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HomeMy WebLinkAbout0067 SPYGLASS HILL ROAD - Health 67 Spyglass Hill Road , el ve 10 Barnstable P =V N * r A 355 002004 c ' 1 i - r .1 � N :xx+r r -4,��{j. a'r y � + ; •t � ` ..r � #' n� 4, ,. .a .. ,. + f t w y • �a �• � 4 d_a ; .�•S:. +tip 7 44 In a C - r! ra f. ..� , Y '., .1• v' - ,u. ��i`''df � '. - ,. ,. - - - Yi.r- S4 • Y 0 r r •' d � 9 v. 'b', ��`~.r. °rs ' ��J��, _. ,. ,V `i.:'. Y - F ;h. ,,. ', � � •4, w _ r �� :T'r � �;{* �-a m, r a �� f M-- .h o_ � .. { - }k z ,a•a {pp. - ' 1 •.5,, '� ^" it .. 7 _ � , ,,, - .y�'� .r.. � sir♦ , '>Y' - �i's r y'�r 'C ., ?� , a ` .�., ,. _� �q � � r. '�� .. _ 3�:A: t a + 4': .+ p '..y. }, ,•S ,.14.a� 'a.` e�":+-4:-. ..p'� � • , • sty n y J'-�� •.y ,. • y i - _ LL A - • y e i�L °� :y T "'y. - k ' + y - , [' e U Y ` ,.M., .-C :'.hti r • `�'a,.J..i ', .. ��..f Y •'z iJ ' , � tfJ • ,. � � �, �t ::,F: a �� 'r '�{.'+ ,r' 1+l«wi, s k e' .+ .R a �.•. , .S• , 5 •1. k, ?. _,. - :'.. • ,.a`h" dg .,:a .Y� `1ipk �' . - ,. r,y '} �'� � .. ,. �i, . E I '�. a .�• � k.",�': ?^ 5 ' `•; "2„ `.� i r ,.: �¢ � _ � r AA Tv i. +�..- } M-o � # r. : e k 3 .4f. (t a 3' ,� '1 Y • - .,r �R t r ° RECEIVED COMMONWEALTH OF MASSACHUSETTS MAR 1 9 Z��2 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR DEPARTMENT OF ENVIRONMENTAL PROT]ECTI NDWN OF BAR,NSTAB E HEALTH DEPT. w MW F W PAM • ®®a- ®o Q— �Q VO ,M 5�0 LOT . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner's Name: GATELY Owner's Address: 7240 COVENTRY COURT UNIT 321 NAPLES FLA 34104 Date of Inspection: 2/26/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes _ Conditionally Passes _ Needs Furt r valuation by the Local Approving Authority Fails Inspector's Signature: 2726/02 Date: t, The system inspector shall submi 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 SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND RAISING ALL COVERS. ****This report only describes conditions at the time of iuspecliou and under(lie cundilious of use al (hill lime.This inspection does not address how the system will perform in the future under the same or different conditions of use., M 41P 5 Incm rtinn 17orm 6/1 NOOM 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUN T ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner: GATELY y Date of Inspection: 2/26/02 Inspection Summary: Check A,B,C,D or E/AALWAYS complete all of Section D. A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS-TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND RAISING ALL COVERS. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. ` *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old,is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to;broken or obstructed , pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed distribution box is leveled.or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): { _broken.pipe(s)'are replaced r _obstruction is removed ND explain: n/a Page 3 of OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner: GATELY Date of Inspection: 2/26/02 t C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the.env iron ment. 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 t _ 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. x _ The system has a septic tank and SAS and the SAS is within a Zone I 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 a private water supply well**. Method used to determine distance n/a **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. a 3. Other: n/a Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner: GATELY Date of Inspection: 2/26/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is Less than 100 feet but greater than 50 feet fi-om 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 forma (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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 " 'es" in Section D;ibove the 1,11-e sVsfem has failed, The mvncr or Oper,tcir 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. 