HomeMy WebLinkAbout0174 SALT ROCK ROAD - Health 1.74-Salta Rock Rob-
IBarnstable 'P
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Town of Barnstable
Regulatory Services
7L.
I"homas F. Geiler, Director
ii SARff Public Health Division
H Thomas McKcan, llircetor
200 Main Street; Hyannis, MA 02601
Office: 508-862-4644 Pax: 508-791
Date; << �c1 "1� Sewage Permit# ZD(O-•45( a Assessor's map/Parcel 3
11)§taller & Desi>ner Certification Form
Designer:
SC. Ell� ifl��t(�(1� "v�C Installer-
.Ga(�Cw;de.. E�1leu�ci�e.:a
J..._.,...,...� �_ _,_.,.._.
Address: ti` ` C � .... ..) - ----_ ._. 3Addre�s: G .._....._._._..
E a t �tJ r G�1 c•rvl t�A U Z;�3 Q.1/� `` V Vw
On L l I) �Zta iJ fn; tt (Q t�6_was issued a permit to install a
- - da(ej
septic system at (...7 �f `"'�'� C.ck. ! C':rC1 based on a design drawn by
S C_ dated 60oc.
(ci-esrgrrcr)
_ l certify that the; septic system referenced above was installed substantially a(:cordiq to
the design, which may include minor approved changes such as lateral relocationt� Y pp g of he
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
l certify that the septic system referenced above was installed with maJor changes ir.k�
greater than 10' lateral relocation of the SAS or any vertical relocatior, of arly O0111poner11
of the septic system) but in accordance with State & Local Regulations. Flan rcN ision or
certified as-built by designer to follow. Stripout (if required) r s.ected and rile soil,
were found satisfactory,
JO"N
fUi'tCNILL
_... , . JFt,
(ins e a
t s Srgnatt... .;.)..: Iv1r
4180
---------- -- ,..,......- -- —----
- ..............
esigner s Signature: (Affix D- gn 1 Here)
RI':7"U1tN I' )° RNSTABL ' PUBLIC HEAL DIVIRION. CI%IZT•1FIC:A'I'ls
(,� �' YIPLIAle1ClE:WI�,I,, NOT' i31SUE�TIL >r3 )TH 7TIS l+'OItM ANI) AS-
3 I " D ARE RECE VE BY THE BARNS�AALI PT�B��H:.I�:�I,I'I{ DIVItiI(
TLI OU.
y'nffice.Igrrns:demgneYccltilicaliun term lac
Tn -4 1QCn 1;117 5=enC �'11J T>4��lJ T-I IJ=i'l f 1.1.-I T7_ +,n nTn7—� T—AnW
TOWN OF BARNSTABLE
LOCATION SEWAGE# W i0 —`t 5(o
,VILLAGE ASSESSOR'S M'AP&PARCEL
"
INSTALLER'S NAME&PHONE NO. �;L�e E�-� 4<,(PA LL(-
SEPTIC TANK CAPACITY i C DC
LEACHING FACILITY:(type) 51pn all--K l.e v+e��`e-l� (size) ti`4'tI��A Z c
NO.OF BEDROOMS 3
OWNER
PERMIT DATE: i\ i J 'zG w COMPLIANCE DATE: 1 1 !1$ 1 2a w
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 L. aching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY � i�`�f Q� s U-C
zit �
su
ER
w
No. ;'0 f U- L/SP Fee [ do�—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for ]Disposal 6pstrin Construction permit
Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) [:]Complete System 0 Individual Components
Location Address or Lot No. 11 !&A IT-Ro c1` /Lc9q Owner's Name,Address,and Tel.No. 2-(Wlr i�wy of
Assessor'sMap/Parcel '3 Upi 'ti"� 3� 17'l 5ri/T24c1.
