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Home My WebLink About0020 BUCKSKIN PATH - Health 20 Buckskin Path Centerville P A = 190 019 i i I fi I NoPC_ H1630R HASTINGS.MN r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6115/2000.Inspection forms may not be altered in any way. A. Certification 1. Property Information: I -5 20 Buckskin Path Property Address Joe Manfredonia Owner's Name same Owner's Address Centerville MA 02632 City/Town State Zip Code Date of Inspection: 11/3/08Date 2., Inspector: Matthew L. Childs Name of Inspector same Company Name 4 Orchid Ln. Company Address ' i W. Yarmouth MA 02676J Cityrrown State Zip cccg 508-989-1479 y =Y'r Telephone Number r Certification Statement: :, I certify that I have personally inspected the sewage disposal system at this addr s and tbt th( information reported below is true, accurate and complete as of the time of the ins ection.The it ection was performed based on my training and experience in the proper function-and m intenar ca of en 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/3/08 Inspector's 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 conditionsQ44W at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. f OL Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface•Sg"u'l�age Disposal System- V Page 1 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20-Buckskin Path Property Address Centerville MA 02632 City/Town State. Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection 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: passes 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: N/A Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: 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 ❑ obstruction is removed Ka.Explain: N/A 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 15.3.03(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 Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•� Page 3 of 16 Conimdmkealti�'i` Mai—ssachusetts .Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 se system has a tic tank and SAS and the SAS is within a Zone 1 of a public water Y p 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. 3. Other: N/A Manfredonia.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form A. Certification (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State ZipCode Joe Manfredonia 11/3/08 Owner's Name 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 ❑ ® 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 'h day flow ❑ ® 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 acceptabtb water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. J ' Manfredonia.doc.•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System Form / M A. Certification (cont.) 20 Buckskin Path Property Address _ Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection 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. - Manfredonia.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form. Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Checklist 20LBuckskin Path Property Address Centerville, MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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: M ❑ 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(3)(b)) Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information _ 20 Buckskin Path Property Address Centerville - MA 02632 City/Town State -Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection 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): 330 gpd. 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd)): N/A 9 ( Y 9 . Sump pump? ❑ Yes ® No Last date of occupancy: current D to Commercial/Industrial Flow Conditions: Type of Establishment: N/A N/A• Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A 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: N/A N/A Last date of occupancy/use: Date Other(describe): N/A Manfredonia.doc•11/1004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8,9f 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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) ❑ 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 718/96 per disposal works construction permit on file at Barnstable BOH. Were sewage odors detected when arriving at the site? ❑ Yes ,® No Manfredonia.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection Building Sewer(locate on site plan): 1.5' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): N/A Distance from private water supply well or suction line: N/A P pp Y feet Comments (on condition of joints, venting, evidence of leakage, etc.): All in good working order at time of inspection Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: Z concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) 9'x6'x5' outside 1500 gal: Dimensions: .2' Sludge depth: 2.9 Distance from top of sludge to bottom of outlet tee or baffle .1, Scum thickness 5 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle .9 How were dimensions determined? sludge judge Manfredonia.