grinder(!11",
Other Type of Building O No.of Persons Showers( ✓SCafeteria( i,
Other Fixtures Lau A:TB�u iic iwA 6 wk , /erg y
Design Flow �Xj gallons per day. Calculated daily flow 331 l ft gallons.
Plan Date I ®S Number of sheets Revision Date
Title t'b C, �4SvC
Size of Septic Tank Type of S. .S. L A10f S
Description of Soil, C" pS ,\ n`c4N 34lyX IDIX I
Nature of Repairs or Alterations(Answer when applicable) 199_ A-0 .DkGn
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 b alt r
t ne Date 97119 6�
Application Approved by Date Nt
Application Disapproved for the following reasons
Permit No. DOO 5 q6 6 Date Issued
" No. (W 5 40 ��„""." Fee
THE COMMONWEALTH OF MASSACHUSETTS _
- !Entered in computer:
Yes
...._ z PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
„Rpplication for ;0*oM *pgtern Construction Permit
Application for a Permit to Construct( )Repair)Upgrade( )Abandon( ) O Complete System �Indiv'idual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
�cr n sib�e 1✓1� Al q-ru����,. r3>=,°rc N Et_��.
o b-4 SAMc
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
R� s C,C 1904Y E1jv, s,JCS. ,-
(o 46 S 39 - }!p!F
Type of Building:
Dwelling No. of Bedrooms .3 Lot Size i -3.tsq.ft. Garbage Grinder(Gl(
Other Type of Building 110(l Z No.of Persons Showers(K") Cafeteria( V
Other.Fixtures tl;i [rkhr,-J 6 rn1A- . L_.AuNO9-`r'
Design Flow �_�C� gallons per day. Calculated daily flow 331 a 80 gallons.
Plan Date CO'S Number of sheets I Revision Date
Title cap �\ �il�S�C�c cQ �Cz t�1GsF? �1 is G7.3�S� S uatet Yl
Size of Septic Tank W Type of SA.S. �� /Al Fl L Ti_t47t e_S
3X /v1X t
Description of Soil;` _�p nr GS\
Nature of Repairs or Alterations(Answer when applicable) e_RQ qSk(_ _�o Qkic)
Date last inspected:
i
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 sbbeen--issued by this-BaaTd of HealtW, G
S a Date �1-I O `1(5�
Application Approved by e 1 Date R 1g' 1
� 1
Application Disapproved for the following reasons
Permit No. c0 5 q0 6Date Issued ' IsK 'S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
,(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(y)Repaired( )Upgraded
Abandoned( )bynr � r,�;�
at ��3L N ��\� . �:r� •T�C?�» .� able has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No,112 5 '06 dated "�1)2/5
Installer ; c"c'7-, ems- -r Designer �_1 -�_. �.u. .1 e,S
The issuance of this permit shal pt be construed as a guarantee t>a the-sy'g w�n h n as desi .red.
Date q ai m} Inspector�
. . No.�w � 7U � ----------------=----------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mie;potar *pgtem Con§gtruction Permit
Permission is hereby granted to Construct( )Repair( )'Upgra (Abandon( )
System located at ;—r ,�n, !"n1�
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 t_�p
r
Date:___ Approved"by--_a..
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems.,Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, hereby certify that the engineered plan signed by me
dated JS I--v 0s concerning the property located at
Wom toe, 7)e- Ca, -% meets. all of the
following criteria:
• This failed system is connected to a residential dwelling only. There.are.no commercial or
business uses,associated with the.dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests at the site without a health agent present.
• There is no.increase:in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information). • ��
B) G.W. Elevation +adjustment for high G.W.
DIFFERENCE EN A and . Q .
SIGNED : DATE: Los
' NOTICE
Based upon the above information; a repair permit will be issued for bedrooms
maximum.. No additional bedrooms:are authorized in the future without engineered septic system
plans.
