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HomeMy WebLinkAbout0060 ANTICO LANE - Health 60 �►ntico .Lane Centerville P A = 172 005003 .oxford NO. 152 1/3 0RA o _ - - - :� t ,� I �. N Commonwealth of Massachusetts 005-0Q3 i~ a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -T1 60 Antico Ln. Centerville, MA 02632 +� rM Property Address t--j- r;- John McDonald 75A Main Cir. Ow Imo' Owner f ner's Name information is required for every Shrewsbury MA 01545 1/31/2018 _ page. City/Town State Zip Code Date of Inspection �Dk Inspection results must be submitted on this form. Inspection forms may not be altered iln any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, - use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Inspector Name of Ins key. R Cape Cod Septic Services Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town 508-775-2825 S ate State Zip Code 5016 Telephone Number License Number B. Certification 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.CM 15.000). The system:. ® Passes ❑ Conditionally.Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/6/2018 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow Of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate,regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *`."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. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal SS t Page 1 � V J commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �< 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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 CMR 15.304 exist. Any failure criteria not.evaluated are indicated below. Comments: System in working condition. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y 0 N ❑ ND (Explain below): t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every _ MA 01545 1/31/2018 CI !Town page. ty State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form-Not for VoluntaryAssessments is • f 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from 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 fecal coliform 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No 0 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 Yz day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to"a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a.cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform 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 2000gpd- 1 0,000g pd. ® The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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. p t. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •°` 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is required for every Shrewsbury MA 01545 1/31/2018 page. cltyrrown State Zip Code Date of Inspection C. Checklist 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, 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: ® ❑ 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 15.302(5)] D. system Information Residential Flow Conditions: 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): 110x3= 330gpd t5ins•3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? . ® Yes ❑. No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): 2016=290gpd Detail: 2017=466gpd Note irrigation system on property. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3?13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald. 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/user Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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)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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22" feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance-from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line was checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 12" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene [I other(explain) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is bury Shrews required for every Shrewse. MA 01545 1/31/2018 State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness oil Distance.from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet cover 6" below grade with outlet 12"below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction:. ❑ concrete ❑ metal ❑fiberglass Q 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is required for every Shrewsbury MA 01545 1/31/2018 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -p y Not for Voluntary Assessments •''` 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is required for every Shrewsbury MA 01545 1/31/2018 page. Z5ty own State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 2' below grade. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: ❑ Yes. ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z •` 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/2018 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 ❑ 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.): 2-500Gal chambers with stone. No standing effluent in chambers during inspection. Soil is clean. No evident staining. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate,on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System 9 p m Form Not for Vo luntary oluntary Assessments . 60 Antico Ln. Centerville, MA 02632 Property Address. John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA 01545 1/31/201.8 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts • Title •5 Official Inspection Form s Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments ' 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbury required for every MA . 01545 1/31/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments p 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is Shrewsbu required for every ry MA 01545 1/31/2018 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10' 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: Date ® 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: Hand auger through dry chambers to 10'with no water encountered. Bottom of chambers at 5'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r` 60 Antico Ln. Centerville, MA 02632 Property Address John McDonald 75A Main Cir. Owner Owner's Name information is required for every Shrewsbury MA 01545 1/31/2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 wUr�Fv.c ► TOWN OFBAPNSTABLE 1?Z' ooj�-0"J LOCATION Q SEWAGE 1ASSEVILLAGE G, (.a,�TSSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACnT-- , S 40 •+ L LEACHING FACILITY: NO.OF BEDROOMS BUILDER OR OWNER 44 o.f. 0 PERMITDATE:_ " 1 c`w 9k COMPLIANCE DATE: A?f13 -q e Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fee Private Water Supply Well and Leaching-Facility (If any wells exist on site or within 200.feet of leaching facility) Fee Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Fee Furnished by%, a (ice v 1 13 ' d S3 'L �o� �� TOWN OF BARNSTABLE 1 Z-' ��� V,.�l LOCATION e=a`1 ct i�� SEWAGE # —380 G VILLAGE Ljk (d .�; —_� ASSESSOR'S MAP& LOT • INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)? 5,00 ex-AA NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 62—1� Separation Distance Between the: s 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 b i' . P f 40 � 44 , '93 2"-J, 1� 2,11 COMMONWIAL.TI-L'Of� MASSAc_;f-lusF,�"rs EXECUTIVE; OFFICE OF-ENVIRONMENTAL, AFFAIRS — d DEPARTMENT OF ENVIRONMENTAL PROTECTION V'Jy MAP PARCEL LOT P Par: TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A • CERTIFICATION Property Address: 60AAntico Ln. _Centerville,Town of Barnstable_ Owner's Name: Gail,David &Jody Barry_ p� Owner's Address: _same z Date of Inspection:_5/19/04 JUN Name of Inspector: Dion C. Dugan TOWNCompany Name:_ 1543 Main St. HEgL Mailing Address: Brewster,MA 02631 Telephone Number:_508-896-9390 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 Further Evaluation by the Local Approving Authority Failss Inspector's Signature: ` Date: 5/19/04 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: *Recommend: Maintenance pumping 3—5 yrs. `"Recommend garbage grinder be removed. ****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. Pagc 2 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_60 Antico Ln. _Centerville,Town of Barnstable_ Owner's Name: _Gail, David & Jody Barry Date of Inspection:_5/19/04_ Inspection Summary: Check A,B,C,D or E/ALWAYS 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 3I0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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' I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _60 Antico Ln. _Centerville,Town of Barnstable_ Owner's Name: _Gail, David &Jody Barry_ Date of Inspection: _5/19/04_ C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 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 "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 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_60 Antico Ln. _Centerville,Town-of Barnstable_ Owner's Name: _Gail, David &Jody Barry_ Date of Inspection: 5/19/04: 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 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 — _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 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.] _NO_(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: N/A 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 _ N/A_ the system is within 400 feet of a surface drinking water supply _N/A_ the system is within 200 feet of a tributary to a surface drinking water supply _N/A __ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWf A)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. i Page 5 of'I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 13 CHECKLIST Property Address:_60 Antico Ln. _Centerville,Town of Barnstable_ Owner's Name:_Gail,David &Jody Barry_ Date of Inspection:_5/19/04_ 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)) Page G of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_60 Antico Ln. Centerville,Town of Barnstable_ Owner's Name:_Gail, David &Jody Barry Date of Inspection:_5/19/04_ 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:_3_ Does residence have a garbage grinder(yes or no): _yes_ 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):_no_ Water meter readings, if available(last 2 years usage(gpd)): 2002: Y0,000, 2003: G%,000 Sump pump(yes or no):_no_ Last date of