Installer's Name,Address,and Tel.No.64 fto. "e fy► jry Designer's Name,Addregess,and Tel.No. -T,�, 'c'7"��
`j bb ` e
Type of Building:
Dwelling No.of Bedrooms Lot Size �J Zoo sq.ft. Garbage Grinder( )
Other Type of Building 5 � No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 gpd Design flow provided gpd
Plan Date 1 I - Iq - o to Number of sheets ( Revision Date
Title 1-7 y 54)1 ge" 1
Size of Septic Tank 1000 Type of S.A.S. S'T�2Le-S S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) e7r 1S A-An
S tom►-�-�ors L�e�.. �4��
Date last inspected: ll7
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 Certificate of
Compliance has been issued by this Board of Hea . f
Sigmd Date G " � ^ 2-0 Cm
Application Approved by Date 11- 1 j-%
Application Disapproved by Date
for the following reasons
Permit No. '�U _ ��' Date Issued 1 - i S'-(o c
No. 0 `t �!° q.._... nsr` Fee do
THE COMMONWEALTH OF MASSACHUSETTS Entered in com r:pute
��-
PUBLIC HEALTH DIVISION - TOWN ,OF BARNSTABLE, MASSACHUSETTS Yes
application for Disposal' pstem Construction Permit
+ Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1-7 4 S4 IT R,, Owner's Name,Address,and Tel.No.20(�7 1 'C�
PA,-
Assessor's Map/Parcel 3 ( PA,-,I)rc "s 1-7 `l S*a-/T-R v J. ✓Ls�
1 �1�r.45rrSt .
Ihstaller's Name,Address,and Tel.No. '(,,4- „�, P�y� Designer's Name,Address,and Tel.No. . ,C-
7, '1 3 L;3', -' 2.C75'Y
Type of Building:
Dwelling No.of Bedrooms Lot Size ?J S 2,00 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3'j gpd Design flow provided 3 5. 7— gpd
Plan Date I Number of sheets Revision Date
Title )"7 L/ 5,6)) IZOC l�
Size of Septic Tank I t)0 0 Type of S.A.S. �7Tu?�(a 5 S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _TjAn6A= (1j
'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 Certificate of
Compliance has been issued by this Board of Hea
Sig ed Date
Application Approved by ,L Date 11 1 5'r
Application Disapproved by Date
,for the following reasons
Permit No. '-7 0 0 ��5� Date Issued l ' I 5- — f�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Se age Disposal system,Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by ✓YS� �-��- '"
at (-74 5 r4!r R ao^-A has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. o u '1/j� dated
Installer G �W'c� u-',L �� t
ip j � L.,�.+L_ Designer .5 . C. Eh r i ot�,p, i c, �
#bedrooms Approved design flow 3 3 U and
The issuance of this permit shall not be construed as a guarantee that the system will tion designe
Date ��{/�/•� Inspector J\
-- - -:.,. .
No. �G I J ' L-/,r!j Fee /U(i-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Prmit
Permission is hereby granted to Construct( ) Repair( nUpgrade( ) Abandon( )
System located at ( � �/ 5A!7- /Zv Ck /Lu cy )/0nr—) r"t C_
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructio must be com leted within three ears of the date of this permit.
P Y p /'C r
Date "Approved by w" 1
Town of Barnstable M� P# j 3/i,�
Department of Regulatory Services
> erAE L Public Health Division
En a`6� 200 Main Street,Hyannis MA 02601
Date Scheduled b/;2 7 10 t Time U..� M
r Fee Pd.— !i'tl r
Soil Suitability Assessment for Sewage is osal
Performed By: 1`iC6, 4 ei feA d i -IT. C&
Witnessed By: V S
OCATION& GENERAL INFORMATION
Location Address 12
]� G Owner's Name bwy� 2� �
Address SQmo-
Assessor's Map/Parcel: -
1 Engineer's Name 1 �
(���i eQ�t 3G Ev15i�1ee:-CM
NEW CONSTRUCTION REPAIR Telephone# JC '1-1 3'O 3-7
Land Use S,nglt 6- ty dwoli;lt
� Slopes(R'o) 5%0 Surface Stones -
Distances from: Open Water Body Possible Wet Area 7'00 _
ft Drinking Water Well ft
Drainage Way ft Property Line -7 �� _
- ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes)
See- a4 a4 Pl at)
Parent material(geologic) pu m:F3 n
Depth to seQrock
Depth to Groundwater. Standing Water in Hole: ��'�
Weeping from Pit Face
Estimated Seasonal High Groundwater 7 1 J(ou
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: _Diteca O�oso-wayo0
Depth Observed standing in obs.hole: 7/54, 7/�6
Depth to weeping from side of obs.hole: 7/��, in. Depth to soil mottles: in.
