HomeMy WebLinkAbout0056 TWICKENHAM CROSSING - Health 56 Twickenham Crossing
Bamstable
A237 062.
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�-Gi'.3 TOWN OF BARNSTABLE tl
LOCTIN, <S� 7°"1�`�IGe�/ ter G �S�y�EWAGE#
VIaAGE A&IVcS��'r le-- ASSESSOR'S MAP &LOT 00—
INSTALLER'S NAME&PHONE N0. ��� >
SEPTIC TANK CAPACITY I '5nC>ZIP`'I
LEACHING FACILITY: (type)d (size) J�x
t9� NO.OF BEDROOMS /
.{ BUILDER OR OWNERS �����,
a PERMIT DATE: L/B, I 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,), ;; ,a Feet
Edge of Wetland and,Leaching Facility(If any wetlands exist
within,,, feet of leaching facility) J; Feet
Furnished by
® ® l
f if 'q�}
No � i r a ,, , Fee V(
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
UBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes
ZippYication for Digaar *pztem Cotvaruction Permit
Application for a Permit to Construct('1�Repair( )Upgrade( )Abandon( ) �omplete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. ?7.S^6 7Y3
A-4-1/nolc% D 00-/&v22i
Assessor's Map/Parcel 9 3—7j 33 j wr Chi nCl� ;
l0� 41/Asr JR�YIS/Y�bfe 414
Installer's Name,AdPI-V,411fi
ss,and Tel.
No. Designer's Name,Address and Tel.No.
D
7 �
Type of Building:
Dwelling No.of Bedrooms Lot Size 9 A�sq. ft. Garbage Grinder(,eto
Other Type of Building Ae S No.of Persons ,.:2— Showers Cafeteria
Other Fixtures ^/0
Design Flow 61119 6 gallons per day. Calculated daily flow allons.
Plan Date A?11,/5 f Number of sheets / Revision Date
Title %c de2 /119 Al i In !3�,�ti�;� 3 r� n414 Y::!�t� ZC44 AIL y M J '•
Size of Septic Tank 16,0y !�Z.4 L Type of S.A.S. ;re'-, c
Description of Soil I/-�l / tee- L/.� 6 f� C O e m 5f V- 120 C
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 issued
Signed _ Date
Application Approved by - Date
Application Disapproved for the following reasons
Permit No. Date Issued
L�lq. ,;,r"', ,P, Fee V 0r
l' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
rPUBL'IC HEALTH DIVISION - TOWN OF BARNSTABLE.,"MASSACHUSETTS ti
pprication for �Digogar `zteni Congtruction Permit
Application for a Permit to Construct( l-Mepair( )Upgrade( )Abandon( ) omplete System ❑'Individual Components
Location Address or Lot No.Sl4 t N �+k(r, Cr vS3;Ls Owner's Name,Address and Tel.No. 7 G 7 r 3
r1 Assessor's Map/Parcel Fell- 1,on-*4
0�3_7 r!Oo2 .S3 iwr'C�i�/�,ffA�'!. !N(�si 6RrrYlsTAb/e /1?�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
KFLty
7
Type of Building:
Dwelling No.of Bedrooms Lot Size�sq.ft. Garbage Grinder(1V())
Other Type of Building Ae S No.of Persons ,.2_ Showers(a) Cafeteria(/VV)
Other Fixtures
Design Flow L/4 /� gallons per day. Calculated daily flow ��eeq gallons.
Plan Date 1,:711 1J 9,K -Number of sheets / Revision Date
Title S:7 e .42 /A i3 40/W in-6/C 4414 i=a eL y t"4"I/rl le�.
- Size of Septic Tank /S'/)0 c/g L Type of S.A.S. /_ to R!S rroe7 c J.
Description.of Soil _1) A 6, rA-,d, L)C, �J
Nature of Repairs or Alterations(Answer when applicable) F
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 is this of
Signed sued Date yt T
Application`Approved by - - Date
Application Disipproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
-THIS IS TO CERTI that the O site Sewage Disposal System Constructed�)Repaired( )Upgraded( )
Abandoned( by , 7V60 . )
k,e v,Lt rt 4.11 .ASS/�
at -s 3 w t n A 0"' has been constructed,in accord E _t
with the provisions of Title 5 and the for Disposal System Construction Permit No. 91-"�dated /2_ Z?'/
Installer Designer / "\ A fX . _
The issuance of t s pe t a 1 .of be construed as a guarantee that the sy to ill function as designed.v
Date Inspector V-0 V V
\�
No. �O --- ----------------- T--------FeeTHE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
xigpogar *pgtem Congtruction Permit
Permission is hereby granted to Construct )Repair( Upgrade( )Abandon( ) ro
System located at .S' 3 C V.,S7/el's %�So-v I., 3 KX4l-f
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
PP g Y
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction m st be completed within three years of the date of thi QPut.