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank shows no signs.of leakage and appears to have been maintained regularly at time of inspection. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A N/A Dimensions: N/A _ Scum thickness 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 N/A Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: N/A N/A Capacity: gallons N/A Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A — Alarm in working order: ❑ Yes❑ No N/A Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' 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-box is level with no solids carryover at time of inspection Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Manfredonia.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System.Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: .. . ❑ leaching 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.): 4 infiltrators were dry at time of inspection showing no signs of hydraulic failure. Manfredonia.doc• 1-1/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form_ Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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 Indication of groundwater inflow ❑ Yes ❑ 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 N/A Dimensions N/A Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection 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 al[W61ts within 100 feet. Locate where public water supply enters the building. Buckskin a. /S #20 A-2-60' B-2-62 A-M6' B-343' Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5-Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal Systern Form 'GSM C. System Information (cont.) 20 Buckskin Path Property Address Centerville MA 02632 City/Town State Zip Code Joe Manfredonia 11/3/08 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water:, Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record ® 9 Y If checked, date of design plan reviewed: 7/8/96 Date ❑ Observed site (abtttting 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: Checked test hole data from system design plans. System was installed within reasonable limits and has adequate groundwater seperation Manfredonia.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR -- y VEt: MAP AUG 1 4 2003 PARCEL, LOTTOWN OF BARNS-1�. .. HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Addr*- j Owner's NameOwner's Addre p UA 0195 Date of Inspection: ? Name of Inspector- please print)< r' "i Company Name: Mailing Address: U- �7� Telephone Number: 7 / 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.se.wage disposal systems. I am a DEP approved system inspector pursuant toSection 15.340 of Title S(310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: //7 Date: //-7/0 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 Ifl,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. ****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 6/13/2000 page 1 r Page 2 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A 1 CERTIFICATION (continued) Property Address: 9 A Owner: Date of Inspection: r #y6s1 pa fpa Inspection Summary: Check A,B,C,D or E!ALWAYS complete all of Section D A. S stem Passes: I have not found an information which indicates*�dicates that any of the failure_:criteria'described in 3 I'0 CMR 15.303 or in 310 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: 2 Page 3 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A. CERTIFICATION(continued). Property Address: Owner: i Date of Inspection: 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 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 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: 3 { r Page 4 of 91 OFFI CIAL INSPECTION FORM—NOT FO R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �24,N >4 Owner: Date of Inspection: j3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to:each of the following for all inspections: Yes No/ _ v 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 %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 V 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. I� 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 coliform bacteria and volatile organic.compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner,should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large.system.the system must serve a facility with a'design flow of 10.,000 gpd to 15,000 .gpd. You must indicate either"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 Page 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW AGE:DISPOSAL'SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner Date of Inspection: AV a 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? _IZ_ Has the system received normal flows in the previous two week period? V'Have large.volumes of water been introduced to the system recently or as.part of this inspection? V,_ 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).pro.vided 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 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(3)(b)]. 