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q ASepdc\pemexemp.doc
12/04/2015 20: 17 FAX fa001/001
Town of Barnstable
Regulatory Services
'Thomas F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862 4644
Fax: 508-740-6304
Installer&Designer Cerdfiication Form
Date: b
Designer: _Shay Environmental Services_Inc, 'Installer:
Address. P,O, Box 627 Address:
East Falmouth, MA Q2536
On — - was issued a permit to install a
( ate) (installer)
septic system at f�}-.l �.� S�Q'�V%CQQ •11
x n b ed on a design drawn by
(address)
ha Environmental Services Inc. dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e,
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow.
CARMEN
nstaller's Si e E,
SHAY
No. 1181
SRN1ran+A`�
(Designer's Signature) (A tx De tamp Here)
PLEASE RETURN TO BAY NSTABLE PUBLYC ITEAT.7U DI"VTSION. CERTIFICATE
OF COMPLIANCE 'V41ILl:, OT BE ISSUEII UNTIE, BOTH THIS FO-" AND AS-
BUILT CARD ARE RECEIN ED BY THE BA TABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Ho'dWSeptic/Designer Certification F tm
LOCATION SEWAGE- ' PERMIT NO.
VILLAGE
INSTA , LER'S NAME & ADDRESS
1� a de/
5
!� .A `
� '
BUILDER OR OWNER
f,4 <
DATE PERMIT ISSUED 7`
DATE COMPLIANCE ISSUED
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No:�S�� �.� - FR$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
s �.1,vim...-..... .OF.... � ....
/�z 1 Appliration for Uiipuual Works Tomitrnrtiun ramit
Application is hereby made for a Permit to Construct (✓f"or Repair ( ) an Individual Sewage Disposal
System at:
Location-
Address
Er JLi2tNo.
Y.
........................................e ... . T
Owner Address
..............
..... ................................................... ............---- .....................................•.....
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............. No. of persons.....__.._._.........__.___. Showers — Cafeteria
aOther fixtures .------•---•----------------------------------•--------•-•-•-•---•-•••--•_-•-•-••-•---- •--•----------------------•-_--•-•--•---------- •----------
Design Flow.._...._...J` .........................gallons per person per day. Total daily flow....... 35cs---..-_•--.----.-_........_.__ gallons.
Ib,W Septic Tank—Liquid capacity.4 �5'E' .gallons Length_A !-° "/.. Width:'�� ...... Diameter................ Depths:``'...
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......L'------------ Diameter.....f4;..t..... Depth below inlet.....4............ Total leaching area..ZA.7.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by...s .- ..� L---�S-•----.-. Date.... � ............
Test Pit No. 1 __�-----minutes per inch Depth of Test Pit... ... Depth to ground water..... ..
Test Pit No..r..:!�:..L..minutes per inch Depth of Test Pit...A3:...... Depth to ground water..................
P4 ..............•--------•- - . .......................................................................................
0 Description of Soil... .`.��- � 4 -..--,-=�`- - � Gr'l �`1 �74 s `
�...... E r..... ��`1 e' '/.I/t�j....�/V°i a�•_ J�I'GS ,--•-----
U .... _
W .- !`3�" � G'. �tT"� .! ...........................................•-•---------•------.....................------.........-•-•--_--
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 TiTL I-2 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has d by the 5o �=.igne .--• ••--••• • ........-• `�V --- ------- ................................
Date
ApplicationApproved By..... .--_ .......... ........................•••.......... ................................
Date
Application Disapproved or a following reasons:-------•-----------------------------------------------------------------------•--------------------......--•-•-
-----...--•-•......................................•--------•----------------------------......._-_•-••--
------------------ --
Date
PermitNo......................................................... Issued......................................................
� Date _
2
`�3- . F�a...... ._..... ....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
..•----- l.n !✓....-----.OF.....J. ... r 3: ,f-6— ..........................
Appliration for Diipusttl 10ork,5 C> ongtrur#ivaa amit
Application is hereby made for a Permit to Construct (=,")_or Repair ( ) an Individual Sewage Disposal
System at:
< L!Gv fid dV/Z 6/t7c,f i Srl'-7 Fj r 4A7 f 0-Z—
................
__..._................• -----•wrZr--•---............•................ -------------..............••-----•--•-Wo..------•-----......_..:..................
Location-Address or Lot No.