Index Well# - _ In. Groundwater Adjustment ft.
Reading Date: Index Well level Adl.factor Adj,droutidwater l..evel
PERCOLATION TEST l)gtg Tfine__ -' • Ah Observation ��"2T�0 >O•YC
Hole# —
Time at 9" o `eu Arl
Depth of Pere
22 -YC T' Time at V
Start Pre-soak Time @ 10:Y6 A4
_ Time(9"-6") �h
End Pre-soak /C. SS At1
Rate IvlinJinch 2-
Site Suitability Assessment: SitePassed_1V1 Site Failed:. /V
Additional Testing Needed(YYN)
Original: Public Health Division
Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one (1)week prior to beginning.
Q:\SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
an isten %Gravel)
jG•22 LS 3/1
L S C7.Yr s/fs -
tJ$-GA C-I JCS jU Nr s/6
60 /act. c'2 5'kif Gcam 2. 5 Y"4
DEEP OBSERVATION HOLE LOG Hole# 2-
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.% ravel
!b 22 A 1,5 j by( 3/1
vs-i;o C-1 KS l0%r S/�
6 -108 C-2 14a.rh
i6 i_15h C.13 FS 2
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Con i to c Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. I
F ,,od Insurance Rate Map:
Above 500 year flood boundary No— Yes .__✓.__
Within 500 year boundary No _ Yes,
Witl;in 100 year flood boundary No,— Yes
Depth of Naturally Occurrinl?Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for tiie soil absorption system? _ `�e-S
If not,what is the depth of naturally occurring pervious material?
Certificatiw,i
I certify that on /d`a7"� (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,expertise and expe ' nce described in 310 CMR 15.017.
Signature-_ - Date
Q:\SEPTICv'ERCFORM.DOC
TOWN OF BARNSTABLE !�
LOCATION 17z1<341__r &k SEWAGE #
VILLAGE ASSESSOR'S MAP & ggLOT
III INSTALLER'S NAME & PRONE NO. v /6
SEPTIC TANK CAPACITY U®® 9,0q't,
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC W TER ;-" LL-
BUILDER OR OWNER
DATE PERMIT ISSUED:
.fir cr,�✓',�y.`�`�`�
DATE � 5 '
VARIANCE GRANTED: Yes No
o
� ht
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMzNTAL PROTECTION
MAP
PARCEL ,,
LpT, I
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: / 7 -s / /cn O c l i
rn spa 6 3� ed�'���►
Owner's Name: o f `
Owner's Address. a arc �J OCT
Gr YJ�V O 2003
Date of Inspection: / c7 3 TOWN oFa
HEALTH IINS ABLE
Name of Inspector: (please print)
Company Name; /
Mailing Address: AF,0
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 the inspection.The inspection:was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal.systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes . a
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails /�
Inspector's Signature: atd i X - 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.
Notes and Comments t
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: AC 4-
/� lh a io2 63�
Owner: l�O b er -r
Date of Inspection'
Inspection Summary: Check A,B,C,D or E 1 ALWAYS complete all of Section D
i
Syste Pauses• -
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15,303 or in 310 CM 15,304 exist, 'failore cxit�?>Qt ova1t>:ltssl are i tod flow,
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or mpair,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 m
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurallv
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 pipes)or due to a broken,settled or uneven distnbvtien box, System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
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):
w broken pipe(s)are replaced
obstruction is removed
ND explain: ,. .
page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: / 1 O(o c 4 Aj
Owner. Pig
Date of Inspection: 9 •f
C. Further Evaluation is Required by the Board of lealth:
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.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from m 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered A copy of the analysis must be attached to this form
3. Other: ;
• Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Rj
Owner.
