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Home My WebLink About0016 COTTONWOOD LANE - Health 6ti�.�ttc�� wood �.ane4� O».ford® NO. ORA `� 10% I{ Commonwealth of Massachusetts .(19 Title 5 Official Inspection Form p C Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4M , 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Impodant: A. General Information When filling out forms to the I O I computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name Qw P.O. Box 896 Company Address East Dennis MA 02641 City/rown State Zip Code 508-385-7608 S13742 Telephone Number license Number B. Certification u^r G 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' nspee#ion was performed based on my training and experience in the proper function and maintenancerof on Of) sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1$:340 of Title 5(310 CMR 15.000).The system: µ' ® Passes ❑ Conditionally Passes ❑ Fails r~n� ❑ Needs Further Evaluation by the Local Approving Authority 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 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every 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: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is Centerville MA 02632 05/01/10 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 Heafth): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 ❑ ® 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 Y2 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required forCenterville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection B. Certification (font.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. ❑ [a 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- 10,000gpd. ❑ ® 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. 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. I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is sequined for Centerville MA 02632 05/01/10 every page. Cityrrown 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? ❑ ® 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)] i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityfrown State Zip Code Date of Inspection 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): 330 Number of current residents: 1 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form wwo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (if known)and source of information: 01/07/03 per BOH Were sewage odor's detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Al u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 6.0 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: ee Material of construction: ® 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 certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 2" 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 16" measured How were dimensions determined? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. CityrFown 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet 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: 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.): 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): --- --- III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) {locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of canyover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G1M > 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 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: 2 ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/aftemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has two flow diffussors in a 12'x 25'field of stones.The diffussors were dry with no sign of ponding or failure. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): Commonwealth of Massachusetts L. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntafy Assessments 16 Cottonwood Lane Property Address Jeff Sutphen E Owner Owner's Name information is Centerville MA 02632 05/01/10 required for State Zip Code Date of Inspection every page. cit r—rown D. System Information (cunt.) Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3� a 3D ro� f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Cottonwood Lane Property Address Jeff Sutphen Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Citylrown 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: 20.0 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: USGS maps show an elevation of over 20.0 feet Q, No. -o(1[)a-- LQ(7 � Fee 5��. Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: S, Yes. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS Zippffcation for Wood Opotem Conotruction Permit Application for a Permit to Construct( . )Repair(x )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 16 Cottonwood Ln Owner's Name,Address and Tel.No. Centerville Roland Cordiero Assessor's Ma /Parcel 2r2-163 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W.E.Robinson Septic Eco-Tech Box 108.9 Centerville 43 Triangle Circle Sandwich Type of Building: Dwelling No.of Bedrooms I Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil; sza Nature of Repairs or Alterations(Answer when applicable) Install Title 5 Leach System to Plans of Eco-Tech ETE-1324 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 nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thivBoA of Health. Signed Date -6" Application Approved by OP 1?S - Date 42- -v x Application Disapproved for the following reasons Permit No. 200 a- 00 —— _ Date Issued-/I 7 -V y No. t D - �,0 c7 .. Fee 50 00 . / ? \ Entered in computer. �V THE COMMONWEALTH OF,MASSACHUSETS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipphration for �Bi5poM *pztem Consgtruction Permit Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 16 Cottonwood Ln Owner's Name,Address and Tel.No. Centerville Roland Cordiero Assessor's Map/Pazcel 252-163 ' Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W.E.Robinson Septec Eco—Tech Box 1089 Centerville 43 Triangle Circle Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons.- Plan Date Number of sheets Revision Date Title 61 Size of Septic Tank Type of S.A.S. Description of Soil sand 4t . . Nature of Repairs or Alterations(Answer when applicable) Install Title 5 Leach System to Plans of Eco-Tech ETE-1324 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 'nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thkisoBoA of Health. Signed / Date re• —�''�._ Application Approved by ` �- - Date Application Disapproved for the following reasons Permit No. a00_-)— l00 Date Issued /-2 -.? THE COMMONWEALTH OF MASSACHUSETTS Cordiero BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired(x )Upgraded( ) Abandoned( )by N•E Robinson Septic at 16 Cottonwood Circle Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z00 a dated �- Installer - Designer The issuance thi permit shall not be construed as a guarantee that the systfm will functio desig d. Date 7 3 ' f Inspector s U No. P0 Fee 50.00 Cordiero THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migo5ar *pgtem Corgi.5tructiou Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 16 Cottonwood Circle Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by u2 _ 1 i TOWN OF BARNSTABLE e I LOCATION i y J�®•`- (al s ✓� C ^ SEWAGE # 0;2' L'c J VILLAG ASSESSOR'S MAP & LOT S — INSTALLER'S NAME&PHONE NO. ��+� %fb'.s'c SEPTIC TAK CAPACITY cam.�, :��, . LEACHING FACILITY: (type)v�' z , (size)" A NO.OF BEDROOMS 3 BUILDER OR OWNER C" �°� 'r-� PERMITDATE: /� �'�l`� COMPLIANCE DATE: f Separation Distance Between the: • Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist - Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by i � 3 i �aLw 30 i �2 !?�� / " # *,01 L 0-IC-A ) N kri 2, yM � IN5TAltiR'S �� m� . A D D .11SS C � 0ATE P E R M I T I SUED o - T' yr' G N l as •s.. r'�' 4A 1 A No.... .......lu FE:s.......5?............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---• .. ..........................OF............... App iratiou for Uh4p ro al Works Tonstrurtiun tirrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..... ._ ...� SZ.._.........:... �......-i!!- --------- ................KQ1........... - . RLocation-Add r s or Lot No. �. _ .. - -1'..f.--••- -------•---•------•--- ....... ------�'V.w•---•-----------------------•-------- Owner Address a .. . ----------------------- ' Installer Address Type of Building Size Lot---I.Zt.01 ......... feet Dwelling—No. of Bedroom_3)......1 ? ............Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons.............•.......__.____ Showers a Other—Type g --------•------ ( ) — Cafeteria ( ) d Other fixtures ....a----qu V '�.......... -1-,5lwwneC:................................................................................... W Design Flow..._06......&4.tW�A---•___gallons per person per day. Total daily flow.................... 3a.............gallons. 1:4 Septic Tank—Liquid*capacity..IAW.gallons Length.....___------- Width....%--------- Diameter________________ Depth.._Sp--------- Disposal Trench—No. ....__ g g q•.____ Width_._. .__.__._. Total Length Total leaching area___.�_.__.._...sq. Seepage Pit No--------I----------- Diameter._ Q_1.4o... Depth below inlet......J..9....... Total leaching area_il`r4.8......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) s r '-' Percolation Test Resul� Performed by � _`.�..............!j i j!1)...P*k:...... Date.....Z ... ` _ ,� Test Pit No. 1................minutes per inch Depth of Test Pit-__1_�...._.__.. Depth to ground water_._____ ............... Gz, Test Pit No. 2....;Z........minutes per inch Depth of Test Pit-----13.......... Depth to ground water__ ............... 1:4 ......••• . ............................................•---•-.......-•••••......----.-_.._.__._........_.:... O Description of Soil......Cl _ :�'--.---. N1EaC:-Q.�.....----•••r Vlv t.••-•-•------•---•--•---••••---•--••--••---•-----•--•---•--- W V ----••-•-•••-•---•••-••-•-••••••.................