� 9L� GlGSu�✓ 1.!frJ�✓i�....7v/G'
........A........................................................... ...................... ......._.....-......_......_.............--.-.-...---....-_-_..».-.._PR; I
$L. Owner Address
W
Installer Address
dType of Building �, Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............-3...........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a
� Other fixtures ......................................................----------------------•--------------------------------------------....._..--------........_._.
W Design Flow............. .........................gallons per person per day. Total daily flow..............._.-3�_.....___.__._.__.gallons.
PG 41
Septic Tank—Liquid capacity..�e!?f?gallons Length__P! `"--_ Width..: 4L".. Diameter................ Depth.:.��....
Disposal Trench—No..................... Width.................... Total Length................. Total leaching area....................sq. ft.
Seepage Pit No................... Diameter.....2_`..... Depth below inlet.....�:........... Total leaching area...% _ .....sq. ft.
z Other Distribution box ( ) Dosing tank ( ) �.
'~ Percolation Test Results Performed by...S/2 .Vic........:'��.. ...� -...... .�__........ Date....gl .L:L :................
aTest Pit No. 1 G_.. -._..minutes per inch Depth of Test Pit...± .` Depth to ground water........................
Test Pit -minutes per--inch Depthfof�Test Pit.__.....i.__._._... Depth to ground water_____ ______________
a :.....................•............ ........_...........*------------------------------------. -----
O Description of Soil...6".7 2`r• ��,�s!cT • �7�
-----•----- ----------------------------••......... ... ---------------------------------......--•---•...
►Ui f 14'-� . G%x•"7t/J�;CT� ..iera/h .../J1'� GLi...7-
'f r �� /IX••.......ZING.' 1x//,//7Z--- J�
....
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 TITLE 5 of the State Sanitary C — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e d by the b' oa of i ,ly
ign ... ........ . . .....• ......................................... ---- ................................
Date
ApplicationApproved By..... •. -•......... -•••••......•..............••...----------•••--•---....._.._........-
Date
Application Disapproved or a following reasons----------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------•----------------•-•.••-•-------•-•-•----•--••-•••-•-••--•---------••--••••--•-••......... .................
Date
PermitNo--------------------------------------------------------- Issued........................................--.............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... 1�,rs✓ }1c N57%) . ...................................................O F......:.....::......................................
_ (lr ifiratr of Tompli�ana
fr
TH - � , dividual Sew ge Disposal System constructed (a )'or Repaired t ( )
...Z
IcIf C �Gt1:v.,GGtG /,IIrx�taller
at........•---•••••---.....--•-•---•-••..................•---•-------•-•-••...-•••-•--•---.•---------•-•.-----------------------.._..has been installed in accordance with the provisions of TI5-9& /Ktate Sanitary in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
SYSTEM WILL , NC ON SATISFACTORY.
DATE....
l. ... � ......-----•-•----....---• Inspector.... ....... ...................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`.! A/.........OF........ � ? ?t{f, J/ G yo
No......................... FEE........................
Permissionhe- by granted f/r`- � -------- --------------
to Constr t�;.. ~ R tf` r
( ep ( Si a Individ S a e Disposal System
at -------- ..................................................•......--------.....------------------...... ----- ==---------------•- -
Street
as shown on the appliC_atjOn for Disposal Works Construction Permit .. .............. Dated..........................................
_--
...................� ,•.•-------------------------------------------------------------•-------
g
Board of Health
DATE f._.. _.l) ._._
FORM. 1255 HOBBS & WARREN. INC.. PUBLISHERS
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+TOP OF FOUNDATION
e
CONCRETE COVER
CONCRETE COVERS
0 4".CAST IRON .12"M `
PIPE (OR 12"MAX
Pill )- MIN. 4"ORANGEBURG(OR EQUIV.)
PITCH I/4'PER. PIPE- MIN. LEACH
"• PITCH .1/4"PER.FT. PIT
0 o PRECAST
-j LEACHING
o' NVERT Q
EL..!lo,00. \-INVERT INVERT e W �.� PIT OR
SEPTIC TANK EL/os-A$ DlST. EL��4<30, , EQUIV.
a INVERT BOX _
e EL.!4`hgs. /000.. .. GAL. INVERT ;: L��a or
��.
