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HomeMy WebLinkAbout0039 SHALLOW POND DRIVE - Health 39 SHALLOW POND DRIVE ,Barnstable A = 234 - 079 Y P O Iz e o e n N s_ Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form—Not for Voluntary-Assessments v9 �� ,44c4>-J'F,,J,0 2 v Property Address ;F v _QAh Lw:J owner 0 Owner's N me �tortnation is raqutred for every Zvi /-P K�. �l S779(BC,c5r � page. Cityfrown Sta e. Zip Code Date of Inspection ,F Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. I wr,t:when 8"out forms AL Inspector I.nfonnation / //aft an go compuler, �Tl O1,C use only the tab �a7a/nR 9 key to move your Name of Inspector cursor-do not use the return key. Company Name ts $, 11 Company Address p Citylrcwm State' Zip Code 6 ,SAS 5 e 7 7 $6 Dy cS. Z, eel 2 Telephone Number License Number B. Certification I certify that:I am a DEP approved system.inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have.personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection 1 have determined that the system: 1. Passes 2. 0 Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails inspector's Signature Date The system inspector shall submit a copy of this inspection reportto the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Please note: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. MMP:d--rev.7/28/2018 Title 5 Mel inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I I� Commonwealth of Massachusetts Title 5 Official Inspection for Subsurface Sewage aisposal system l=o/mt-fait for Voluntary-Assessments Property Address oo/z� Owner Owner's Nam k6mietion is epWred for every ` l" ps�ge. City/Town State Zip Code Date of Inspection. C. Inspection Summary Inspection Summary: Complete f, 2, 3, or 5 and all of 4 and6. 1) 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 CHAR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: / k a P/t 2) Sy m Conditionally Passes; ❑ One r more system components as described in the"Conditional Pass"section need to be repl or repaired.The system,upon completion of the replacement or repair,as approved by the Board f Health,will pass. Check the box for ' es","no"or"not determined"(Y,N,ND)for the following statements. If"not determined,"please xplain. The septic tank is metal d over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substan' I inffitration or exfiltration or tank failure is imminent.System will pass inspection If the existing tan ' replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass.insp 'on if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is s than 20 years-old is available. " . ❑ Y ❑ N ❑ ND(Explain ow): GbXPADc•rev.712612018 Title 5 official Inspection Form:Subsurface Serra Disp osal posal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Faun Not for Vdwr ftrY Assessments Property Address Owner Owner's Na reWred b oor is Information Me. City/Town State Zip Code Date of inspection C. inspection Summary (cont.) NJ 2) S tem Conditionally Passes(cone:): Pu Chamber pumpslalarms not operational. System will pass with Board of Health approval if pum alarms are repaired. ❑ Observation sewage backup or break out or high static water level in the distribution box due to broken or ob trvcted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection i (with approval of Board of Health) ❑ broken pipe )are replaced ❑. Y ❑ N ❑ ND (Explain below): ❑ obstruction is re oved ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is le ed or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 time a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of t oard of Health): broken pipe(s)are replaced ❑ ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y N ❑.ND(Explain below): Nh 3) Fu or Evaluation Is Required by the Board of Nealth: ❑ Conditions exit v�hi uire further;valuation by the Board of Health in order to detemiine if the system is failing to protec alth, safety or the environment. a. System will pass unless Board of Health es in accordance with 310 CMR i 15.303(1)(b)that the system is not functioning in a manne h will protect public health, suety and the environment- t doc•rev.7/IMIS, Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface SM-age Disposal System Form--Not for llotr�ntar�+=�lssessrrtar�ts- - '-5d 4w eorn► Property Address r Owner's Name rnation is ►squired for every "y. /1-e pop- Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ 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 b. Sy wIH fail unless the Boats of Health(and Public water Supplier,N any) t>eternrines the system is functioning In a manner that protects the public health, safety and Ironment: ❑ The system s a septic tank and soil absorption.system(SAS.)and the SAS is within . 