'l he system owner should contact the appropriate regional ollice of the Deparlment. a _ Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 SPYGLASS HILL RD CUMMAQUID,MA 02637 Owner: GATELY Date of inspection: 2/26/02 Check if the following have been done. You must indicate"yes" or"no" as to each of the following:. Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks _ X Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection'? X _ Were as built plans of the system obtained and examined?(if they were not available.note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site'? . X _ 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`? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 f Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner: GATELY Date of Inspection: 2/26/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: n/a Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no). NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)):tea 100c) " l COO. Sump pump(yes or no): NO Last date of occupancy: n/a d"��l qq COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO " Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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/Alternative 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): n/a Approximate age of all components,date installed(if known)and source of information: 1997 BY AS-BUILT Were sewage odors.detected when arriving at the site(ycs or no): NO Page 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 SPYGLASS HILL RD CUMMAQUID,MA 02637 Owner: GATELY Date of Inspection: 2/26/02 BUILDING SEWER(locate on site plan) rt Depth below grade: 30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Continents(on condition of joints, venting,evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5' 6" W 5' 8"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SY STEM'S USEFUL LIFE. RECOMMEND RAISING ALL COVERS. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,sciuctwral integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner: GATELY Date of Inspection: 2/26/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain):.n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day ' Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps andrappurtenances,etc.): n/a r , Q Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: 67 SPYGLASS HILL RD CUMMAQUID, MA 02637 Owner: GATELY Date of Inspection: 2/26/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON LEACHING leaching chambers, number: 2 CHAMBERS leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: nla " n/a innovative/alternative system n/a Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): CHAMBERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. BOTTOM IS AT 61. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a r Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 SPYGLASS HILL RD CUMMAQUID,MA 02637 Owner: GATELY Date of Inspection: 2/26/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. vE'el� oA ° C . k I� J�b Sc 15 Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 SPYGLASS HILL RD CUMMAQUID,MA 02637 , Owner: GATELY Date of inspection: 2/26/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. LaaCi�8. - 0A i%- TOWN OF BARNS T ABLE N SEWAGE # - VtT:i:UAGE cf(d ASSESSOR'S MAID & LOT 156 6 6 0�{ IN8TA.LLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ` S zo LEACHING FACILITY: (type) CA—QM ize) 'NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /� Feet Furnished by �l CA. 53`' TOWN'OF BARNSTABLE WCATION S ZC IASS I41 I SEWAGE # - Ms— V LLAGE 11 0.m 1' A Cd u i ASSESSOR'S MAP & LOT 3{ -dp2 INSTALLER'S NAME&PHONE NO. R ,,AJ /,^2 SEPTIC TANK CAPACITY U LEACHING FACILITY: (type).o0, J,G/ I-eA111 61 i A M)'-,(size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: �' l 7 COMPLIANCE DATE: Co Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any.wetlands exist within 300 feet of leaching facility) Feet Furnished by �J-� � � : � II Ji c ,,. 