ELl.4.:�7 INVERT w W •;.. 3/4"TO I I/2,
a EL.!4.$... .• �: ;. WASHED
W STONE
�.• -- +--WDIA.
/O' DIA---+-��+ueowrweE�
PROFILE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
5EZ- 5f/6Z- -di ,ra,e 7Z3' � NO .SCALE
SOIL LOG WITNESSED BY :
DATE TIME.��.�30 .4r7 T, N .TAcor3/ BOARD OF HEALTH
TEST'HOLE I TEST HOLE 2 .57Z�3'o�v �_ /�i}LL �,5.
ENGINEER
ELEV. .!!¢.So . . /L,Zo J •
ELEV. .. . .
" �� .So z4�� `'"" DESIGN DATA
P-11cmM 3
,*,✓D NUMBER_-OF BEDROOMS
84„ Z. �o7,go eo"PAP TOTAL ESTIMATED FLOW . . .330. . . GALLONS/DAY
SA*/D
�„P y w1r14 BOTTOM (EACH 1 NG AREA 78�c. . SO.FT. /PIT
s.a+.a w�na
F7NV&-3 gy SIDE LEACHING AREA . . . SO.FT./ PIT
�, io2,8u144 GARBAGE DISPOSAL . . .(50% AREA INCREASE)
Frni� TOTAL LEACHING AREA SO.FT
wrtr7Z.7-
PERCOLATION RATE 73Mp. MIN/INCH
—
LFACHaN&---AREA PER�ERCOLAT1ON-RATE_-';FQ. SO-FT.
- --_-Np .WATER ENCOUNTERED
NUMBER OF LEACHING PITS . 1. .
APPROVED . . . . . . BOARD OF HEALTH T'r'V�• T O� :ST�w .�N A?'{�
.3/aE3
DATE . . . . . . . .
AGENT OR INSPECTOR
SH OF 414
a�T11 OF o�
e EDW cCD p, a
Lo 7 Z � '.
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PETITIONER : °tsT x
rlm \
Commonwealth of Massachusetts , .,Executive Office of Environmental Affairs 04
p * Department of
[Environmental Protection
William F.Weld
Govemor
Trudy Coxe
Secretary,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION*
./ _/ ^� �.
Property Addres��0 1 jQj1-/ Address of OwnerO�r� `��'�`�
Date of Inspection: "7—a�-r-t (if different)
Name of Inspec or. g7c V �j� S
Company Name, Address and telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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:
asses
— Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspe ion report to the Approving Authority within thirty (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 repot to the appropriate regional office of the Department of Environmental+Protection.
The original should be sent is the system owner and copies sent to the buyer, if applicable and the approving au:horit .
INSPECTION SUMMARY:
Check A, B, C, or D:
Aj SYST M PASSES:
. 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
81 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.
trevised 8/15/95) 1•
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART A
CERTIFICATION (continued)
Property-Addrtss: I OZ� Jt 1 rJ W jA,0 10
Owner: 1L�v_e
Date of Inspection:-7_ a 3-- f _
B] SYSTEM CONDITIONALLY PASSES (continued)
7 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or 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 levelled 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 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 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.
1) 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:
_ lhp wstem nay a 5epUc tank ano soil ausorption syxem and is:withlii 100 foci to a Su1ai.c 'watei Swpp!) or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I 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 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•
D] 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 into facility or system component due to an 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.
1
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION (continued)
Property Ad
Owner:
Date of Inspection:�_,�3_a�
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 1/2 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 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply.well. '
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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 above:
The design flo-,N, of system is 10,000 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 suppiy 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.
• C
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prope t5s:
Owner: N
Date of Inspection:
-7--q
Check if the following have been done:
,, mping information was requested of the owner, occupant, and Board of Health.
�ne of the system components have been pumped for at least two weeks and the system has been receiving normal 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.
- The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
_The site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on the site.
Jfhe 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.
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.