Date: l� e Approved by /�'`
TOWN OF BARNSTABLE
LOCATION - 5i r4f ckewliaA G/955/e EWAGE #
f i
VII.LAGE 14�r/ S�'a'�f��' ASSESSOR'S MAP & LOT —
INSTALLER'S NAME&PHONE NO. gel-&/► J /_�9 ,S7` 7 7/" i�� '
SEPTIC TANK CAPACITY 1 _'
(type)Ugoa ' � 3J �X
LEACHING FACILITY: 4� (size)
NO.OF BEDROOMS /
BUILDER OR OWNERS
PERMITDATE: 41101 I COMPLIANCE DATE:
i
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
" t
1 � ®
k
67--3 TOWN OF BARNSTABLE b
LOCATION rbV1Cke'e11'a'* G!'d9S:5%'-EWAGE #
VILLAGE__j&ZL4_1,Jq'41 ASSESSOR'S MAP&LOT n
INSTALLER'S NAME&PHONE NO. �� ��
SEPTIC TANK CAPACITYI
LEACHING FACILITY: (type)C (size) 3�X
NO.OF BEDROOMS _
BUILDER OR OWNERI���v�J,
v PERMTTDATE: 4z/B A9 COMPLIANCE DATE:
l
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 andl.eaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
. I
I
o a a �-
I _
-� COMMONWEALTH OF MASSACHUSETTS
i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
(DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM FORM
PART A 4
CERTIFICATION
Property Address: _ Y rsjf
Owner's Name: , 12
�fP� �g'�n.('Qr7✓z,(.� _ 4_
Owner's Address:. 0 (/F
3 9'
Date of Inspectionf?_, �n,�'� -
s �-•ter. r �� ".
Name of Inspector, ease rint) r'� t,_
Company Name: _ �
Mailing Address: 2nr �-
%�00—,& 7
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
Conditionally Passes
Needs Further Evaluation by the.Local Approving Authority
ails
Inspector's Signature: Date: /0J6
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 orb eater,the inspector and the system own;r 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.
R 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.
Title,5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I 1
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART A
CERTIFICATION (continued)
Property Address:
Owner: g tli'A 12,/ " I
Date of Inspection:
Inspection:Summary: Chec
k, A�B�C� 'o r E AI
WAYS
coin
Plefe all of Section D'
A. System Passe s.
I� r.I have not found an 3 y information which indicates that an of the failure criteria 'y r� described m�10 CMR
15.303 or.in 3 10 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below,
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 repair;as approved by the Board of Health;will pass.
Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old, or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent:System will pass inspection if the _
existing tank is replaced with a.complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available. .
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is_leveled or replaced ..
ND explain:
The system required pumping more than'4.times a year,due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAIL SYSTEM INSPECTION
"FORM
PART A
CERTIFICATION•(continued)
Property Address:
Owner . �✓
Date ofInspection: ;' e aQ
C. Further.Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation bythe'Board of Health in order to determine if the sv_stem
is failing to protect public health, safety or the environment.
L . 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
Z. 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
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 l'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.we1L
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform .
bacteria 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. I 1
OFFICIAL.INSPECTION FORM—NOT FOR VOL:UNTARYASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
r ,4
Owner:
Owner
Date of Inspection: ,
D. 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 clogged SAS or.cesspool
— _ Discharse.or ponding of.effluent to the surface of the ground.or surface waters due to an overloaded or
J clogged SAS or cesspool
/ Static liquid level in the distribution box above-outlet invert due*to an overloaded or clogged SAS or
cesspool,
Ud Liquid depth in-cesspool is less.than 6"below invert or available volume is less than day flow
_V Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
99 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.
l/ Any portion of a cesspool or.privy is within a Zone i of a.public well.
�! Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
4/ Any portion of.a cesspool.or,privy is:less than 100 feet but.gre4ter 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.]
X/O )The fails
Yes/No: system . I have determined
( y _ 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"yes" 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
_ 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.
4
I
Page 5 of II
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: s14
Owner L
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following*
Yes No
Pumping.information was.provided by the owner,occupant, or.Board of Health
Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period?