occupancy:_OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd 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:_unknown: owner Was system pumped as part of the inspection(yes or no): NO_ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system —Single cesspool _Overflow cesspool _Privy NO_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): Approximate age of all components,date installed(if known)and source of information: Installed_10/13/98 B.O.H. Records Were sewage odors detected when arriving at the site(yes or no): NO i Page 7ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE, DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_60 Antico Ln. _Centerville,Town of Barnstable_ Owner's Name:_Gail, David & Jody Barry Date of Inspection:_5/19/04_ BUILDING SEWER(locate on site plan) Depth below grade:_2'_ , Materials of construction:_cast iron _X-40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints, venting,evidence of leakage,etc.): _Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_1'_ Material of construction:_X—concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_1,500 Gallon_ Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:_29"_ Scum thickness:_1" 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: 13" How were dimensions determined:_by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Pumping not needed at this time. Tank and tees in good condition, no sign of leakage. *Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP: _N/A_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.): Page s of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_60 Antico Ln. _Centerville,Town of Barnstable_ Owner's Name:_Gail, David&Jody Barry Date of Inspection:_5/19/04 TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: , Material of construction: concrete metal fiberglass___polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0" 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-Bog is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 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:_60 Antico Ln. _Centerville,To`vn of Barnstable_ Owner's Name:_Gall, David&Jody Barry_ Date of Inspection:_5/19/04 SOIL ABSORPTION SYSTEM (SAS): _YES_(locate on site plan,excavation not required) If SAS not located explain why: , Type leaching pits,number: _X_leaching chambers, number:_two 500gal@ chambers w/4' of stone_ 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.): Chambers found w/9"of liquid in them,no staining,no sign of failure. CESSPOOLS: N/A_(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.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:_N/A(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.): f Page 10 of I I i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 60 Antico Ln. _Centerville,Town of Barnstable_ Owner's Name:_Gail, David &Jody Barry_ Date of Inspection:_5/19/04_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal systeru 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. A - C - 16' 1po�_0 - b 3q'6 A �, F (-�ovs� #6D � = zoo Q l D ^ '40 c 0 r Page I I of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _60 Antico Ln. Centerville,Town of Barnstable_ Owner's Name:_Gail,David &Jody Barry_ Date of Inspection:_5/19/04_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_28_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: 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) _X—Accessed USGS database-explain: You must describe how you established the high ground water elevation: By U.S.G.S. Atlas H A—692. f 0 2_ _ 4 A 7 - 44 A, r33 t TOWN OF BARNSTABLE LOCATION C , t- 1 1 �� '�� r SEWAGE # VILLAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. itk 1. J C✓ ( , rr, SEPTIC TANK CAPACITY LEACHING FACILITY: (type)l"'L -) S-00 NO. OF BEDROOMS_ BUILDER OR OWNER SC, PERMTTDATE: " � `/—�els- 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 ', 30 V��Is No. Fee 110 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes IPUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppttcattort for Mtqogar *pgtetu Cott5tructtort Verttttt Application for a Permit to Construct()�.)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.LoT C Ae rr 1 Lc>L o,w G Owner's Name,Address and Tel.No. �—2Z Z C�w�v t L ®L V C E-&A--MC ?_eA.L:V-� Assessor's Map/Parcel 17X g�cr3s 3-1 �2 - -e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 42.6 Type of Building: (_t_u5rL=Z SUBVIV,t'kpk) Dwelling No.of Bedrooms 3 Lot Size f7',ZZ9 _sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3Z gallons per day. Calculated daily flow gallons. Plan Date 0A0k-(1Z C t 12!�S Number of sheets Z Revision Date "C)Y-4 G Title S 1T1-1 x9i-AiQ A-AD 25W SeP �141`au LoT Atxr<co COOPS Size of Septic Tank G A.U_0CJi Type of S.A.S. �Zx25 1-A=—&-f-kA',40 6 K °( K Description of Soil 0—Z © 2, L�, `r R� �-C,—SZ 4& Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agree he constru ' n aintenance of e afore described on-site sewage disposal system in accordance with the p visions of Title ie E ' nmental Code not to place the system in operation until a Certifi- cate of Compliance has en issued b is oard o Health. 