00 ,r9, � No. '7 t, 7- 3 85 Fee THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for 35i!6po$al *pgtem Cow5truction Permit Application for a Permit to Construct(1/�Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.67 S P Y6,(,ASS tf ML f?P Owner's Name,V Address and Tel.No. 'DAU(o �ty- �Q�,j e� Assess is Map/��arcel MN 0 49v lIt �`V pI A ( ( (O8 �o aw o o p /�/A , 6o11) 7b 1-46� Installer's Name,"Address,and Tel.No. 7 Designer's Name,Address and Tel.No. la>lzo s • 7 yARMDdrA'FD2rt MA e-WMMAtUcp IRA Type of Building: 25�� Dwelling No.of Bedrooms Lot Size 7 sq. ft. Garbage Grinder( ) Other Type of Building y2AA/I l! No.of Persons Z Showers(Z) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 56pno gallons. Plan Date umber of sheets 2 Revision Date Title 5 Size of Septic Tank Type of S.A.S. L (!-�lJl1G v Description of Soil 9 -5AMD LoAAA, (0YR 614 Nature of Repairs or Alterations(Answer when applicable) 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 d by tpi Board of Health. Signed9j4CA,,,.*A,' Date 2 Application Approved by Date 7- , 6 ' °7 Application Disapproved for folloAng reasons Permit No. Date Issued j` No. 7 ��� Z_� w, Fee �CiO THE COMMO i WEd�Lf- �OF MASSACHUSETTS Entered in computer: Yes 'PUBLIC HEALTH DIVISION -1T16N'�F BARNSTABLE., MASSACHUSETTS Application for �Di5po5af *pgtent, ongtruction Vami tt Application for a Permit to Construct( 06air(' )Upgrade( )Abandon( ) El Complete System ❑In 'vidual Components Location Address or Lot No. 67 S P YG L A S.S H U L r,?P Owner's Name,Address and Tel.No. Y' '/ UAV �ArtEL`/- r-V'E 2��1 C(126L6 Asses TbF cel GANO evyaT PLAN �f"/2 / w(�/.6 N o 2 w o o p MA , 6 31k 2-661'y Installer''s Name,Address,and Tel.No. -'Designer's Name,Address and Tel.No. c-r c s ��s . 3�z -(4 S7 'EVV/A(LD _E, KE�C.E y yA1Pm o 6-rA P9 s2-r MA . , Type of Building: ' Dwelling No.of Bedrooms Lot Size 25�� 7 sq. ft. Garbage Grinder( ) Other Type of Building PiMM e No.of.-Persons Showers(?-) Cafeteria( ) Other Fixtures A Design Flow qR-. q' gallons per day. Calculated daily flow gallons. Plan Date � 'a*t'1 f Gl1%_ Number of sheets � Revision Date Title''Cyr C PL k��-~ 11_T._a Size of Septic Tank Type of S.A.S. l,,-_�j 1 AJ� I Description ofs So A k y , i+ 3( n 0g;x . C.Of�N` r 0 yR ,,z -`; Nature of Repairs or Alterations(Answer when applicable) Date last inspected: t Agreement: ! { The undersigned agrees to ensure.the construction and maintenance of the afore described on-site sewage disposal system in accordancemith 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 s orof Health. Signed ' Date - Z �' Application Approved by Date 7- 3 -7 Application Disapproved for thY following reasons Permit No. 2 - 23 S ' Date Issued ————————————— —------——————————————— — THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comphance THIS IS TO CERTIFY, that the On-site Sewage )isposal S stem Constructed(✓)Repaired ( ) Upgraded( ) Abandoned( )by '"===�_ h nf'* C;1ACQ./O i at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7:36 { dated Installer Designer The issuance of this permit shall not be cons ued as a guarantee that the syste wil function as designed. Date Inspector . — _3 Fee —------------=---—_-- -- .