••-----•-•••---••-•-•-----•--••-----••••••-•---••-••••------------•-----•-•-•--•--•----•-•-•••-------•-•--------•..................................... W VNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•--•----•-----------------------------•------•----------...-----------.........---------------------------------•---•••----•-----•-••-••-••--•-••----••--•-••-•-••------••-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITl TLE 5 of State Sanitary Code— The undersigned further agrees not to place the system in operatio unti rti f mpliance as en issued by the board of heal Signed..... __. ' Date - Appli n pprove By............................. --•---- `2= -6)-------- Date Application Disapproved for the following reasons---------------------•-----------------------------------------------------------•------------------------------- •---------•---------•---------------------------•--------•--•--------•-••--------•---------•-•-•-------...-----•-----------------•------------------------------•-----------.._..........------.....---•- Date PermitNo......................................................... Issued....................................................... Date -i. NO. .1.:�. till Fps, • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... ----.--------.....OF..........................._........... Appfiratio" n for Disposal Works Tonutrurtion rruti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Location-Address or Lot No. •--•- --....... 1-......n)Ksln-...................... ...... .....Auax :_......------................-•----... Owner Address Installer Address U Type of Building Size Lot... 1-2t.6.46..........Sq. feet DwellingNo. of Bedroom ...__..__.Expansion Attic— . ...... -- ----- p ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ------ `-.---•-•• P ( ) — Cafeteria ( ) dOther fixtures ...o�-•- Mh' ---------- ------------------•---------------------•••---- -------••--------.----------. W Design Flow....1.16......&4toos l.......gallons per person per day. Total daily flow..................*3.;30..............gallons. WSeptic Tank—Liquid capacity:4 ._gallons Length---6........ Width... .......... Diameter---------------- Depth...t x Disposal Trench—No. ... ____________ Width... .......... Total Length..... .......... Total leaching area_ ........... ft. Seepage Pit No.__----I........... Diameter.1.0.11 s..... Depth below inlet.....,6.l........ Total leaching area 4,,8_..____sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test ResuJU Performed by.. .. .... ..... ' _. Date......__ aFir�yy f� Test Pit No 1 mmutesper.mch' Dept of Test 1 if'wepth to groud tt�f fZ4 Test Pit No. 2...Z.........nunutes per inch Depth of Test Pit..._�,y............ Depth to ground water__. W --•-- D Description of Soil....�°O.- v- ....... U -------------------------------- •--•----------- •......................................................................................................................................................... W U Nature of Repairs or Alterations—Answer, when applicable................................................................................................ -----•---•----------------------•-----------------------•--•---..<__--------.....------...---...------...-•------------------ -------------------------------------------------------•---•---.......•---' . Agreement: The"undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliant a 'en issued by the board of heal1, ( 6 Signe _. : Application Approved B �D1ate A PP PP Y ;:. ----;m - -�-;i5�le------••--•--- Application Disapproved for the following reasons:..............................................................................................................- --•--•.............•--------••-•---------•---••---------•••----...•--•......----•-----......----.....•-•_- •-----•-............................................................................... Date PermitNo................................................... . . Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... wr#ifirat a of (goutfliultre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-4V fit .-.,.;5r.----- - --------------------- ------------ -........................................................................ ......................... Installer ,r . ��. y .... has been installed in accordance with the p ov sio of TI le. j fats Sa? dry l7tle as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUAR EE TH T THE SYSTEM WILL FUNCTI N SATISFACTORY. x DATE.................... ......... �-........ Inspector.............. . i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0�/'-�`� ...........................................OF.............._.................-----................................................ No......................... FEE........................ Disposal Sur p Tonstrpdiott rruti# Permission is hereby granted------------- •--------------------------...---------•----......-- .............................. " to Construct ( ) or Repair ( ) an I idual Sewag�spo;Qal System DIo.' _l.t-ti• y -------•---•------.