✓l 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 7
Were all system components, excluding the SAS, located on site
_ Were the septic tank manholes uncovered, opened,-and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum?_
Was the facility owner(and occupants if different from owner)provided with information on the proper,
maintenance of subsurface sewage.disposal systems
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Y
o
Existing information. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to.Part C is at issue approximation of distance
is unacceptable) [310 CMR 1 5.302(3)(b)]
Page 6 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM:INF.ORMATION
Property Address:
Owner
Date,of Inspection: -®CO
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual).:
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 Qpd x N of bedrooms):
Number of current residents: -2 `
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(ye or no)/7L&1if ves separate inspection required].
Laundry system inspected((,yye��.or no):2
Seasonal use: (yes orno,):/-/Q Q Q �?Z.ed a
Water meter readings, if av -ilable (last_years usage(gpd)):I�
Sump pump(yes or no):,�U
Last date.of occupancy:. } 2a
COMMERCIAL/INDUSTRIAL./vv
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/persons/sgft,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: MO-4 /X"-/ late" 'OY' .a6d &/KC� 99
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?.
Reason for pumping:
TY,KOF 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/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):
A proximate age of all components,d to insta d(if known)and source of information:
1J/9
Were sewage odors.detected when arrivin at the.site es or no :�`6.
g (Y ) —
6
Paae 7 of l l
OFFICIAL INSPECTION
ION FOR
M_NOT FORvOLUNTARI ASSES
SMENTS*
TS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART;C
SYSTEM.-INFORMATTON(continued).
Property Address: ,:!�6h'�i���rr�� (�
p
Owner: fJ . j.
Date of Inspection: `
BUILDING SEWER(locate on site plan)WO
Depth below grade:
Materials of construction:_cast iron. 40 PVC - other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.): .
SEPTIC TANK:_(locate on site plan)
Depth below grade: ;
Material ofconstruction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is aae.confirmed by a Certificate of Compliance(yes or no): (attach a copy of
-certificate) y
Dimensions:A)I—s—, k(,,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: .
Scum thickness: >i
Distance from top of scum to top of outlet tee or baffle.-
Distance from bottom of scum to bottom of outlet tee or baffle: rp _
How were dimensions determined: 4 4 4/ Lei/9 A
Comments(on pumping recommen ations, let and outlet tee or baffle.con d iti on,.structural integrity, liquid levels
related to outlet invert, evidence of leakage,etc.):
A/oa
Gaza✓, eQ &Z4ixj
GREASE TRAP: 0(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom'of outlet tee or baffle:
Date of last_pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as.related to outlet invert, evidence of leakage; etc.):
7
Page 8 of 1.1
OFFICIAL INSPECTION FORM=NOT:FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Ad ress:; s �d
Owner:
Date of Inspection: t 7(!�o
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(loc.ate on site plan)
Depth below grade:
Material of construction: concrete- metal_ fiberglass_polyethylene othe,r(explain);.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alain present.(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site.plan)
Depth of liquid level above outlet invert: �` "T
Comments(note if box is level.and distribution to outlet,. rfal, any evidence of solids carryovet,,any evidence of
I kage intoaor out of box, ete.
l
PUMP CHAMBERALO (locate on site.plan).-
Pumps in working order(yes or no);
Alarms in working order(yes or no): t
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
3
Page 9 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: /
Date ofApection: �?
SOIL ABSORPTION SYSTEM (SAS): F/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
1 aching pits,number: _.
/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::
CESSPOOLS:A/O (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: (locate on site_plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9:,
Page 10 of 1.1
OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART-C
SYSTEM INFORMATION(continued)
Property Address•,5(,,%7,h-AAp
Owner
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system includin-ties to at least two,permanent reference landmarks or
benchmarks.-Locate all wells within 100 feet:Locate where public water supply enters the building.
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10
Page I 1 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION(continued)
Property Address: t
Owner: /, 2
Date of nspection:..
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high groundwater elevation:
Obtained from.system design plans on record-If checked, date of design plan reviewed: .
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain: -
You must describe how you established the high ground water elevation:
_ 11
I .
Permit Number: Date:
Completed by: il ^
"HIGH GROUND-WATER LEVEL COMPUTATION
Site Location rf/�' G�0 ✓ 1 � ' � � Lot No.
Owner: Address:
Contractor: sra( a�/' 1 'i � j` Address:_ �`._ �9�'+��.?� �
Notes:
STEP 1 Measure depth to water table
tonearest 1/10 ft. ..............................................::...I..................._......... .Date s
month/day/year
STEP 2 Using Water-Level Range Zone;,
and index Well Map.,locate
site.and determine
/ e
O.Appro.priate,:mdex we l ................. l...............
OB Water level range zone .....................................