100 feet of a surfa water supply or tributary to a surface water supply. [I The system has septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a c tank and SAS and the SAS is within 50 feet of a private water . supply well. ❑ The system has a tank and SAS and the SAS is less than 1.00.feet but 50 feet or more from a private waters y wen**. Method used to determine dbs ce.: *"This system passes if the well water an is,performed at a CEP certified laboratory,for fecal coliform bacteria indicates absent and the ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fa re criteria are triggered. A copy of the analysis trust be attached to this form. C. Other. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ® ryr Discharge or ponding of effluent to the surface of the ground or surface waters `ry due to an overloaded or dogged SAS or cesspool SbapAoc•rev.m6no18 Titre 5 Official IrispeC6on Form:Subsurface Sewag e Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface Sew -Sewage DmPosal System F ..Not,ft3[�feluntar�r=Assessments _:-=: Property Address . �I u— r Owner's Name kdormation is reqWred for every Al tom• CitylIown State ZipCode Date of P Inspection C. Inspection Summary(coat.) 4) System.Failure Criteria Applicable to All Systems:(cont.) Yes No' . ❑ 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 Y2 day flow Required pumping more than 4 times in the last year NOT due to clogged or 0, obstructed pipe(s).Number of times pumped: ❑ 177 Any portion of the SAS, cesspool or privy is below high ground water elevation. W/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 11/4 well.portion of a cesspool or privy is within a Zone 1 of a:public water supply ❑ A4 PA Any portion of a cesspool or privy is within 50 feet-of a private water supply well. ❑ fn /J�4 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 coliforrn 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 2000 gpd- ❑ p!P` 10,000 9pd- ❑ The system fafts,.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. NJ� 5) La Systems: To be considered a large system the system must serve a facility with a design 10,000 gpd to 15,000 gpd. For large systems, ust indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No 11 ❑ the system is within 4 eet of a surface drinking water supply ❑ the system is within 200 feet o tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If of a public er supply well GkMpAoc-rev.MGM TO 5 Olridal Inspection Fonre Subsurface Sewage D' System- Page 5 of 18 Commonwealth of Massachusetts Fite 5 Official Inspection F®rm Subsurface Sewage Disposal System Form- -Not-forVoluntary-Assessrnents Property Address owner owner's Namebdimm ftqu anon is in y_�D Z V 9 quired for every �14 - Z S P"e. City/Town State Zip Code Date of inspection C. inspection Summary (cone.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. • 6, You must indicate"yes" or"no for each of the following for off hmpections: Yes No ❑ Pumping information was provided by th owner upent,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 an system components,eg"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 dispersal systems? The size and location of the Soli Absorpt• system(SAS)on the site has been determined based on: Me: rv�e7%7,5 I 'L,N s egi.} �� .. ❑ Existing information. For example,a plan at the Board-H�palth. g,1/gv��" f ❑ Determined in the field(if any of the failure criteria related to PPartt a7is at issue approximation of distance is unacceptable}[310 CMR 15.302(5)] Gkop.doe•rev.MM2018 Title 6 official Inspectlon Form:Subsurface Sawage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official inspection for Subsurface Sewage Disposal SystemTorm=--Not for-Vduntafy-Assessments Property Address �oa,Qs owner owner's Name r information is required for every Y l!