2 3— Signed _Dattr Application Approved by Date Application Disapproved or the following reas s Z:en Permit No. Date Issued No. } Fee ���00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS e Zipprication for Migaal *potent Congtruction permit t Application for a Permit to Construct(K)Repair( )Upgrade( )Abandon( ) 0 Complete System ❑Individual Components Location Address or Lot No. IOZ 6 Avvr 1 Co L#Nw G Owner's Name,Address and Tel.No. 5t)b- ZZ Z — 8� GE N Ti=ev I L L t-, QL V C C-&A-rCG Assessor's Map/Parcel 17 ECo vb ir IG 0eGp Tian. g vK G155 3-1 3-2 - OZA-7- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ate.$-334 4 ` 0\v(65 16-0tC(,S9 'Type of Building: (� -jV (-U U 5 r'e2 S0&T>>\),st o VJ Dwelling No.of Bedrooms 3 Lot Size V7 ZZI�? sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafgteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow 33 gallons. Plan Date ►N1 1 Number of sheets 2 Revision Date lso r� G Title S 1-cF �?LAQ CL0R:Z>C0 SG;PnC_ A,..iT Nco \/�_)0025 Size of Septic Tank A_-Z_Z)0 GkA LLC t" Type of S.A.S. 12 x zS Description of Soil _-O-Z 2 i ro �. - Z ( 32- )ZA4i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned aFeen ees he construc a Finaintenance of e afore described on-site sewage disposal system in accordance with the pvisions of Title e E mental Code a not to place the system in operation until a Certifi- Cate of Compliance has issued b s oard o ealth. Signed Dat Application Approved by Date Application Disapproved or the following reas s f r Permit No. ...Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(4Q Repaired ( )Upgraded( ) Abandoned( )by at Cu c C ►L,L has a constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. "" ted Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will,functio designed. Date 1n Inspector ( V r ————————————— ——————— —— — No. "�w —— —— Feek� ..� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS MtOpogar *p5tem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at ta-n U t= C,MI.iT-,,?_V% L( t� and as described in the above Application for Disposal System Construction Permit.The applicant recog izes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction inu t be co 1 ed ithin three years of the date o Date: Approved by 4 no � O PEN SPACE 2Z3.79' +i r --- i W DGc n _j LQ. 0l Ld= ®TH-2 A !bl 0_ �SE.PrIC TANK H� 0jy V-oox N ANT/CO (m (D T1-4-1 b LANE. rt PAIN.' I -C-- NG I 1 \C)SER.�E , ,k OF 1 PETER gyp,\b AREA 1-7,Z.29 S.F. $ SULLI AN NO 33 PLAN VIEW- LOT 6 6ViL s�sr,E ° Scale I = 40 O O, TH- I EL . 7f 0 0� 'TI-1-Z 70,0 PINE NC..L.DLLS PINE NEEDLES ^„ O ORGAp11C MAT, O ORGANIC MAT c ---- ----- -...- 2L A VGR\/ DISK, GP,A'/ LC^,M \/ER`I DARK G<<A'1 LOANA !b' PINE SAND A FINL- SAND YEL, r3R1\1 . LOAM I>3 \IGL, 13RN. LOAM FINE SAND „ 13 FINE SAND ✓Gn PI=RIK TEST ,, PER1< TEST 50 - -j_1- ----- --- id----U — LT, `/tL, a>p2 ' LT,"4EL , BRN. C V. FINE. SAI\ID C- V. F1N16 SAND 13 2!". -- - ,- PERCOLATIONI TEST PG_-RCOLAT►OJ�I TEST CLASS 1 MATERIAL. CLASS I 'MATERIAL DCPTH 50'' GEPTN 68'' LESS THAN 2-MIN./INCH LESS THANI 2, MIN/IN-CH NO WATER P-NICOUNTED NO WATER I-\\kCOLJNITERED DATE 05/1y /q$ N0. ', P-91572 t-WCHNEL-R'- SULLIVAN ENC-INEI=RING INC \AWTNIESSt 1,DUNNING -r,OFB-) B•OF H, ' SITE PLAN PROPOSED SEPTIC SYSTEM 1. Plan Reference, Cluster Subdivision No. 755 AT "ANTICO WOODS", Endorsed Feb 10, 1997 LOT No.6 ,ANTICO WOODS Book 531 Page 83 C ENTERVI LLE , MA 2. Map 172 Reconfigured Lots 3-1, 3-2,3-3, 4-1, 4-2&5-3 3. Set Backs Front=20' Rear/Side=10' FOR 4. The proposed foundation shown hereon complies with OLD CENTRE REALTY the Town of Barnstable Zoning Set backs and is not within SCALE: 1 =40' DATE: MAY 26, 1998 a flood plain SULLIVAN ENGINEERING INC. SHEET I Of 2 OSTERVILLE, MA NOTES DESIGN DATA k Water Supply ForThis Lot is Municipal Water. Single Family-3 Bedroom With no Garbage Grinder 2 Location of Utilities Shown on This Plan Are Approx. Daily Flow=110 x 3=330 GPD At Least 72 Hours Prior to Any Excavation ForThis Septic Tank:3�O GPD x 200%=660 GPD Proieet The ContractorSholl Make The Required Use 1500 Gallon Septic Tant• • Notif ication to Dig Safe(1-800-322-4844) 3 The Contractor is Required to Secure Appropriate LEACHING AREA Permits From Town Agencies.For Construction 330 GPD/0.74=446 SF Required Defined byThis Plan. Sidewall =2(12+292=148 S.F. 4 Install Risers as Req%irefLtoNithin 12°'of 448oS.AF.Total Pro idea 300 S.F. Finished Grade. LEACHING CHAMBER DESIGN 5.All Structures Buried Fowr Feet or More or Subject' All Pipes to be Schedule 40.Use to Vehicular Traffic tobe H-20 Loading. 2 -500 Go1.Leaching Chambers Ina 6, Septic System to be Installed in Accordance With 12'x 25' Washed Stone Field as 310 CMR 15.00 Latest Revision And The Town of Shown. Barnstable Board of Health Regulations. 7. All Piping to beSch.40PVC FG.70.0 F.G.70.0 czz rl 67.0 66.0 66.8 66.6 Top El.67.0 66.2 Sot.E 1.64.0 Bedding as Per Title 5 10'• 10.5' 1 1 Bottom of Test Hole E1.59.0,No Water DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM' ' Not to Scale ' H OF PETER Finish SUUJVAN Grade $ NO.,29733 ti CIVIL T �a 9FGrSJQ��� Filter Fabric �—"Compacted Fill- HA Ica Poo Stone SlZG�S� • Leaching 3/41'-1 1/2"Double :a Chamber Washed r 4-Id 12=0° CROSS SECTION OF CHAMBER NOT TO SCALE C P.rlTiRev I Lt.e SHEET 2 of 2