--- ----- f — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Di.5pozal *pztem (Construction Vermtt Permission is hereby granted to Construct Repair( Upgrade( )Abandon( ) System located at ro 2n ;- G OT 7 s ff c`I t VU 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: Consltu tion ust be completed within three years of the date of thine t. Date: L( 7 Approved by R. K t s'i T�= LOCATION BAltz�vs7f�f3CG!'�!yq�v„iD� SCALE . , A"' 1 DATE ?tFl-.'vl :Z PLAN REFERENCE ,-;64?NG,... ...T .. :7... . S'� )V N VA/ L/�i;/D �'o,a/LT'• .'� . . . . . . . . . . . . . . . . . p N 00 �oT 99,se �N l i OF D AE. ; KEU-EY C /1 41} y. 1 f n fi N/�o. 26100 ,+ tell , v fss! STE g /+, µr• /' 4k. + 4�NJt Y` s(a r�/'�' ', �I �` .IV. SAL LKN® /• t / ` `` a C 4 •/, 1 I S)O V �`�► O i �,� j \� j 147= 00N I /169 ley, �y �.� 4131 .,Ito _ r 00 f' `C / s _ i Y f��d ^'�• 0.�, ° Y� at z+a 1 C," ��� ti*� t��^,at>I /�C'T!T7o�vc ;p . i TOP OF FOUNDATION ; e•' CONCRETE COVERS 4*'CAST IRON 91 OR SCHEDULE 40 n 4"SCHEDULE 40 P.V.C. (ONLY) 9'MIN LEACHING TRENCH (L)REQ. r P.V.C. PIPE MIN. 6� MAX. _ PIPE-1/4" . - I/8"- 1/2" WASHED STONE _ .., PIT CH 1/4"P�.FT PITCH I/4�PER.ri. - ..� •«. 4�-..� r.«..� , 8 ;'• ICI C7;Q•Q-;Q):C7� 4„ v'•_ INVERT rp%O �CC]•�� -� EL.iozsl- SEPTIC TANK INVERT DIST. INVERT CI'4==14L��:I��'CI' r�'t::_ lt3 - a`% 24" EL c2.oc 60X ' O,,�J��O'I�.;L fJ• �j� • INVERT -- L7.� r /Sao GAL.. INVERT 9 .e, EL/oZ_..,5 - .....•• EL/bi 8,3_ INVERT Precast 500 Gal.Leach 3/4"-11/z"--f - . , 1 ) REQ_ Chamber WASHED STONE 6'CRUSHED STONE vVEz 246 PROF]LE 0 /= 89/3 GROUND WATER TABLE SOIL LOG SELVAGE DISPOSAL SYSTEM, TYPICAL CROSS SECTION DATE Nod/*IW�. T I I*t= .//:l �.��. No SCALE LEACH I NG -_TRENCH - TEST HOL= I TEST HOLE Z ' ELEV. .!o 70 .. . . ELEV. io3. 9o... DESIGN DATAVa'-�i2�. . 9:' 1diN. Y'"S�EJ -36"MAX. 1'L./o3,4vTOTAL ESTI ATED FLOW .. . T=f�. .. GALLONS/DAY - =-y: -� 14 8" /oS/S BOTTOM L-ACH I .G AREA ..Z��.7.Q.. SO.. T/ircENC �' �;LZ! 2" ; 24' Q iY erc a 43 c - _ //7.3z - - / P.D.- , ;C1' d,dr� ,3L -SIDE LEAC41N o AREA ... . . ... . . Z- aO.r i./ �R ENCH/2C.8L �. &Z. - . v NONE or G•P.D �- /L C,rG GARBAGE DISPOSAL . . . . .L.?�.T(y50 ro AREA INCREASE) - - - . ,�• L r�/�� "•�'i'i�� - TOTAL L.`.i'�C'MiivG ARi=A �t j� SQ.:1. / r� �y O�LTL /Oy/,e 8�� �0 5--�+-6 PEP..=, s'�r� a CCFrsa PERCOLATION PATE Z"'°�!'� . . PER.INCH r' CLASS T.. /oQ '' /Z/o f' /o yz L Gi_S_54f-,fa L-ACHING AREA PER PERCOLATION PATE �.... Sv_F—ii �. G Skt/_ /No�lc f�fCOLkTET-C�j t u /Ot//L �/y GROUND Wl.TER i.•,_LE / C-z_8�'.70 /3Z-1" [2 SIX APPROVED .. . . . . . . . . . . . BOARD OF HEALTH I �q...WATER ENC0UN i E R E D DATE... WITNESSED BY : AGENT OR INSPECTOR ��t� of ��r .•���q©v40'�. N �9 L=p/G!/� LI21L 60A.'.D OF HEALTH zo T s��' �d EDWa �. 1 ��o�ys ` qry.. N 1. ST G ST�Ts�.co �i�LC ,?S G7 SFyG'L/ass �GG /�, 2s1000 `t C ,.. . . .. . . ... .. . ENGIN. v H -t L�7JdS/. . . . . . . . . . . ... . . . . .LGBHH; /S-7A13GE-�u.•r.y/a4'!J/z�� �sISTE��s �. l DMAL 1Ki10 �tp s P_i I T IONErR �iq7�/1� �/�?�-�. ► sQ RfD ►N OQ' �� . . . . . . . . . _ brD�EVAWA�Q�.s FORM Ill - SOIL EVALUATOR FORM Page 1 of 3 No. P- 8f/ Date: Commonwealth of Massachusetts Massachusetts Soil Suitability Assessment for Can-site Sewage Disposal Performed By: ................'�r��✓. ,.. %�.L..�,,.. .;...GF3.—. �?�� �✓.��� Date:. n a e.. .!1,../.P9..4.. Witnessed By: !'✓q 1a.. Rai:/.... Rc,C �r. ., 'c�s...O.F. .h! 9Lr.,f/,'.F..�.x �9�4A..E,.. E[4��;..��C.S' Location Address or / `dp7�7hif.SeS/J/L.G rl d LL/✓rWl�1Ql1�� Owrer's Name. Lot N �J Address,at d / Telephone,0 jk New construction Z( Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes LJ. s'o�.0 s�R✓�Y��Ri�B�f Ca��✓r�/ Year Published 0..9J.... Publication Scale Soil Map ...... Drainage Class .............. Soil Limitations , <.L'•` %^! '49.,.AS...... Surficial Geologic Report Available: No ❑ Yes Year Published / 7a..:,:..:::..:..... Publication Scale Geologic Material (Map Unit) /q/"is....ay? .................................. Landform ...................................................................................................