Date of Inspection: o
D. System Failure Criteria applicable to all systems:
You must indcate`yes"or"no"to each of the following,for all idozks
Yes No
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged S_A_S or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
'cesspool
_ i/f Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow
:'Requi_rCd pumping more than 4 times in the last year NOT due to clogged or obstructed p]pe(s),Number
/of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
,,.,water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ My portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered,A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or 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•
You must indicate either"ves"or"no"to each of the following: {
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
tr _
_ 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 CMR
15.304.The system owner should contact the appropriate regional office of the Department
' I
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Preeperty Address: / 44
n / .z S e /j OR 6-7,
Owner. /{a`�Q,r
Date of Inspection: O
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes o
g information was provided by the owner,occupant,or Board of Health
_ Were arty of the system components pumped out in the previous two weeks
�— H. s 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,looted 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:
Yes no /.
r/ 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
i unacceptable)[310 CMR 15.302(3)(b))
r ,
f
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /ePr 7 ka _ ,
Owner.
Date of inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . �o
Number of current residents:
Does residence have a garbage grinder(yes or no): /1C"9.
Is laundry on a separate sewage system(yes or no):�O [if yes separate inspection required]
Laundry system inspected I. or no):_/
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):kV
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sg8,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:gallons—How was quantity pumped determined?
Reason for
TYP F SYSTEM
_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alumutive 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 if known)and source of information:
��0 s— O (,v vt.ei✓ .
Were sewage odors detected when arriving at the site(yes or no):ZOO
' a
't Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
f SYSTEM INFORMATION(continued) "
Property Address: ` �7 40C 4"
Owner. 040
Date of Inspection: l
MOLDING SEWER(locate site plan)
Depth below grade:
Materials of construction cast iron — PV
other(explain):
r
Distance from private water supply well or soclion line:
Comments(on condition of joints,venting,evidence of leakage,etc.): 1
SEPTIC TANK:_(locate on site plan)
Depth below � �
Material of constructioJGa�iboncrete_metal ._fiberglass_polyethylene
—other(explain) ,
If tank is metal list age:— Is age confirmedby a Certificate of Compliance(yes or no): (attach a copy of
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: of
Scum thickness: 117,
Distance from top of scum to top of outlet tee or baffie: T
Distance from bottom of scum to bottom o et tee or baffle:
How were dimensions determined o � <as
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as ryjxted to outlet invert,evi nce of leakage,etc.
^� / � CS (� oar i' i p.,• ,
GREASE TRAP:_(locate on site plan) `
1
Depth below grade:_ E
Material of construction:_concrete_metal_fiberglass polyethylene other,
(explain):
Dimensions: t
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): f
F _
I a
` Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM
// INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
TIGHT or HOLDING TANK: tank must be pumped at time of inspectionxlocate on site plan)
f
Depth below grade: }
Material of construction: concrete metal fiberglass -_polyethylene f other(explam): '
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping p
Comments(condition of alarm and float switches,etc.): E
i'
DISTRIBUTION BOX:LiX(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 o bof etc.
O /tea
+ o Q
PUMP CHAMBER:eocate on site plan) - !
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
a .
g
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirnwd)
Property Address: 2cf, .Ste'�� pa l✓ ��
Owner. Wo
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type CX,,6Teachingpits,number: ~`S�
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.): �� ��cr r✓te
—cam. u ,
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:2�o0 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.):
e_
f Page 10 of I 1
r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSR+IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM UOURMATION{ooatintzed)
Adams:
Owwr. o
Dsaeoion: .