� /y-ZFS-l 9 ("e, City/Town State Zip Code Date of inspection D. System fnforllat :3n 1. Residential flow Conditions: Number of bedrooms(design): -- - Number of bedrooms (actual): - — DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#.of bedrooms): Description ) i,A''•� Y � (� �roujE' d 1"ui'T zo /6 r70 eV-,a s7A4OCA7 YVv Q GO C 1' vLY �?'Il ✓l Ott U Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes rl No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection 0 Yes No information in this report.) Laundry system inspected? ❑ Yes NoA,� Seasonaluse? Yes No Water meter readings; if available(last 2 years usage(gpd)): Detail: 7- 7 Saoa CJ zol e., �G Sump pump? ❑ Yesl No Last date of occupancy_ golf Date 4UMPAM•rev.712&2018 TWO 5 official Inspection Fomr Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System<fom,-Not-for-VduntaryAssessmoft-.. Pw Property Address ®wryer Owner's Name Nbrmation Is Mquired for every P"e- CityJTown State Zip Code. Date of Inspection D. System Information (cone.) Alh 2. Comm ial/industrial Flow Conditions: Type of Estab merit: Design flow(based o 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(sea /persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 s tem? ❑ Yes ❑ No Water meter readings,if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: AOL" Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons ' How was quantity pumped determined? W/� LY�-< " Reason for pumping GkispAloc-rev.7/26WI8 title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System i -NotforrVoluntaryAssessments-- &b1410� Pe Property Address �OU/le✓ Owner Owner's Namja Irdb mation is required for every , U�/� per, Cityfrown State. Zip.Code. Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box,sort absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Q Shared system(yes or no);(if yes,attach previous inspection records,if any) ❑ innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): App ximate age of all components,date installed:(if known)and source of information: Were sewage odors detected.when arriving at the site? ❑ Yes No 5. Building Severer(locate on site plan): 2 � Depth below grade: feet Material of construction: ❑cast iron V 40 PVC ❑other(explain): Distance from private water supply well or suction line: � ev�r✓es �!' a. feet O9-�e0 " Comments n con ' 'on in enting eepce of Leakag , etc.): MSp doc•rev.7@5M8 Me 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official .Inspection Fora Subsufface Sewage Disposal System:f n-.�.JJ=Nat-for VokoitarymAssessments, _ -=-_ - Property Address oaater Owner's Name hftmation is City/Town state Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete 0 metal El fiberglass 0 polyethylene other(explain) C�celz v- lr tr If tank is metal,list age: years Is age confirmed by a Certificate of.Compliance?(attach a copy of certificate) 0 Yes No Dimensions: X 5 -Z Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3Z ' 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 N/g Mow wereTe-- nsions determined? r Pornments �pem ecsomm a' ,(inlet and ee�or baffle condition, tructdral fn�tegr'ty, Nquid lev�irel t to outlet i e Bence of leakage, c. : `� G p.docfta •rev.7/26/2018 Title 5 official Inspection Form.Subsurface Sewage Disposal System•page 10 of 18 Y� B Commonwealth of Massachusetts' . Fills 5 Official Inspection Form � fo�VoltSubsurface Sewage fllspat `ornt Not ry Assesonts= -- _ - Property Address 00...E Owner's Na lri ation is 2vf/i mWired for every �Z- 63 Z . �D 2-5 r9 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) � 7. Grease Trap(locate on site plan): Dep efow grade: feet Material o nstrucfion ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outl ee or baffle Distance from bottom of scum to bottom of ou t tee or baffle Date of last pumping: Date Comments (on pumping recommendations,inlet and ou t tee or baffle condition, structural integrity, liquid levels as related to outlet Jnvert,evidence of leakage, ): VA 8. r Holding Tank tank must be pumped at time of ins etion locate on:site l 9 ( P an p )( plan): Depth below gra Material of construction: concrete Q metal ❑ f ss El polyethylene [I other(explain): Dimensions: Capacity' gallons Design Flow: gallons per day %ShVA=•rev.7 26W8 Title 5 Of gi ins�F--Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts T e 5 Official Inspection Form Subsurface Sewage Dis Systemfot ---Not-for-Vduntary.-Assessroe€ft= PIZ Property Address *Po Owner Owner' Na � ion is fir/14 Ile � 11�Z632, required for every s per_ Citynow' State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight o Holding Tank(cunt.) Alarm prese t: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping. Date Comments{condition of a . and float switches,etc.): 'Attach copy of current pumping contract(required). copy attached? ❑ Yes ❑ No S. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level a veeooutlett�inv$rt6� ments(note if xis iev`el and distribution to outlets equal, ny evidencev�of solids ca ove an (e2videnceny Y of Leakage into or out of box,etc. /3-�3 so�r1 J^i sreY �� t5kap.doc•rev.M 2018 rme 5 OfBaalinspedon Form:subsurface Sawage Disposal system•Page 12 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System- „-Not-for-V duntairAssessments �94J�� Property Address Owner Owner's Name J infiorrnation is e�h�CXd! <� ��32 for every fired '� pW, CiWown State Zip Code Date of Inspection D. System Information (cont.). AlA 10. Pum Chamber(locate on site plan): Pumps in orking order ❑ Yes [� No* Alarms in workl order: 0 Yes ❑ No` Comments(note condi of pump chamber, condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a�w -onal pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): SAS located,explain why: C S7 aw_( 7 t��-and , W12 s K tn Vet,4- Type: leaching pits number: ❑ leaching chambers number: ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number ❑ innovative/alternative system Type/name of technology: afflop-doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official l Inspection Form Subsurface Sewage Disposal)Systerrt Fom--Not forVc untar-yAssessrnents Property Address OD�?� Oar Owner's Name WOMation is Ea 6P _ sy hWforevery `9 bZ632 �U-Z�S� P"e, city/Town state Zip code pate of Inspection D. System Information (cone.) 11. Soil AbsoMtfon System (SAS)(cont.) Comments(not nditgon of so , ns of hydraulic failucvel of ponding �qcondftion of etation,etc. : J 'wee �F kit,✓ham►/ / G'v�iG �'ISL'r� L''Oa�co 1/ey yv�/ 12. esspooIs(cesspool must bepumped as part of inspection)(locate on site plan): x Num and configuration Depth—to f liquid to inlet invert Depth of solids la r Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow' El Yes ❑ No Comments(note condition of soil,signs hydraulic failure, level.of ponding,condition of vegetation, etc.): tt' p doo•rev.7/2 MI8 Title 5 Orfidal inspection form:Sabx�Sewage Disposal System•page 14 of!8 Commonwealth of Massachusetts Title 5 Officiat On's ect on Forte Subsurfaee Sewage Dispm system furl-Not#or VduntaryrAneswnefds; - = Property Address Owber Owners Name i quiredion is 1aQuired for every q Cityfrown State. Zip.Code Date of Inspection D. System information {font:} �1 13. Privy(lo to on site plan): Materials of cons ton: Dimensions Depth of-solids Comments(note condition of soil,signs of raulic failure, level of ponding, condition of vegetation, etc.): p ffftlWac•rev.7/26/2018 Title 5 Otfidd Inspection Fome Subsurfam Sewage o7sposd System•Page 15 of 18 Commonwealth of Massachusetts T'ifle 5 Official Inspection Form Subsurface Sewage Disposal system Form: Not for--Voluntafy-Assessments= Property Address owner Owner's Name htorrnation is required for every ` lam` 3 Pam, City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the!wilding. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately H A L 71 UA �ZK _ 2 l2-0 u dkiWdoc•rev.h2W018 ride 5 Official Inspection Form:Subsurface Sewage Disposal System•page 16 of 18 Commonwealth-of Massachusetts Title 5 Official -inspection Foy I Wo Pd Subsurface Sewage Disposal System Form--Not for Voluntary=Assessments Property Address Caner Owner's Name kdorrnation is required for every AIX Me. City/Town State Zip Code Date of Inspection $- D. System Information (font.) 15. Site Exam: j Check Slope Surface water �[ Check cellar d\171 t I Shallow wells Estimated depth to high ground water: feet Please indicate all methods,used to determine the high ground water elevation: Obtained from system design plans'on record If checked,date of design plan reviewed: Z ZZ��3 �"'�Imo `'`' Observed site(abutting property/observation hole within 156 feet of.SAS) ❑ Checked with local Board of Health-explain: Checked with local excavators,installers (attach documentation) ❑ Accessed USGS database 4 explain: You must describe how you established the high ground water elevation: ' ' \ \ems z3 J�LA I Before tiling this Inspection Report,please see.Report Completenes C ecklist on next pae� •rev.7lzmi8 Title 6 official inspection Form:Sul$nrface Sewage Disposal System•Page 17&18 Commonweai#h of Massachusetts Fitts 5 Official Inspection Fore Subsurface Sewage Disposal System form.--htot�for,Voluntary•Assessments - Property Address owner Owner's Name I3Wr f is eg �Ulred for every City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information.Complete all fields in this section. B.Certification:Signed&Dated and 1,2, 3,or 4 checked (� C. Inspection Summary: 1 1,2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed �] D. System Information: / For 8:Tight/HoMng Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included WkwpAoc•rev.7/Y MI8 Tide 5 Official Inspecdon Forth:Subsurface Sewage Disposal System•Page 18 of 18 qv dfuTOWN OF BARNSTABLE .0Q9ATION L-oV' H2O C h9"V- SEWAGE # VILLAGE 2Z ASSESSOR'S .MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 0-0-0 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR LIC ATER UILDER R OWNER tJle��t� 43 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �' VARIANCE GRANTED: Yes No !