_ he faciliov. ;J-_2 occupant., fro"n ov,ne' were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8115195; 4
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
Prope�A,dsiress:
Owner: \ -ec.Q
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL-
Design flow: U allons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Laundry connected to systerrl(yes or no):,-
Seasonal use (yes or no): /
Water meter readings, if available: L Id -
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available: '
Last date of occupancy:
OTHER: (Describe)
Last date of occupant},:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes,.volume primped: gallons
Reason for pumping:
TYPE OF TEM
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)-/—^/
(revised.8/15/95) w K 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART C
(� (` SYSTEM INFORMATION (continued)
Propert s:
Owner: ddres"o—
Date of Inspection:
TIGHT OR HOLDING TANK:
9
(locate on site plan)
Depth below grader
Material of construction: _concrete metal FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(Locate on site plan)
Depth of liquid level above outlet invert: ^L
Comments:
(note if level and distributiol, > eyua;, e.;uence of so:id: ca;r�u�ei, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
% (locate on site plan)
Pumps in working order:(yes or no)
Comments: +
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
i
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddress: ��j fi4)0V'k\,U0 s®Y`o.Q� t•l�S � .
Owner: �.+e
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: -
leaching pits, number.
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
Say
CESSPOOLS: I
(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 (cesspool must be pumped as part of inspection)
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.)
$
(-revised 8/15/95).
v
,^ r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property'Ad ress: a, �`o `� c)
Owner: I;��o, c� �
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
I I .
`N
a
060 Sir
DEPTH TO GROUNDWATER
No(U,g r-
Depth to groundwater: feet T
method of determination or approximation:
(revised 8/15/95) 9 J
2-10" DIAM. ACCESS MANHOLES ,-
- SECTION A A w t�7-�4-
OUTLET� ;: a m*. a10 mint. fromNOTE. ALL PIPES ARE TO BE 4 SCHErDULE 40 P.V.C. iN�tT
vEaT PIPE o Leoet z4 tnches tali :'PROFILE VIE1P O LEACR•ING SYSTEM(( '121 PS rf Ane iKEx+shng foundation house to wsept(c tank Schedule 4d PVC w Charcoal Odor FilterSe ctank caves must b#1 0. 0 Ass med r "TOP OF FOUNDATON ELEV. 0 0 ( u ) 3 oft 8 t 2 Woehed Peaston «awithin a k1 01 flni#hed rode r9 _ _ THE ACCE55 COVERS fOR THE SEPTIC TANKtrade overseptio Tort- 98.00 Trod.over D-Box ,».eo owr SAs 9T,30 3J4 to 1 1/2 Washed GumFted stoneDISTRIBUTION Bt)X ANb LEACHING COMPONENT SET t'�EEPER THAN 0 MCNES BELOW flNISHEDGRADE SHALL BE RAISED TO 1NN1H1N a OFFINISHED GRADEs o.a2 �HOLE H-taSTEEL'REINFOf2CED PRECAST CONCRETE r e -EFev -S4 30
ap t.00 4Dist. BOX 3 Maximum Cover � tNSTALL 1UF-111E GAS BAffLES OR EOUALSV .EXIST.': O.ot or + ! !3 .,,, 14 .theater 1 beax 1 CA5 _E IST. TFE �� LP s- a0t r toot ♦ ou♦tPe as 3-24 Rttovra�E tov�Rs,, o'erteeti�. to rRDN Ex1sT. rtwNnAnDN '� . SEPTIC T{+NK b � a2ar+sttansrt,,�tnattys ��'i.N:,5 Units t 6.25 301MCONCRE?E i111t t'Ol1NU4T10N--� 84� 0.83 10 inches 3 3 .�t ) •1 . GENERAL NOTES
� n tr 315 _� t, � 3 mtn��, dsorance 13„ tNL[T r1.;, - 0 min. m :4_ !t •- INLET 2 h. i+lat to outletln. } 3 ♦ 1 0 , tt mf�e o i 2 1 •PROFILE 3�•25 OUTiFI o r r
SYSTEM,, > M T1. C nt actor s es onstble for-Dtgsafe notification
compacted#tons � a, u d 1e�-
> Td o'm 3e ffective Le th w+ 14 pE ►tg and protection of ai} under round utilities and t es.