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pe ref Tc=landmarks or
beaclun ris.Locate all wells within 100 feet Locate where public wager supply eaters the ba kkg.
/- 0� �
e
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE D WPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
owner:
Date of Inspection: o�
SITE EXAM
Slopg
Surface water
Check cellar
Shallow wells
Estimated depth to ground water °?9 Abei
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
rved site(abutting property/observation hole witbin.150 feet of SAS)
To Checked with local exavators,installers-(attach documentation)
Accessed USGS database-explain:
You must�cril�TO you established the hig�d wate� atio
41f) tvd 4 o? eve
Tm
a (0/C
� �•. po �� fit .
r
9-d,
F .
� ��v
� }'� �J
S�
T.O.F. EL.= 84.8'± PROVIDE EXTENSION RISER INISH GRADE OVER D-BOX= 82.5'± 4"SCHEDULE 40 PVC MIN. SLOPE 1 % PROPOSED PVC VENT FINISHED GRADE OVER BIODIFFUSERS= 79.5' - 825 GENERAL NOTE S
WITH COVER OVER INLET& SLOPE @ 2% MIN.
INSPECTION PORT WITH UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
- OUTLET TO WITHIN 6"OF F.G. REMOVABLE WATER-TIGHT COVER OVER ACCESS BOX TO WITHIN 1.
FINISH GRADE RISER TO WITHIN 6"OF FINISHED GRADE 3"OF F.G. (ONE PER ROW)
METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
@ FND. EL.= 83.8'± FINISHED GRADE OVER TANK EL. = 83,8 ± 5" DIA. OUTLET(S) CODE AND ANY APPLICABLE LOCAL RULES.
} 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
EXISTING 4" PROPOSED 4" 9"MIN. SEE NOTE#21 DESIGN ENGINEER.
SEWER PIPE ��._ PVC SEWER PIPE
36"MAX. 60"MAX. TOP OF SAS/B.O. = 77.5j0' 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
SYSTEM UNLESS OTHERWISE NOTED.
6�3" 3" DROP MAX " PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
- 2" DROP MIN 3 9 MIN.SLOPE @ t% L=102'± JOINTS (TYP.) ELEVATION = 77.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
10" 4"PVC IN FROMAliPH 1.08' Q " 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
ZL
14" , *$Q,3'± SEPTIC TANK 4" PVC OUT TO
(TYP.) " 13 THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
- • LEACHING FACILITY 0.59' IFOE7.13"(NP)
5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
�� I 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
CONTRACTOR CONTRACTOR SHALL 12 6 , 77.01' 76.42' (laid flat 2.875'(34.5")--I STONELESS SYSTEM
SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 78.80 MIN. 78.63 l
AND CONDITION OF EXISTING TEES 5.0' (TYP.) 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
EXISTING SEPTIC AND REPLACE AS GAS BAFFLE 6"CRUSHED STONE (TYP.) 5' `I 7 MIN. FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
OVER MECHANICALLY
TANK NECESSARY COMPACTED BASE REQ'D NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
20.0' AND DESIGN ENGINEER.
5 OUTLET DISTRIBUTION BOX 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 83.00' ESTABLISHED
- -- TO BE INSTALLED ON A LEVEL STABLE BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 69.00' BIODIFFUSERS (END VIEW) ON A NAIL SET IN A TREE AS SHOWN ON PLAN.
EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 20 - BIODIFFUSERS (PROFILE) 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
(BY ADVANCED DRAINAGE SYSTEMS, INC.) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
*CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL 20 - ARC 36HC (#3616 B D) BIODIFFUSERS (H-20) TO THE DESIGN ENGINEER.
TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
'
PERC NO. 13115 APPROPRIATE AUTHORITY.