5 Page 6 of 1 l OFFICIAL INSPECTION-FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION Property Address: /ju p� Owner:. Date of Inspection: p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):. DESIGN flow based on 310.C.MR 15.203(for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence..have.a garbage grinder(yes-or no); G/,; -& Is laundry on a separate sewaae'system ( es or no) [if yes separate inspection required] Laundry system inspected (yes or no) - Seasonal use: (yes or Water meter readings, if available(last 2 years usage(gpd)):,O/�//®�OZ-1✓`-�dam® Sump pump(yes or no): f Last date of occupancy: ?L,' CO MMERCIAL/INDUSTRIALA& Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(•seats/persons/sgft,etc.): . Grease trap present es or no): Industrial waste holding tank present re (yes or no Non-sanitary waste discharged to the Title 5 system'(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. Was system pumped as.part of the in pection (yes no If yes, volume pumped: gallons--How was quantity pumped determined? Reasom'for pumping: . TYF OF SYSTEM ptic 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): roximate a e of all co_mpone s dafe installed if known) nd source of information: Were sewage odors'detected when arriving at the site(yes or no 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL: SYSTEM INSPECTION FORM PART�C SYSTEM INFORMATION(continued) Property Address: _ AL� Owner: PV -`� 44 L?JJ ;.4 Lo, Date of Inspection: BUILDING SEWER(locate on site.plan�'� Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well.or suction liner Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: I/ (locate on site plan) l Depth below.grade:/�O Material of construction: ✓oncrete_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:l(�• S X ' X S ___ _ ..: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or baffle: _ How were.dimensions determined:�. AQe (ij�Z�P /Pl�'I . Comments(on pumping recommences, let and outlet tee or baffle condition, structural integrity, liquid levels /a'�related to outlet invert, evidence of leakage,etc.): C:a7NA GREASE TRAP (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 of 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ..SYSTEM INFORMATION(continued) Property Address: Q� d . Z ) Owner: Date of Inspection: `� , 6bo 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/day Alarm present(yes or no): y Alarm level: Alarm in working order(yes or no): Date of fast pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invemaw'o" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of kale into Qrout f box, et A PUMP CHAMBER/ (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address, JILIA Owner. 4- Date of nspection 1&PA"a SOIL ABSORPTION SYSTEM (SAS): 1 (locate on site plan,excavation not required) If SAS not located explain why: Type leaching.pits,number:_ leaching chambers, number: eaching galleries,number: leaching trenches; number, length: leachins 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.) a � CESSPOOLS:Llh(cesspool must be pumped as part of inspection)(locate on site plan) Number and co/nfiauration: 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 pondin(;cbndiiioti of vegetation;etc.):. PRINkY_;,-�pcate 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 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t � tW Owner: ' Date of Inspection: c� 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 sppply enters the building. t ,U0 0 10 y i Page 11.of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Fs� Owne 6 Date of Inspection: SITE EXAM. Slope- Surface water Check cellar. Shallow wells Estimated depth to-round water feet Please indicate(check).all methods used to determine the high -round 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) Accessed USGS database=explain: You must describe how you established the high ground water elevation: f 11 Permit Number. ^ Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �C`fG1GS e�?4 �lj G �J �e Lot No. Owner: 0 CJ j�� Address: Contractor:—. A1 1.ddress:L � C��'/ ��•�� /�yj�}i�� Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. ...........................................................................:.... .Date morth/day/Year STEP 2 Using Water-Level Range Zone and.lndex WelI'Map locate site and O determine: . I J p A pro.priate index well................................. ................ OWater-level range zone ...............................................::.... STEP 3 Using monthly report."Current Water.Resources Conditions" I. determine current depth to I water level-for index well ........................... L t7i a� 1 month/year ST`P 4 Using Table of,Water-level Adjustments. for index well (STEP 2A), cun:ent depth to Water level for index.vvell (STEP 3)., 'and water-level zone (STEP 2B) determine water-level adjustment-.......,... ............ .................................................. STEP 5 . Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from'measured'de'pth to water levelat site (STEP 1) .:.................'.................:.......•._................................................ Figure 13.--Reproducible compuiaion form. 45. I Ij i • i I - iI tel.(508)362-4541 -939 main street rt 6a fax(508)362-9880 yarmouth port mass 02675 down cope engineerialg civil engineers& land surveyors structural design April2002 24, Arne H.Ojala P.E., P.L.S. Daniel A.Ojala, P.L.S. land court Thomas McKean,RS Timothy H.Covell,P.L.S. surveys Director, Health Department 200 Main Street site planning Hyannis, MA 02601 Re: 20 Buckskin Path, Centerville sewage system designs Dear Tom: inspections I have reviewed the available information on file with the Health Department in relation to the above-referenced lot. According to the as-built card, the existing septic system consists of a 1500 gallon septic tank, d'box and 4 infiltrators with 4' stone all around in permits a I x 33' x 2' deep configuration. The calculations for this system are as follows: 2(10.83 + 33) 2 (74) = 129.7 gpd (sidewall) 10.83 x 33 (.74) = 264.5 gpd (bottom area) totals: 394.2 gpd (532.7 so Allowing for a 3 bedroom house at 110 gpd/bedroom, there is a surplus of 62.2 gpd. Based on 310 CMR 15.203(5), a school with no cafeteria, gymnasium, or showers would be calculated at 5 gpd per person. It is my understanding that the proposed "Harmony House"pre-school at this site would fit,.into this category, and as such the septic system would accommodate 12 children in addition to the 3 bedrooms which the dwelling contains. If you have any questions, please feel free to call me. Very trule1u, s, Arne H. Ojala, PE, PLS Down Cape Engineering, Inc. cc: Robert Shields, Executive Director rI . . COINIMONWEALTH OF MASSACHUSETTS . .........__ ExECUTIVE OFFICE OF E.N-VIRO.NMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTI -TER STREET. BOSTON NL-k 0210S ONE 'VVEN (617) 292-5500 49 V TRU`1- CONE `Se retary '9 Fe, ARGEO PALL CELLUCCI DAVID B.:�3RUHS Governor Co sioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORW� :9 v( PART A C. CERTIFICATION V LOT- %S1 A Property Address: kkb2- .Name of Owner Xuae_k o Address of Owner: Date of lnspectic>n:'OXk Name of Inspector:(Please�pl.�tw -C// ,.nj cc I am a DEP approved system a c inspetor pursuant to Section 15.340 of Title 5(310 CMR 15.000) Ek 1. L� e Company Name: IqZY +cc I - Mailing Address:_?_0 A,-, , I-rAl- oZC4-cl Telephone Number: 4 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 inspection. The ir.-.Epectinn was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fa* Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. It 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 `6 [Innied on Recycled Paper z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: l i3 �Si verL Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, o/ D: A. SYSTEM PASSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria ' ri not evaluated are indicated ed 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. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to de rmine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDAN E WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC H TH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetl d or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(A PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PU IC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absor ion 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 soil abs rption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil a orption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil sorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a w I water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that cility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to deter ine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 31 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine w t will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or logged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface ters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to a overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available