STEP 3 Using monthly report':':Current
`UVater.:Resources Conditions =
deterrriine current deptf,to /"w
.-watef.1eve1 for index well
month/year
STEP 4 Using Table of=Water level Adjustments
:for index well (STEP..2A),:cur-rent depth
to water level for index well-(STEP 3),
and water level zone (STEP 213)
determine water-level adjustment '
................................................................
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) :.......................::.........:...........
Figure 13.-Reproducible computation form.
15
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IT-
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Jvlw6
3 ' REFERENCES:
Ei
o
Q'j o o Assessors Map:237
3 m Parcel: 062 ZONE:RG
See Plan Book 286121
Setbacks:
a yam• t Front: 30'm in
Side: 15'min
co °` 7 r'St/neert F�F -Rear: 15'min
0/7
0121
,V
° "\\` '� S6 N/F.
1 o I i ,, `34g:3°•• Michael J &
Nancy J Canty
L=227.96 �\ i
30' Frontyard I 1
c U-)
Lot 3 i
85,259±SF
1.96±AC
o° Wo-i
i'
i. ` I U
i 1
Z � 1 °Elec oh
ioutletFlog
Poleo 1 �� �' O
�\ � Proposed , o o =o
i Garage i 1; h3 co
I , ,
1
i43.3 ::::':1.......... 56 I �U
W i:).......................• :. 't;3. 1 1\2S y W/F i 3
�. Dwelling
Deck.................
Approx. eckI .r7 N
i ..k...... ::::..:::;::::... i Septic
24t' System f.. 52.3' I ^
Z I (to be removv—eql i ............:i..�..'i..
I Port I 38.0' I
--•-- --•----•-- ----— •--•-- . --
— L__._—• = 15' Rearyord 1
N8152'00"W 95.43L- N81'52'50"W 159.;
OH
39.47 POF d
N80'26'00"W N/F
William D Knott
�NOF US Irrevocable Trust
3 RICHARD R. PLAN SHOWING PROPOSED GARAGE
L4EUREUX ..
NO 34312 �o At 56 Twickenham Crossing
BARNSTABLE
it
A N I ►N�� ,.. ..... . .
v
Town of Barnstable P H yjco 9
Department of Health,Safety,and Environmental Services
oF�til Public Health Division Dale
367 Main Street,I lyannis MA 02601
9A aNaTAHM j
rto � Date Scheduled ^/v l/_ 0, /J`5 fj Time//=-Ta /1r-j Fee Pd.X�V• z74
Soil Suitability Assessment fog, Sewage Disposal
Performed By: A?_ Witnessed By:
11L INVOR A 't N
Location Address Owner's Name
5Z >W/CifL�/,//-1r-i ��GSSiN6
Address
Assessor's Map/Parcel: 2 37 — Z Engineer's Name 572-7,So._1 /Z- /./i12t_
NEW CONSTRUCTION REPAIR Telephone H 47-6-G 3G
Land Use 2c-s/,D�7/i/i9� Slopes(%) -5-zc, Surface Stones yzr_
Distances from: Open Water Body "/1 R Possible We Area k/A ft Drinking Water Well K/A ft
Drainage Way 11/1-4 It Property Line ���, ft Other ft
SKETCH: (Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
N
Tw�cK�yq,y �J?
C/ZoSS/�tG
ii
r zt'i
b
ZT 3 0
Az,Re- zge Pc L1
v
�z
is 781
39, 3
kN
yS 460 157,7 8
Parent material(geologic) Depth to Bedrock
Depth to Groundwater: Sta»ding Water in dole: Weeping from Pit Face NO NLr
Estimated Seasonal High Groundwater A14
bI';'I'CYtriH1 A'rIb1V I+OR SEASONAL HICA�"�Ti'�A�Ys r <
Method Used.
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment R.
.-Index Well N Reading Dale:— Index Well level..___ Arij. factor Adj.Groundwater Level
PczWOzJ ►Tzory TLST Hfne
Observation /
Hole N Time at 9"
Depth of Pere 1.16 Time at 6"
Start Pre-soak Time® /Z,L.0 P-7_ Time(9"-6")
End Pre-soak /z.4o /w�
Rate Min.Anch `fIA/ /Ner1
Site Suitability Assessment: Site Passed l,".'- Site Failed: Additional Testing Needed(YIN)
Original: Public Heallh Division Observation hole Data To Be Completed oil Back j
.
DEEP:'008PR'VATIo" K IYO LCI < z 01e
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
Consistency.%Gravel)
.5, r>1 l,,,rry
FWe-
DI';EPI CABS RVATiON HOLE LOG Ii01e #' /tq
Depth from Soil horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
�� e
Oraych
V d2C, /d Y/Z
/ /Z
3p4 Q any �A� /O y �G
SILT
L F/NLSS4Vt /oy 7 L
Df ;0I35IZVA'I'1�N'X �C L( C 10lc# Z .