NoE to Saale f - ;. , _ ♦ � q. P p4 4 a >• 2. The'septic tank a distri 9 ton box shall be set
SOIL `ABSDRPTIpN-SYSTEM tSAS3 � d5 ., �c . i=_ level on 6of 3 f4 -�1 1 �2 stone.
- �i 4 0 mtn. / /.• 04 ,. id d to 3. Backfill hauo 3 cl n son ra in.of 3/4 1 1/Z „ iNFiLTATRCIR HIGH CAPACITY fH-20 LOADING>l GEDRGE d BRIEN o �' ep s ea d o grave with no
compacted #tone Eff etive Vtdth „+8stones over 1" in :size..t i w„ Not to Sca e . .NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHIN B BELOW GRADE (OR EQUIVALENT)Bottom otT#et Mas 1 Etev.-e5,0o m 4. Th+s system Is subject #o lnspsctton during Installation
No Groundwater observed o 144» » „ .,; NOTE. OVERALL HEIGHT OF INFILTRATOR IS la3 /EFFECTIVE HEIGHT IS 10 ••�.�•,:• •, '+�.�•.t. •� .. ,,: ': . . � , .. � • l by,;Carmen E. 'Sh0 ,- Environmentgi Services, Inc.
Y4' -10- 5. The contractor shall install this tem fin accordance
ENO-S Tlt)N with Title V of the Massachusetts state code, the approved planCROSS SECTION EC and Local`Regulations.
6. If, durin installation the"contractor encounters ansoil onditions r , i n h r ,f YTYPICAL. 1000 GALLON SEPTIC TANK c di a Btte ;condito s t at a e dI ferent
from those shown on the soif 'log or In our design
NOTTO SCALE instailation must halt &:immediate notification be
made to Carmen:E. Shay - Environmental Services, Inc,
rT7. No vehicle or heavy machinery shall .drive over the
t- ERCOLATION TES I septic system unless noted as_H-20 septic components.
PL
�� �O165.00' '� °p8. Install Tuf-rite gas boffles or equals on all outlet tee ends.
01 rn �- - 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes.
\ Date of Percolation Test: AUGUST8, 2005
Test Performed By: CARMEN E. SHAY, R.S., C.S.E. 10. Alisolid piping, tees do fittings shall be 4" diameter
Results Witnessed By. WAIVER (per Barnstable B.O.H.) Schedule 40 NSF PVC pipes with water tight joints.
EXCAVATOR: Shay Env. Svcs. 11. SITE and Surrounding Properties are Connected
Percolation Rate: 2 MPf 0 38" to Municipal Water.
Test Hole Test Hole
No. 1 No. 2
DEPTH SOILS ELEV. DEPTH SOILS ELEV. ROM,097.00 o 97.50 THE PROPERTY LINES ARE APPROXIMATE AND
LOT#102 ` t t, t COMPILED FROM THE PLAN EDWARD KELLEY of OSTERVILLE, MA
Sandy Loam Sandy Loam „ENTITLED CERTIFIED PLOT PLAN OF LOT #102 PALOMINO DRIVE,
44,734 Square Feet + - t I I 10 YR 3/2 10 YR 3/2 BARNSTABLE. MA" DATED'NOVEMBER 11, 1983
0,-6" A/O/E 96.50 0" s' A/O/E 96.75 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
Sandy Sandy THE SEPTIC SYSTEM INSTALLATION.
Loom loo(� ID YR 6/8 10 YA E/IS
8»- 36" B 94.00 9'- 38" Be 94!50
FINE FiNE NOTE ANY STRIPPED OUT SOIL CONTAINING LEACHATE
Sand Sand FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED
LS Y e/s 2.s Y 3/4 OF AS PER BOARD OF HEALTH SPECIFICATIONS.
38"- 144 C, 38'- 144 C+
Q) EXISTING LEACH PIT TO BE PUMPED DRYFILLED WITH CLEAN FILL MATERIAL.