olume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT d to clogged or obstructed pipe(s). Number of times pumped_. _ Any portion of the Soil Absorption System, cesspool o privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fe of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a ne I of a public well. Any portion of a cesspool or privy is withi 0 feet of a private water supply well. Any portion of a cesspool or privy is le -than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If a well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic c pounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to eac of the following: The following criteria apply to large stems in addition to the criteria above: The system serves a facility with design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the envir ment because one or more of the following conditions exist: Yes No the system is w' hin 400 feet of a surface drinking water supply _ the system i within 200 feet of a tributary to a surface drinking water supply the syste is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water su ply well) The owner or operator of ny such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Departmen for further information. revise 9/2/98 Pagv4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: \l3Z53U,44 ]�ky2.kz_ Owner: Date of Inspecti O ?,/el /4 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been-receiving rwrmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. x _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: S.1R Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)I The facility owner (and occupants,if diHerew from owner) were provided with information on the propermaintenancz-of T\ SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION 'roperty Address: Owner: oa f IC7 y Date of Inspection: fQ ` l Lam.. ��.pa �a�a S e FLOW CONDITIONS RESIDENTIAL: Design flow: 'ZA30 g•p•d./bedroom. Number of bedrooms(design): Number of bedrooms (actual) Total DESIGN flow E>�� 0 Number of current residents: 0 Garbage grinder(yes or no): If yes, separate inspection required Laundry(separate system) (yes or� Laundry system inspected es r no) Seasonal use (yes or no):,&.1 > Water meter readings,if available (last two year's usage(gpd): Sump Pump(yes or no):Q Last date of occupancy:—SV—*A ,i— OS'�L COMMERCIALANDUSTRIAL: Type of establishment: Design flow: 22d ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information-1 System pumped as part of inspection: (yes or no)!�.D If yes, volume pumped: gallons 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/95 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 1`32�tJW��kSn nR-"'aR-c Owner: 4 _ l aL Date of Inspection: BUILDING SEWER: (Locate on site plan) r�11 Depth below grade: 0 Material of construction:_cast iron t\'40 PVC_ other (explain) Distance from private water supply well or suction line'T� t-3 tJ%�o3-e Diameter_t-Vl Coents: (condition of joints, venting, evidence of leakage,-etc.Os— SEPTIC TANK: J (locate on site plan) Depth below grade:`2v' Material of construction: concrete_metal _Fiberglass _Polyethylene_otheriexplain) If tank is metal, list age_- Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: --v'- ` Sludge depth: L\ _ l� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 8'" tr Distance from top of scum to top of outlet tee or baffle:Az�- Distance from bottom of scum to bottom of outlet t e or baffle:_ How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation t outlet Inver , structural' eg , evidence of leakage,etc.) --LESv t 1 l jtt GREASE TRAP: (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page?ortl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) Iroperty Address: 1 l Z V-Akx4f Owner: © ,1 6 "1� Date of inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:' (locate on site plan) Depth of liquid level above outlet invert: `L�-� Comments: (note if level and distributio is equal, evidence of soollids carrO�er, evidence I age int or t of box, etc. 0 PUMP CHAMBER:LID (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.) revised 9/2/98 page 8orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: 4 - Date of Inspection: c� SOIL ABSORPTION SYSTE (SAS): (locate on site plan, if possible; excava 2on not required, location may be approximated by non-intrusive methods) If not located, explain: Type: 6 . leaching pits, number: �_�LUX. leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of on ing, mp soil, n0ition ve tation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on Me plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: ��3Z bvWn�S �VC,4� L� )wner: , G©",ex --> Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 33 n 3 � 3 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: \37i 6-141Ap� V\v�� Owner: oZo�06'/5 `� Date of Inspecti w NRCS Report name PD Soil Type_ - Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope t4 Surface water Nr] Check Cellar bV.