Depth from Soil horizon Soil Texture Soil Color soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
%
O 0/W. /d ,�L �Z
/ A 5-4v D 45,4 r- /a r /z
41� 49 Q .514vo 4>,1'y /o V/z 9/6
'itt��—/Zo" C HAD,.Ssi�/D Co B8LE5
!DEEPi O1�SERVATIOlt1!IIOI� LOB IllC# . �
Depth from Soil horizon Soil Texture Soil Color Soil Othcr
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
stcncy.%Graycl)
0ii / „ 0R6. /o tz z
S,i A SANt7 LDA r� /U XLZ
34 z� .SA*aAr /z G 6
-5. "-/Zo" C -1r�,sRr%o Col3l3LE3
Flood Insurance Rate Maj
Above 500 year flood boundary No_ Yes r�
Within 500 year boundary No— Yes
Within 100 year flood boundary No— Yes
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 system7 V tsS
If not, what is the depth of naturally occurring pervious material7
Certification
I certify that on (date) I have passed the soil evaluator examination approved by the
Department of Environmental Protec ion d that the above analysis was performed by me consistent with
the required traini a se 1d cc described in 310 CM[Z 15.017.
Signatur Date I'zs ,4
vl
Ila
7PVIC-
70 46-d IC-774 Cel-74�: f-71 4 -'Z4, Ov 37
CAOO S_T Al 4 Z-
1 Z-
4-
E-L..
82.0
TOP OF FCUNCA.K)IJ
CONCRE7F COVERS
74'
4"CAST IRON
7-9 T i. -;AC
OR SCHEDULE 40
4"SCHEDULE 40 PV C. (ONLY)
PV.C.PIPE MIN 3 MIN. LEACHING TRENCH ( I)REO 3 6"MAX
PITCH PIPE-M IN 1/8 1/2" WA SH ED STONE
PITCH /4P�:�z i2i 11
2"
C=J, 0
: 4
GAS'i�FIIL'E-�- it -T
- Ictill �= = Clcii -c=
t TA I N V;.?�,
IT 7 7,-4 2-
24"
L 5 SEPTIC TANK -L
L LPIT
NV=
ct�,,; t3, c�j C3 1=
RT
GAL. v_ii T DISTi
-N -i7---1. 1 3/4"-1 V2"-/
INVERT Precast 500GaI.Le0Ch
EL
RUSHED STONEM BOX 7, (-4)REO
I ........ ChaMber WASHED STONE
PROR LE'
9 311-3 51
SENVAGE DISPOSAL Sy S EliGROUND wart
AT 7A?LE
SOIL LOG
CROSS SEC71ON
T I ME NO SCALE LEACHING T R EE N C H
5 7 TEST
DESIGN DATA '
3r:RCC%,.S . . . 36 MAX
W,
TOTAL ES71MA-713 FLOW GALLONS/04Y
Zz�� 7- 3 -C:-3, 0-,a,, 4
- L---4CHING A ... - - 3� . 4: =�,E;�,C�,,,r
DV B3,70M REA SO.FT./ Ie
30.FT./TRE-,IC4 1137."d
A 'n, z 77, !OE: LZACHING AREA , f;
GAAZAG7- DISPOSAL ..(50% AR-A INCREASE)
41-r
T,:,AL- LZ,:,CH;%3 AAEA IL.. SV.;1. N
I Q 6 �� ,.� I �' WI7Tl L Wll*' P-r.RCCL-710N RATE ZIE7 Mdb, 4ArlAll
I
C-0 LEACHING AREA ?---:I PERCOLATION R-17- 453•'.z-sc..F7 r-
\ ``. /�_' E1. L7_a,c. /.7-0 I � E""L.9e.a"
A PP R c V EC BOARD OF Ht-AL7-H GRCL;,%D N,:�-,7 R 7Z, L E
/ ` ' �� , I r-NC0UN7=-A-=D OATE..
WITNESSED BY
-y- BCA,70 OF --AL7,.i
573
iwI4 4-,vS 7-4 g4 6
D.CAVA E Zoat.1
7W 14 A4,L&
lot
Aj
f
1?.010
,q
y
Ci
z Z-
A,1,: V& 7
4.z,:2 71 A'
*4
4&-y
15y 78
U
—I',-z Z- cf) Et LARD
5 7
'KELLEY
E
VAL0�
STILT, 4u
LANa
Z7-VA 7-1 .5 z