ASSESSORS MAP - 297 PARCEL - 054
ZONING - RESIDENTIAL
Perc �1 FLOOD ZONE C
Depth to Perc: 38" to 56"
7.25 t rrrPerc Rates 2 MPI,.,, , IOBSERVED H2O Elev. None Observs,.r = „ ¢_,.. _ OFETHEAPROPERTY AND AREAASD SHIOWNA 20(T' RADIUSTEST HOLE #1 D-BoxrELEV.= 97.00 DIS RIBUTI N BO SHALL BEE LEGEND
SET LEVEL rnR AT LEAST 2 FT. CONCRETE COVERLOT#101 Failed t ,LET . .�. ..... 2 DENOTES PROPOSED
Leach Pit ; 1r INLET KNOCKOUTS
8X0 SPOT GRADE
LOT#103e.
DENOTES EXISTING
r------�_ TEST HOLE #2 tl g ,r . i It t rf ,ae• x 104.46 SPOT GRADE
i 1
� 1 1 �� � i 1 � I 4' - SCH. 40 T.,/ 1,Te'
FLAN SECTION CROSS-SECTION
7Ev. s7.50 i ttt , \`. -_- ? PL PROPERTY LINE
�� ��♦ ; 1 1 \t tt i
t i i t ►t 3 IjOL1* DISTRIBUTION BOX - :H-10 LOADING "�'-' ���' PROPOSED CONTOUR
♦ 1 1 i i 1 NOT TO SCALE
♦`� l �2♦t i tt t\ 97- -- -97 EXISTING CONTOUR
Deslan Calculation DEEP TEST HOLE &
it l t
EXIST. 1b00 GA4 ttt ;
O I SEPTIC TANK
.PERCOLATION TEST LOCATION
t♦•
Patio Ill i \ t i ► I �� DO Number of Bedrooms: 3 Equivalent to 330 Gol./poy (330 Got./Day Min. per Title V) �- -;� FENCE
OJ t Garbage Grinder: No
cV
Cr) t i i t }' `� M Leaching Capacity Proposed: 330 Got./boy Minimum (Min. Per Title V)
---- --'- Enclosed t i l t ♦ Septic Tank ; -- 2 x 330 Go[../Days60 uSE;Exi5T. 1 000 GAL. Se tic Tank. PRIVATE DRINKING WATER WELL
i DECK Porch tt `♦ 9� P P
i I � g f <2 min./inch
i t i t t ♦♦` �rf SaBot ABSORPTION
0.74 ga1%sq. ft. sq. 273.8 gallons
g q, q REVISIONS
EXIST. t\ ` Sidewail Area: 0.74 al. s ft. x 78 s ftI = 58 gallons
GARAGE t \t Providing: 331.80 gallons
t EXISTING t l i NO. DATE: DEFINITION
t 3 BEDROOM t ! Use: $ INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' 10 INCHES EFFECTIVE DEPTH
t 1 I ( } t )
HOUSE_ it j I TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE _
t ) 1 ! t
t ON THE ENDS. NO STONE UNDER. 1
EXiST.
00- -, DRIVEWAY
` I
PROJECT BENCH MARK
TOP OF FOUNDATION t PROPOSED
, ' l l
V. 100.00 Assumed ', i i
ELEV. (Assumed) tl �, f t �� �i ' . gl6
PREPARED FOR *
3 ; ,-�♦ ����- SUBSURFACE SEWAGE DISPOSAL SYSTEM
i r r r st l
OF
,� NATHAN I EL BATCH ELD ER
# 121 PALOMINO DRIVE
"
# 121 PALOMINO 6RIVE
BARNSTABLE, MA
PREPARED BY:
0 20 40 50 BARN STABLE MA 6 0
`♦ o� AR E SHA
�.C1 RffT1 1' aJ .
ENVIRONMENTAL SERVICE'S INC.
0.
l \
L a
-'S �F � P.O. BOX ,627
r 0•p p
TV
s \>� EAST FALMOUTH MA -02536
NITAR
�• ,¢
- Or
L FAX 08 7 66
.. . : TE 5 539 9
--__ ..
-.cam"- .�....�_r. \ I.
SCA E. 1 D DRAWN Y. C S A L 2 D B E DATE AUGUST 17 005
_ _ _ 2
O RI
_ ,
100
-,.
i R J 7$ NAM PP W P O ECT SD 9 F LE E 5D7$D .D G H i"5 EET 1 'I
4 F RIGHT WAY
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