� '� I h� 1 � � a � �� �� �. p� ^l � v �� ���O I 1 !j Na`•--j....... -- Figs. .............. THE.COMMONWEALTH,OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Allplutttion for Diripuial Wurk.6 Tn' tuitrurtiuu 1hrmit Application is hereby made for a Permit to Construct (4) or Repair ( ) an Individual Sewage Disposal System at: i No, 27 f/fJLL ot� VI'-'tom --------------------------------••-••--•---..----- -------•--------------- ----------------------- -----------------------....---......--- � l1lL" 1%t� �' 1�� r o. �7�8 c�C Address ......... --• •--------- Installer Address Type of Building Size Lot.._ _..�fr.ZSSq. feet ., Dwelling—No. of Bedrooms.-__-.3 3................................. Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ------------------------------------- - . -- W Design Flow---11e.P1,6PRN..........gallons per person per day. Total daily flow.._53b..............................gallons. ij R: Septic Tank—Liquid capa6tvJ,5.*40__gallons Length..1_6.'C'_. Width-5'.16-....... Diameter................ Depth..5..7.... Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....0_.1Y6----- Diameter....10........... Depth below inlet...,6............ Total leaching area..2.6.15�....sq. ft. Z Other Distribution box (x) Dosing tank ( ) ''" Percolation Test Results Performed by_L_CF 1.y,... 1� 1? <�.....p....7�.1r._Z... Date----3."�..�...�.............. ,.� Test Pit No. I................minutes per inch Depth:of Test Pit.................... Depth to ground water........................ Gx Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t --•--------------•-•••-••----------- -•-•- ----••.........--•••-----------•--•----•....-•----•...---•-...........--•-••--------•---.............--•-.--•-- 0 Description of Soil..................12....S'.._%Q1 ...kdjSD/.L-------------------- Ile------------------------------- x --- ......................................... -"�14------ INA6--- .M_ --------------------------....................................................... 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation-until a Certificate of Compliance been issuLdd_by the board of health. Signed ---------- -- ---- ----- - -----0........................... ...................... ................:.... ......... ... Da Application Approved By . .. .. ............. © ----------- -..... -...... -- ---------- ---- -- ---' - -. ... .................. ...... ..'--- g ..... t -- It Application Disapproved for the following reaso . ...................................................................'................ ................ ................................................. ....� .... ....... ...... � Dace Permit No. .... ................... _........... Issued ............-.. .. ....................... ...,,r,..-..,�.,..o,.....-�',,; .f, ,rJ� : c..r v�..-- ^t�..C:rJ ti.�y�°' v . v. 5,•• s. .. . ,� . . e _ �a _ - _. Nol.... ==j FEE./ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE >+ Appliration for Di►i,poial Workii Tonotrnrt"inn rrrmit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal �1 System at: G L cation-Address r Lo o. ro-----------------!064_-_f ,9��1�_.sz'_._.1. �.__ 7 8 ............ ON ner Address . .. _._..._.._.���J� g, --••-•---...--•--•--•--•--••....--•-----•......................................................... Installer Address d Type of Building Size Lot...1�' n_.:- � Sq. feet U Dwelling—No. of Bedrooms-------3-----------------------------------Expansion Attic Garba e Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ..................................................................................................................................................... W Design Flow...j P/,&PR_/_ ...........gallons per person per day. Total daily flow....530..............................gallons. WSeptic Tank—Liquid capacity.1SdA__gallons Lengtli__j_6'C'__. Width_ ' Diameter................ Depth___q_'-7 x Disposal Trench—No. .................... Width.................... .Total Length_-___............... Total leaching area....................sq. ft. Seepage Pit No.___.044.6..... Diameter-----10............ Depth below inlet_..-6_........... Total leaching area__2_4_6_....sq. ft. -; Z Other Distribution box ()() Dosing tank ( ) Percolation Test Results Performed by--- v.-Y f---EL1? (s ....... z'-- Date.,.. S_.-- d.............. ,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.......... Depth to ground water........................ 