�,.k Shallow wells Midi, a Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe c�how you gstablished the High Groundwater Elevation. (Must be completed) �A I 5LI kk revised 9/2/98 Page ltof11 . _. . •� . . Q _ _ . . .�/ . . ' • 38' . ' fps, - . ' BORTOLOTTI CONSTRUCTION, INC.' 765 WA."BJ VROAD,MARSTONS MILLS, MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: _n k �111 -"Z-A. QA=ze-�� Date of Inspection: 11Q9 199Inspector's Name: AW Owner's Name and Address: 7 D 9 S/S` CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true, accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Pas ; Needs Further uatio to Local Aprovmg Authority Fails , .: Inspector's Signature: Date: 4, lt' The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SU MARY• A)SYS') M PASSES: t/ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CNl 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,c,Tacked, structurally unsound, shows substantial infiltration or exfiltradon,or tank fadppq ij imminent. The system will pass inspection if the existing sep- tic tank is replaced with4 conforming septic tank as approved by The�Board of Health. Sewage backkup or breakout ids sigh static water,level observed in the distribution box is due to broken or obstructed pipe(s)or due to a.broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - ,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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, APPROPRIATE.),DETERMINES THAT THE`SYSTEM-IS FUNCTION- ING IN A MANNER,THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE : ,ENVIRONMENT:,. The system has�aseptic tank and soil absorption system and is within 100 Feet to a surface water supply,or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a.well water analysis for coliform bacteria an volatile organic compounds indicates that the well is free from pollution from d g po the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppin. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 dueto an ovterloaded or clog- ged.SAS oucesspool A Liquid depth in cesspoo jAess than 6,below invert,or,available volume is less than 1/2 day flow. Required pumping more'�W"Li 4.times in the last`year NDT due to clogged or obstructed pipe(s).,Number of times pumped -2- f SUBSURFACE SEWAGE DISPOSAL SYSTEM''INSPECTION FORM PART A , CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist:• . , :The system is within 40.0 Feet of a surface.dru►k�ng wader 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 11 of a public water supply we'll.-. The owner or operator of any such system'shall bring the system'and facil►ty,into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if a following have been done: ping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast.two weeks and the system has .been receiving normal flow rates during that period: Large volumes of water have not been introduced into the system recently or as part of this inspection. _As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _jeLThe system does,not receive non-sanitary or industrial waste flow. The site was inspected for signs.of breakout. �1 system coiiiponents,l;cxcluding the Soil Absorption System, have been located on site. he septic tank manhoJea*y re uncovered,,opened,aiidrthe interior.of the septic tank was in- "' spect`ed for condition gf, alTles or tees;material of bo�istruclion;dimensions,depth of liquid, depth of sludge,depth.of�spum. The size and localion'of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- t , t•:1l,i�Y fla�+'�,f� r4 i• x'�}r +",.��I 7 U H SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C. SYSTEM INFORMATION FLOW CONDITIONS RFggInV 111AL� Design Flow:336 gallons Number of Bedrooms:. 3 Nw ber of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use:A 7�) Water Meter Readings, if ilable: Last Date of Occupancy: - .. vC0 ~M .R ALt NDUSTRiAI .-,;)j- v ._ _Type.of Establishment .s Design Flow: Qallons(day Grease Trap Present:,(yes.or,no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERALINFORMATION PUMPING RECORDS and source of information: Z2&zfAZ Pi1J Y ,Tzc4G System Pumped as part of inspeciion:_2w if yes,veluine pumped: gallons Reason for pumping: TYPJ,VP SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): ROXIMATE GE of all compo lenXs`date installed,(if known)and.source.of information:', Sew ge odors detected when arriving at°f f,site: ��r) t ` I " r SUBSURFACE SEWAGE BISPOSAL SYSTEM INSPECTION FORM GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP_Other (explain) Dimisions: /O15SX v X, Sludge Depth: 3 Scum Thickness: Z Distance from top of