••--•-•---•----••----••----•-•----•----••--••--•-------•---••-------•-•-••---•................. Street as shown on the application for Disposal Works Construction Permit NP..................... Dated--- -------- ............................. .... r It DATE............................................... FORM 1255 A. M. SULKIN, INC., BOSTON TOWN OF BARNSTABLE . C I CC :1l�iV /G L.a JT GU 4�✓l C i s SEWAGE # O�"G t9� VILLAGES t Y�'i�' � ASSESSOR'S MAP & LOT 2v— `3 INSTALLER'S NAME&PHONE NO. I�a� 0 jVJ6 SEPTIC TANK CAPACITY /L LEACHING FACILITY: (type) �" ` ;L — (size) NO. OF BEDROOMS 3 BUILDER OR OWNER COKA M-A-6 PERMITDATE: /�-�;yL�`p COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by L- 3 i fjf � f A ,�2 FLOW PROFILE V PIPE ENT TOP OF FOUNDATION RAISE COVERS TO WITHIN EL - 5670 +- 6 in OF FINAL GRADE ONE INSPECTION RISER FOR LEACHING GALLERY 2" LAYER OF 1/8" D-BOX 1/2- STONE �3' DROP H-20 FLOW LINE TEE lo• = 14- H-20 48" GAS�� ,'' PRECAST BAFFLE �,�i >• DRYWELL mat'$'^ >;ti; STONE #.. �• BOTTOM OF 46.50+- 6 in SOIL ABSORPTION I\EXISTM STONE \465.00 LEACHING SYSTEM OaSTNG BASE EXISTING 46.17 GALLERY 45.85 0asnraa 5.00 Ft 1000 GALLON (END VIEWS 43.85 E)asnNO SEPTIC TANK 22.5 fr al 5 f r 12.5 f r bl 14 f r ESTIMATED 4, 38.75 SEASONAL HIGH GROUNDWATER to In >n � f 100.00 ft m t!A N N Q z� m r m' �O W �v m rn n k $Z -n ti n -r-3 my O >= m O N m 7C7 A N� n m A O 22 fr N • Ns ��r,2� � O u �d -7 rC1 Q t Q w o, I ma�� dM m 7 Zo its o � 2 � 3 \ .0 Ul ao I \ i \ \ cmo m N c m� m rn >O In o \ m A-o I 3ZD 9 \ Q \ r Q > r Z ° G) 3 3m \ cn, Ut a�DI 3N \ / m y-I C) 6 N Z O 00 z T'ar m m z C p fT 1 00 rn o o m �_ mcxn oo mom o oX In m � �� -1 O l o y_ cn cn } M 4 m m m O Q" < OMM Z =� X �yZ m vO cn z b c� C) 00 n = p m m cn C OI{ , Z7 y y r • _ � o U1 C) m D r x m � cn C m � _� f— 1 � wove Z z r A �� o m o o O z 7C7 m Cz N �ti.FD � 0 ��-� Oo O m = S113S ® O ® 0 o o� C �o � = 3 m n mm ° Nam ' ��a -4 Sa p r Q o0 n o�Z� am r- 3 N D3 ,^o �o Zin O Z m �(Tl G) tom— m Mn oqvrlj m� m rn f > p z ti A y SOIL TEST LOG ' DESIGN CALCULATIONS DATE OF TEST: DEC 15. 2002 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD WITNESSED REQUIREMENT WAIVED SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS GROUNDWATE TEST PIT I PAORENTT MATE IAL: E ROGLACIALDOUTWASH PERC AT 58 in 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IS SOUND STRUCTURAL ELEVATION - 49.75 ;- CONDITION, IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. INCHES) HORIZON TEXTURE (MUNSELL) MOTTLNG 0-9 FILL SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 9-1 1 A SANDY LOAM 10 YR 4/4 NONE FIRM A b o t - ( 24 x 12.5 ) - 300 s f Asdw - ( 24 + 24 + 12.5 + 12.5 ) x 2 - 146 sf 1 I-44 B LOAMY SAND 10 YR 5/8 NONE FRIABLE A t o i - 446 s f 44-I32 C MED-COARSE 10 YR 6/4 NONE LOOSE-20% STONES V t 0.74 x 446 - 330.04 G P D SAND USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED LEACHING GALLERY CONSTRUCTION DETAIL H-20 DRYWELL UNIT STONE 8'-6'x 4'-10'x 2'-9' 2 ft EFF. DEPTH 24.0 fi 0 NOTES . M o 1) GARBAGE GRINDER -NOT ALLOWED WITH THIS DESIGN Ln N v N 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. N 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS I o OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES 2.S' 8.5' 2 fr 8.5' 2.5' BEFORE EXCAVATING FOR SYSTEM. 24.0 ft NOT TO 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED SCALE 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM, SEWAGE DISPOSAL SYSTEM PLAN 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. -TO SERVE EXISTING DWELLING 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING ROLAND & ELIZABETH CORDIERO 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED 16 COTTONWOOD LANE CENTERVILLE. MA FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. ECO-TECH ENVIRONMENTAL 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-1324 I DEC 16. 2002 2/2 4� 'Te 4t �DATE P, 4 �'LOGS` ES � ,PIT, L" "T" 11 't.4 11 1 tQ B 0 H : :AGENT,,, CiA F 1--o 1;2.D _NGINEERZ _ EXCAVAT OR v T P 7 7 7 vk NO , ELEV �,ELEV,� ":"t 'T j F: V5 TT— T Ll et iv, 2AVEL Z Z KOT _r- r shlre ir �rn Y L&t Y o",ol �T; 01 PLAN REFERENCE �4 Vt Sl_ Ix ' ASSESS NO. OR$ LOT, 71, 7'. 'T, c 3 NOTE A NMETHODS TO ONF RM TERIAL$ AND CONS' TO TRUCTIO I LL MA iTLE V �:'COMMONWEAJH`: OFWASS' ENVIRONMENTA 'C L,WDE,T Z AS 15TA, WA, , p P��pos ED":Qasi D p,�E-ro stL' cok�tAer- 70' M U t-4�e-1 P LNV A v Tg 4 -REVISIONS it 'CERT"I FY ia, T 4N ' ELAT G R ON TO EXISTIN HAT�JH FOONOATION-ON THIS LOT�'ISLOCATED ENTS SH ow N,! N ON U M AV -C�TH U LI N P.�2 DATE; DAVID , T_' " X", A.- OF -PLAN A IQ �c H U, N 29�9-6 SCALE 0 ZC>' -p 611111, Q /sT DESIGN DATA-, -7 _>Q3,A DESIG LOW - A 'S I t,4rn Ls TRUCTURE 'X, s Ly P_ N 0 A-P_e�P"Cl M r42WWDF—;?_ SEPTIC `7_ 15 'LEACHING�RATES SIDE 'AREA -GPD/SF T NK A -T, BOTTOMAREA .'�,GPD/SF` j. T, 7 6 CPO _0 AST-.,-,7SANDWJCH "MASS.��,_�"r'�'T, E 74� D AVID 'GTHULIN ' -T*L., sq cap>c:> D IT I ill,�, , - 4C ' 'SE 10 N R U, PTIGI H 0 R SCALE 'k VERT T R`By" DATE OR BY, I THU L__Q