REMOVE UNSUITABLE MATERIAL DOWN so � � - - � # �� INSPECTOR:
David W. Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
TO"C-3"SOIL AND REPLACE WITH CLEAN - ` N EVALUATOR: Michael Pimentel, E.I.T. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
OO COARSE SAND PER 310 CMR 15.255 MAP 316 7 + � q ` p C.S.E.APPROVAL DATE: Oct. 1999 THEY SHALL WITHSTAND H-20 LOADING.
q °i it +� � DATE: October 27, 2010
13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
Benchmark LOT 12
TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
/
Nail Set in Tree a a MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
/ Elev. =83.00 ® ELEV TOP= 82.00' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
Approx. M.S.L. • OCUS +� ELEV WATER= <69.00' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
f
PERC RATE= 2 min./inch 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN co • """ SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
w
v/ +� DEPTH OF PERC= 22"-40"
EX. CBN a # 16. PROPOSED PROJECT IS LOCATED WITHIN:
o",., R=75.4± /
„ / Sg8o40 EXISTING 1000 GALLON SEPTIC TANK TO BE N ,r Q p TEXTURAL CLASS: 1 ASSESSOR'S MAP 316 PARCEL 14
19" UTILIZED AS PART OF THIS DESIGN Y
o OWNER OF RECORD: ROBERT& MAUREEN P. DWYER
PROPOSED TOTAL 20 ARC 36HC (#3616BD) m •
BIODIFFUSERS (H-20) IN A FIELD CONFIGURATION gyp/ EXISTING LEACHING PIT TO BE PUMPED, FILLED Z �' # 0" 82.00' ADDRESS: 174 SALT ROCK ROAD
WITH CLEAN COARSE SAND &ABANDONED a * BARNSTABLE, MA 02630
PROPOSED INSPECTION PORT WITH � 82` --- Fill
e 16" 80.67'
/
ACCESS BOX TO GRADE (TYP OF 5) TREELIN
Loamy Sand
eas � c E TYP.) p 22" 10Yr 3/1 80.1 T FEMA FLOOD ZONE C
/
PROPOSED 4" PVC VENT PIPE; COMMUNITY PANEL# 250001 0005 C
-4'°� gas-� �, q► .:�
EXACT LOCATION PER OWNER f� `^ --- ue ' Per " Loamy Sand
\ TP �s c► , e40,. 1 OYr 5/8 78 67' 17. DEED REFERENCE: DEED BOOK 17722, PAGE 206
' 48" 78.00'
18. PLAN REFERENCE: PLAN BOOK 222, PAGE 85
/ 19 s, 20 y f MAP 316 c-1 Me OYr 5/6
Sand
LOT 41 I 60„ 77.00, 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
Q- TP �,r:' LAX / / d 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
Q w 0 82 0/ L0 #174 / a -_ _ _ _• .____ 1 . �_� C-2 Silt Loam FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABIIJTY
I
O �r\y 1" EXISTING a �� + _ 2.5Y 7/1 FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
J, 3-BEDROOM / o C
Vow `N DWELLING ` r 5 108" 73.00' 21. IN ACCORDANCE -
� -� � _ r�. - 1� O NCE WITH 310 CMR 15.401 15.405,THE FOLLOWING LOCAL UPGRADE
L / APPROVAL IS REQUESTED FROM 310 CMR 15.221 (7):
�\ LP (1.) A 2.0'WAIVER(5.0'-3.0') FOR THE MAXIMUM COVER OVER THE LEACHING SYSTEM.
ine Sand
GRAVEL DRIVE \ LOCUS PLAN C_3 F2 5Y 6/6
��1•/ / SCALE: 1" = 1000' 156" 69.00'
04
/ No Mottling, Standing or Weeping Observed
CO C5Cb
/ DESIGN DAT TEST PIT DATA � m�
co
I
PERC NO. 13115
END
DECK NUMBER OF BEDROOMS(DESIGN) 3 INSPECTOR: David W. Stanton, R.S.
CO Q) 50xO EXISTING SPOT GRADE
PROPOSED DISTRIBUTION BOX DESIGN FLOW 110 GAUDAY/BEDROOM EVALUATOR: Michael Pimentel, E.I.T.