`.............................................................................................................. Flood Insurance Rate Map: P/�/✓% G eSoDl Coo_ C i Above 500 year flood boundary No ❑Yes ❑-'- -OIV�n<, Within 500 year flood boundary No []Yes El Within 100 year flood boundary No ❑Yes ❑ Wetland Area: Wto ' National Wetland Inventory.Map (map unit) ..................................................:............................................................ Wetlands Conservancy Program Map (map.unit) ....................................................................................:.............. . Current Water Resource Conditions (USGS):'Month Range :Above Normal ❑Normal El Below Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/07/95 • y { .F FORM, 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. ZOT N7 �pYG�s'�ss f/�L, ��1M�9Quip On-site Review Deep Hole Number .. :'?: Date:... 1 �%� Time:... :'%5�9�'I Weather !zT`�RT �I.s�✓'✓1�- �F Location (identify on site plan) :::..::::.:.......:.:.....::.:.::.:::..::...r....:::..::...::::.:,::::.w...::.,:.: .:.:..:..,:.:. :...::: ..:::....::..:.:...:...:::.::.:.::..:.:,::..:..:: Land Use .............:.:::.. . Slope (%) .:...:::.:.::.. Surface Stones .;..::.:.:.::..:..::::...:..::::::.:;:..::::;.....:.............. .:.:::.::..:;:..:. Vegetation . '✓oG:rn.�D...-::.:,. 'in/ ,t:::. r-:o. rCS:.:::::..:.::.:,:::.:.::::::.:,..:..:::,..:.:.::,:::::::.::.:..:..:.::::.::::.:::::::.::.::....:...:::.:::.::.:....:..:.: Landform ...._ Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way ..:...._... ._ feet Possible Wet Area ...:... :. . . feet Property Line :::..:..::...:.:.. feet Drinking Water Well feet Other ....::.:::::.........:;.:::..:,..:..v:... DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones,Goulledllrs, Consistency, % Go"7-6 BF N Ire —/46 C` �/n��.J'i3i►'D /U y�CY'1l C044'vc Y /08` —/32 C'� F,.✓�.1-61�✓a io y�2�/� G� 's 2 -,-1'o14 . Parent Material (geologic) /�710R'?/M5 DepthtoBedrock: ' J,66 Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: ^143 Estimated Seasonal High Ground Water: . r DEP APPROVED Mitts-12/07/95 ^ 4 ` FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Ldr R 7 7", c;4 TZ Ct��rr�,y J,a /✓jam Determinati Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole.!✓........ inches ❑ Depth weeping from side of observation holel✓044. inches , ❑ Depth to soil mottles MOAIX-inches ❑ Ground water adjustment ........:.......... feet Index Well Number .................. Reading Date ................... Index well level .....:............. Adjustment factor ................... Adjusted ground water level ....................... ..........:.F................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �S If not, what is the depth of naturally occurring pervious material? 'Certification I certify. that on/►No✓ Icl (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 experience described in 310 CMR 15.017.E r Signatu Date .,3 6 ily( 'f DEP APPROVED FORM-12/07/93 ,a r"r L TOWN OF 13ARNSTABLE LOCATION �.�� S `/'/C, IASS I-1� SEWAGE # p► r u ASSESSOR'S MAP & LOT.��$S 601.eo VILLAGE 11 o M M Y INSTALLER'S NAME&PHONE NO. & rl ti Y C A LA /4 SEPTIC TANK CAPACITY I SU U "(size) LEACHING LEACHING FACILITY: (type) a NO.OF BEDROOMS c BUILDER OR OWNER PERMIT DATE: `q, COMPLIANCE DATE: �� Z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet PrivateWater Supply Well and Leaching Facility (If any wells exist on-site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by .� , a.�3tl �h�=3 `J fl