sludge to bottom of outlet tee or baffle: 35—// Distance from bottom of scum to bottom of outlet tee or baffle: // Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to utlet invert, structural integrity, evidence of leaks etc.) ` GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) —_ — — — — Dimensions: _ Scum.'Thickness: . Distance from top of scum to top of outlet lee or baffle: Comments: (recommendation for pumping, condition of inlet and oiutlet tees'or;baffles,''depth of liquid level in relation.to outlet invert, structural integrity, evidence of leakage, TIGHT OR HOLDING TANK:�d Depth Below Grade: Material of Construction:.._concrele__nuetal_FRP—Other(explain) Dimensions: Capacitv: gallons Design Flo%%: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float swi(ches, etc.) DISTRIBUTION BOX: V Depth of liquid level above outlet invert: Comments: (note if 1 el and distribution is equ, ,evidence of solids car}•over, evide a of leakage into or out of box,etc.) PUMP C .. . . 1f3AMBER:.w _ - �..w._. Pump is irrwoiking order: ...-.-,Comments.: (note,condition,of,ptimp Chamber,.condition of punips aid.-appurtenances, etc.) t. _5 SUBSURFACE:SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments: (note condition o it si of I► draulic failure level of pondhi condition of vegetation, etc.) CESSPOOLS: /.w Number and'configuration: Depth-top of liquid to inletinvert: Depth of solids layer: Depth of scum layer:" -,-.i Dimensions of Cesspool: Materials,of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:—�XIv Materials of construction: Dirneusions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)- -6 - 4 ,. "SUBSURFACESEWAGE.DISPOSAL SYSTEM`INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. • DEPTH TO GROUNDWATER: C / Depth to groundwater: Feet Method of Determination or Ap roxi anon: /©rf"/ 47 � u ✓� T 'To D O Q UIQ Q�1 Uf , fl,ISr -7- No, S/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS Zipprication for Migpogai *pgtem Congtruction 30ermit Application is hereby made for a Permit to Construct( )or Repair( 4an On-site Sewage Disposal System at: Location Address or L t liio. Owner's Name,Address and Tel.No. 2pucl�5,�� been, Z I ler's Name,Address and Tel.No. Designer's Name,Address and Tel.No. nstool n—rG®W 6411w`" Type of Building: Dwelling No.of Bedrooms ✓� Garbage Grinder( � Other Type of Building eve/ eWce No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //® gallons per day. Calculated daily flow 33y gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or 41terations(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 by thi oard al Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued No. 96ZFee � THE COMMONWEALTH OF MASSACHUSETTS 'f F PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS � Ar 0(ppYication for nizpaal *pgtem Construction Permit Application is hereby made for a Permit to Construct'( )or Repair( wl an On-site Sewage Disposal System at: Location Address or Lot tio. Owner's Name,Address and Tel.No. 6l7 zoucl� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. - yD A4y. Mr,f S Type of Building: Dwelling No.of Bedrooms ya Garbage Grinder(/ 0 Other Type of Building 1Q P_SiGf'�i9�P_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //B gallons per day. Calculated daily flow 3�3' gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or A/lterations(Answer when applicable) 'F /JUDO 9�' /�-/® ✓z' 1-%C Al!'rl,� Date last inspected: �- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site.,sewage disposal system M 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 by thi oard Health? Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System installed( erpaired/replaced( on by 0// �f��07�/ � 1,5�`�/L'�i'a+l for `y7_e4e, t� 19 4✓ as '7 g2 A 1Zr V S,_'/ 1&ZZ;4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / A, , n dated Use of this system is conditioned on compliance with the provisions set forth below: ' No. Ill� f�/ ----------------------�� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *p5tem Congtruction Permit _ Permission is hereby grantd to ®��D L ill / to construct( )repair(Vol)an On-site Sewage System located at 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. I� All construction must •e completed within two years of the date below. I, Date: �7 Approved by i r Y CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTItUCHON I'Etti111'1'(IVI'1'IIUU'I' DESIGNED PLANS) 1, Aief;,�— . AI)b6 i hereby certify that the application for disposal works construction permit signed by me dated /2 Zl ?Z� , concerning the property located at meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system ✓ here are no private wells within 15o lect of the proposed septic system is observed groundwater table is 14 feet or greater below the bottom of the leaching racility There is no increase in flow and/or change in use proposed Y There are no variances requested or needed. SIGNED: DATE: l f� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. �t tY� 0x +wry F t t'S a4 =,�e ,�,, s. m, .