-
[ .S.E.APPROVAL DATE: Oct. 1999 - 5p - - EXISTING CONTOUR
r. CO� TOTAL DESIGN FLOW 330 GAUDAY r�
/ DESIGN FLOW X 200 % = 660 GAUDAY DATE: October 27, 2010 PROPOSED CONTOUR
/ TEST PIT#: 2 D/H/W EXISTING OVERHEAD UTILITIES
MAP 316 USE EXISTING 1,000 GALLON SEPTIC TANK
ELEV TOP= 82.00'
LOT 14 ELEV WATER= <69.00' W W--_.._ EXISTING WATER LINE
35,200 S.F.± MAP 316 PERC RATE _
INSTALL 20 - ARC 36 (#3613BD) BIODIFFUSERS (H-20) GAS ---- EXISTING GAS LINE
LOT 39 DEPTH OF PERC=S�1°5�•49" -�- TEST PIT LOCATION
220 oa, SYSTEM CAPACITY TEXTURAL CLASS: 1
MAP 316 _
(TOTAL L.F. OF BIOS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)=GPD I� EXISTING 1,000 GALLON SEPTIC TANK
LOT 16 (100.0')(4.8 SF/LF)(0.74 GAUSQ.FT.)= 355.2 GAL. LEACHING/DAY
0" 82.00' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
Fill
TOTALS: 16" 80.67' ❑ PROPOSED DISTRIBUTION BOX
TOTAL NUMBER OF BIODIFFUSERS: 20 A Loamy Sand
10Yr 3/1 PROPOSED ARC 36HC ( )
I TOTAL NUMBER OF COUPLINGS: 0 22" 80.17' (#3616BD)BIODIFFUSER H-20
TOTAL LEACHING AREA: 355.2 Loamy Sand
_- -- - - TOTAL LEACHING CAPACITY: 480.0 B 1 OYr 5/8
48" 78.00'
(4 C-1 Medium Sand REV. DATE BY APP'D. DESCRIPTION
HC-1 NOTE: 60„ 1 OYr 5/6 77.00' PROPOSED SEPTIC SYSTEM UPGRADE
(1 EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM THE
DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER Silt Loam PREPARED FOR:
C_2
"MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO ADVANCED 2lt 7l1 CAPEWIDE ENTERPRISES
SWING-TIES DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003 (LAST MODIFIED JUNE
(3 20 3, 2010). TRANSMITTAL NUMBER=W000052. 108" 73.00'
'0 #174
2) EXISTING DESCRIPTION HC-1 HC-2 LOCATED AT
3-BEDROOM BIODIFFUSER CORNER(1) 28.2' 33.5' C-3 Fine Sand 174 SALT ROCK ROAD
DWELLING 2.5Y 6/6 BARNSTABLE MA
TOF = 84.8'± BIODIFFUSER CORNER(2) 39.3' 24.4'
=
HC-2 \ `\ BIODIFFUSER CORNER(3) 52.8' 43.2' NOTES: 156" 69.00' SCALE. 1 INCH 20 FT. DATE: NOVEMBER 9� 0 10 20 ao ao' 2010
FEET
N
BIODIFFUSER CORNER(4) 45.1' 48.9' 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF o Mottling, Standing or Weeping Observed
!' of"JAS
�-
EACH SEPTIC SYSTEM COMPONENT. ✓\� s~ =_
JOHN L. PREPARED BY:
�\ RESERVED FOR BOARD OF HEALTH USE \ CHILL JR JC ENGINEERING, INC.
CHUR
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF CIVIL 2854 CRANBERRY HIGHWAY
THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST NO 41807
'SITE PLAN PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL ��� 3T EAST WAREHAM, MA 02538
� r 508.273.0377
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. ® -- - -08 - --._ ----
SCALE: 1"=20' Drawn By: BSM Designed By:MCP Checked By:JLC JOB No.1901