9 ------------------------------------------------------------------------------------------•••------------- -....... •..... ---•••......... -................. __- O Description of Soil.................42 /..!S 12p5(l/3SOrL-_.._....---•------ ............................................................... UW --••--------•------------------------------ ..-...........---------------------------------------......_..-----------.._...._. 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 Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ligs been issued by the board of health. Signed .........- �?-..... ....- = ....-'-" Ii-.--...................... .............. IL -_ ..... .....1:..--.................... Application Approved BY / "l�i' _--- �--�-- = -/-/ �!'- 1 G'%: ' Application Disapproved for the following rea.rogr�-4...................................................................... ....... ......................................r,-..A...I............... ..�. -'.._......-.......... . --.. ..._.-...................-............-- /-........ . .-.......... -..._....-.......... j� X �} Permit No. ..�./..... '-�U .¢....-....... Issued /,-'2/.....I... ..... J 7 Dale l ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifica#e of Compliance e THIS IS TO CEFT FY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ......... :...� �.... ....................... .. -__... .._............._.... .----..... ..._..........- has been installed in acco ance with the provisions of TITI, of he rate— nvironmental Code as described in the application for Disposal Works Construction Permit No. ... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED­AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. G� .-. DATE. .........' r ... / Y` Inspect .r - ..<�.,.......... _............ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l TOWN OF BARNSTABLE No.......... ._ FEE.......................... �io11011tt1 nrko Tnnotrudinn "Prrmit Permission is hereby granted _?'S ............... to Cons t u-t ) � Repair ( an Individual Swage isposal-System at No m _ i' l /.. \. 111 _ �r, .1.- ���� ------ Street �(_• U . P _._.._. y .. as shown on the application) for Disposal Works Construction-rP.&,"'it Noy_________________ �Da�ted�-f?....................................... DATE Fes• Board of Health ' FORM 36508 HOBBS&WARREN.INC..PUBLISHERS i S ' IL BOG f � L 10. 1 - 0SITE PLAN Et. 6�2.7 S</BSG/L I TOP OF FOUNDATION El. : < so `-4VEz 6 I `..A' I G.eq ! I W1�111 Sz ��Nv �oF MIN. 2% FINISHED G R A O E P, IN EL G 3.L 6 /i CLJ�. ,ter Ccs✓E.e.. I0 -----� r . MIN. COVER _. IN (L I N t l wMV111V /Z of IF G. I I 1 2 COVER 1/8 3/8 WASHED STONE >A„/.o i ., IN EL:2Z o° .• ,• .' ° • 3/4 1 1/2 WASHED STONE �v/ s SUMP i 4 " LIQUID LEVEL • : • ; o o :°° I �, I •. i • 0 bbDEPTH ; .•0 °• • P E R C TEST RESULTS PRECAST SEPTIC TANK WITH • . .' PRECAST LEACHING PITS P f R C RATE : I 56. 20 • i CAST IN PIAGE INLET AND El. � • • • — •' d°• ° -- - •owE $ l� E: G 'yi•�+. .r 6��, r�Ev�r� _`r B�,e,ey T � Np•• WITNESSED BOARD OF HEALTH OUTLET S PER TITLE V z /D I A -- —ST ti 3 - s - yo SIZE : 15�o G A l L 0 N S , � OF STONE DATE : ( 6-'6 L ON G x 5-a" W I D E x 7 D E E P I � Pervious io 'DIA ---►! ALL AROUND I Material /� 7SSz II Z2.2 ' El. s2.z A1-2l>F x ��oUND Wi4TE� 1 �� /�ON,p PROFILE OF PROPOSED SEW -AGE SYSTEM � � °sue �i8 ��iVF 5 3 i SYSTEM DESIGNED BY THE TOWN OF _ 511A' S7AOLE REGULATIONS AND 2LEMENT *GS.94 STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4"-► 1 ' 0 ''N . ' I N.S. - -- 1 . All PIPES SNAIL BE SCHEDULE 40 P.V.C . SEWER PIPE 2 ALL PIPES SHALL BE SLOPED 1/4 "' PER FOOT EXCEPT FOR T�" �,v,�,,�,�`''�`���►-G +. �- 49' I THE FIRST 2 FEET OUT OF THE 0 /8 WHICH SHALL BE LEVEL `8s ' 3. DESIGN FLOW J' BEDROOMS AT 110 GALDAY PER BR = GAL/ DAY I i SEPTIC T K SIZE 3jo X � � �9S GAl °� ��c�o I N i �yee 2 i G i I �USE -� GAL . Wl GARBAGE DISPOSAL I LEACHIN6 SYSTEM : USE = ONE X �' FL�PTh� �� T /✓ T G✓/T 13 . EFFECTIVE AREA : SIDE 2-Tr2h * 2 -5 z.,-rrA- zs= -¢71 BOTTOM 2X�o - M I TOTAL FLOW 47if tee- s�9 �Po j i TOTAL REQ'D FLOW s30 X W/OdT OARBAGE DISPOSAL 1 RESERVE FLOW 24v - 3-30 Lz2/9 G / 0 Y Al � IN RESERVE I , RE EE RENCC PLANS oT /V40. 27 Pik �"� i I •-- I ➢�51 NI II APPROVED BY I i BOARD Of HEALTH it I DATE . PROPERTY OWNER SITE AND SEWAGE PLAN ��i�_�^MgJ,',t H OF 'U f O R : N/CKUL AS fstl/L.I.�i�NG CO. •-" •j J .171 OH" .\ •:°. .�. �VILLIAMS4(r TtieEE BEDROOM SINGLE FAMILY DWELLING LIEBER a T Na. 2 7 'S�A<<o1✓ i�.vv vE <, DOYLE.III s L 0 T I - Mo.93rie9 � ` A10. 2 71" it O A T S 2O /9 93 o y BOYLE ENGINEERING ASSOCIATES, INCORPORATED L I �ti Box 595- 530 Thomas B. Landers Road W. Falmouth, MA 02574