�r-�. z'`pi �kz, -- 2"� s'� :R�,t � <��r�.� ,finsr�z.'r:•.;ax .r+r �'' ��.. _;t>�� .R., u. e..., r. V Y 7� I VA Most cf�Sli�l 74, y. e ' t .o *ram {e"_ ,p, "Z°x , rx k m e;. x ,>- -•k .. (Y r d. .n@.'s��'f'-t. �t sow�•.}�a--'��r<.,..: rr ��t3,c$ r f�- 3 3'� J _ }"�''fh '� .,,�-'P �"' - Y'�.t�''#�r' � �fi� ~ ..�_�"' ,3 r+.. r ��s �'•�it`��" '��`. al, ,tc, �':�2° _�'" x�Z`'-� s'' ,/� TOWN OF BARNST/ABLE LOCATION �® ./a gnoL4 ? /,Vlxm l SEWAGE # ? —131D VILLAGE ("p 0 *1V111e ASSESSOR'S MAP & LOT I -DI INSTALLER'S NAME&PHONE NO. Al^l- `% Cf��cS�` ; '7/—�,j�lJ SEPTIC TANK CAPACITY I S_v O G1.L LEACHING FACILITY: (type) 4,) l (size) lI �l� 33 �X A NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 71 g/ OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3 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) W16 Feet Furnished by a,, /1 c�� q, �� 5�b ., y1 � O _ �d ��' 1 , 7 OUTDOOR . NEW NEW NEW NEW SLIDING NEW !1 Tw roeEN ANDERSEN: -�,. :` AN 235 'DOOR.(OWNER mDER N ' TIN z6s TW 2e+6 CN 236 SUPPLIED) � � 0/0 bU �gNO u /O E-- E101 � ?! NEW 1I I o #1 STORAGE Qo REMODANGE : _ --- I� REMOD j O KITCHE DINING' I EXISTING 28x6e NEW4x6POST (VERIFY KITCHEN ; NEW I O I 3V'FOLDING BEDROOM#1 ..`. IN WALL WI SIMPSON LAYOUT W/OVVIJEP) 1 .1 1 N GLBI ETS DOOR I ( � BC POST CAP I REF 1 ... .. . m�.. �a I.CLOS.EXIST NEW2x4WALLS _ 3 . BATH n NEW.NEW 64 FAMILY FASTEN II CLw LIN. w wlroow SMOJ _ . ... .. « (OWNER 1 REMOVE EIOST. -ROOM HANGER ___ =_--c__ :� UN .:. .. SUPPLIED) I DOUBLEHUNG 1 NEW FLUb}i ULTI LVL BEAM . . T — �+,�- - - . CENTERED• .WINDOW .ryAULTED CEILING TO G1RRYiCEIUNG JOISTS .. DOOR .EXIST T. 'STj � I • _ w oA�e�ON. I . POST UP FROM NEW B-0 HALL. BEAM TO RIDGESEAM: ¢I :. • ..- .,. _ ... .. ' 'd BUILD NEW WALL .. .. _.. UP TO RAFTERS .. - ._ .. :. L. J I 1 y EXISTING - LL REMOD: EXISTING CIO BEDROOM#3 _ z I LIVING , .BEDROOM#2 ` FROM R .. NEW - DOOR - � L�S _ I (VERIFY MFR.,STYLE, �C OS-I I &DETAILS W/OWNER) .. -I NEW NEW NEW NEW _,, NEW fix-6POST - NEW. plyy ..- . TW 2" .. TW 2646 TW 2616 m2srs l W W/SIMPSON _ �. - .. NEW RIDOEVENf .. . .. IN ----_� BC POST GIP EXIST . L---= -- ------- ----------------------= --- — --1 LINE OF O.H,ABOVE - SISTER FRAME NEW 2 x 10 RAFTERS NC a.e. " - _ . - - N1IY 2-1 31�x 1�LVL TO T INSULATION NSU A 2 x 6 RAFTERS.INSTALL NBM/' . RIDGEBEAM(VERIFY _ - . � BAn INBULA7TON(R"3Bj Nx8PACERS Bl1YI�N -, .. .. :• q. SIZE w/SUPPLIER) N�rEB B FOR AIR FLOW ROOF -" 3'-0` rd. 3� .. NEW 2x BY®.la,o.. " -- .-� FIRSTkN NOTES: 12 Ex I SST. .1.) CONTRACTOR IS TO VERIFY.ALL EXISTING CONDITIONS LEGEND: &DIMENSIONS IN THE FIELD. 0 EXISTING WALLS NEW WALL TOP OF 2.).CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS,.. r__� NEW 1r2 GYP.BOARD ON DETAILS,&FINISHES IN THE FIELD WITH OWNER. --�'.. CO 10 E 1s CsTRAPP STRAPPING 4 NEW boFFiT CONSTRUCTION TO BE REMOVED 3.) ROUGH OPENING HEAD HEIGHT OF WINDOWS AT NEW CONSTRUCTION. NEW WALL CONST. "- VENTS i FIRST FLOOR TO BE 6'-8"ABOVE SUBFLOOR 1.2 x a STUDS•1e'o.c. A NEW z.lrrZ(R-12)B PLYWOOD OWNI FO f. FAMILY _. 4.) ALL CONSTRUCTION TO CONFORM T0780CMRMASSACHUSETTS a.a1rl(R"zt)BLowNMFOAMINSUL NEW 6-aAnlNsuu ATOM(R-1� BnNc2x• STATE BUILDING CODE,SEVENTH EDITION 1 14.17I GYPSUM BOARD ROOM WALLS TO RE►WM Z 5.) FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION OF ALL 6.mIEK VAAPPO�R�B SIDING Ewsr,r e cpLrvwoD �. SIMPSON COMPONENTS' a. .. _ SUBfLOOR GLUEDb MATCH EXIST. 6.) .VERIFY ALL PLUMBING&ELECTRICAL DETAILS W1 OWNERS ON THE SITE SUSFLOOR000 )' DURING FRAMING CONSTRUCTION r.2x B. i6•o.c. P.T:z: 1 D.C. NEW P. '7.) .ALL SINGLE WINDOW&DOOR ROUGH OPENING HEADERS TO BE 2-2 x Vs: Ewsr.CONCRETE sue•' NEW s P.T.2=+oBEAM . .. TALL NEW CONCRETE 8.) INSTALL NEW 2 x 6 COLLAR TIES Q 32"o.c.TO RAAFTERS IN ATTIC BNisocKs nro:oo NEW r RIGID INSUL.(R-6) I 9.) VERIFY.LALLY COLUMN LOCATION IN THE BASEMENT UNDER THE RIGHT LOCATIONS FOR NEW P.T. EMT.FOUND. wi B MIL Par urCER SIDE OF NEW BEAM.INSTALL NEW LALLY COLUMN&FOOTING IF REQUIRED SILL To MATCH DUST. SEALER WALLS 1zd' 10.)VERIFY ALL WINDOW ROUGH OPENINGS AND DETAILS"PRIOR TO START OF SILL HEIGHTS /�`�` �/CONSTRUCTION AND WINDOW ORDER PLACEMENT A SECTION NEW Y FAMILY ROOM I . ERRORSORMUSSIONSMEFOLOWCN SCALE: DRAWING NO.: COTUIT BAY DESIGN. U.0 . NEW REMODELING FOR 1HENORAWND9PNp-MUM"a Ftf OF _ ES EK THENDua~T/EDR OIN000MIMLTOR 43 BREWSTER ROAD. . IF FM THE MASHPEE,MA. 02649 1 "°»wY"'o.:ue 1/4" 1'-0" COMMENCES VWTHIx" . : ILL & VIMS r PH.(508)274-1166 THEW* 1NDt D. 1 I: ` DATE :: I .. THESE DI'DaF109RMUUVIER THE �1�' 12/16/2009 FAX(508)539-9402 20 BUCKSKIN PATH CENTERVILLE . MA ARaZE�1UI��PYR1�1 ,ECTx,N