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HomeMy WebLinkAbout0098 KATHERINE ROAD - Health (2) 98 KATHERINE LN. , CENTERVILLE A = 228 053 I uommonweann oT massacnuseLis Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address l Matt&Ann Corkery Owner Owner's Name 4.r"9 information is r, required for every Centerville MA 02632 01/18/15 - page. City/Town State Zip Code Date of Inspection E b o Eye Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: I�1— key to move your v / cursor-do not Trevor Kellett use the return Name of Inspector key. Co Septic Co�y mpany Name 38 Vacation Lane Company Address West Yarmouth ma 02673 City/Town State Zip Code ,.. 5085795502 S113744 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 p XAAk7 01/29/15 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. o '"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Offid Ins ection Form:Su Sewage System•zdbsurface �\ itoommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 haye not found anyinformation which indicates that any of the failure criteria described in.31-0 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 uommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments °M 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town, State Zip Code Date of Inspection B. Certification (cost.) { ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or•high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 itommonweann oT massacnusens Title 5 Official Inspection. Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 1/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I tommonweann oT massacnusens Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 98 Katherine Road Property Address Matt&Ann Corkery Owner Owners Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r %,om onweann OT massamusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town 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)] 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 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 tommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2+ Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t#ommonweann oT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 uommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 6/15/00 per DOC Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.2 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): 1.8 Depth below grade: feet 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: 1500 g Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 toommonweann or massacnusens Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary.Assessments wti 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic Tank is water tight and structurally sound with both tees intact and water at the outlet invert, no sign of back up or failure 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 t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 uommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach co of current pumping contract(required). Is co attached? ❑ Yes ❑ No PY P P 9 PY t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 t ommonweann or.massacnusens Title 5 Official: Inspection Form Subsurface.Sewage Disposal System Form -Not for.Voluntary Assessments. wM 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is Centerville MA 02632 01/18/15 required for every page. City/Town: State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 d box is level and water tight with no signs of carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 toom onweann OT Ivlassacnusens Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): This leaching consists of two 500 g leaching chambers that are completely dry with no high staining or ponding inside the chambers Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 .,Title 5 OiMcial Insppoon Form:Subsurface Sewage Disposal System•Page 13 of 17 \ ltommonweann or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � s 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 uommonweann or massamusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. CitylTown State Zip Code Date of Inspection D. System Information (Cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 04 A00% y Ad 3� s A ,3 30 a v� M i�t4 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 tommonweann or massacnusens Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM s 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town 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: 40+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 shows ground water at 40 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 uommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 98 Katherine Road Property Address Matt&Ann Corkery Owner Owner's Name information is required for every Centerville MA 02632 01/18/15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CD � �$5 �{> Citizen Request Management Request ID: 21680 Created: 3/17/2008 1:02:03 PM ' Status: Assigned To Staff Assigned To: Stanton, David Health Office _ Anonymous: No Category: Article X - Food « Foodborne Illness E.C. Date: 3/21/2008 Created By: Crocker, Sharon Citations: Nam' Health Office erg; Time Worked: 2.00 Response Time: 2.00 Request Location: ? Parcel Number: Map: 228 Block: 053 Lot: 000 sr.. Request: BARRY HOLTS WORKS FOR AN INSURANCE COMPANY WHICH HAS A FLOOD CLAIM AT ABOVE ADDRESS. FIVE FEET OF WATER IN BASEMENT WHERE THERE IS AN OIL TANK. DOES NOT SEE OIL SPILL BUT WANTS TO VERIFY DOING PROPER PROCEDURE FOR CLEAN UP. (BUILDING AND HEALTH) PLEASE CONTACT BARRY AT 774-236-9866 ASAP. THANK YOU. Request Work History: Entered on 3/18/2008 8:10:39 AM Last modified on 3/18/2008 8:53:04 AM On 3/17/08 DS called Barry Holt of Servpro (contractor for clean up) DS met Barry at said location. Observed severe water damage and mold on first floor. Observed basement about 3/4 full of water, approximately 25,000 gallons of water. DS did observe the oil tank fill pipe, vent and gauge all intact and appears the tank is submerged completely underwater. There was no evidence of oil leakage observed. The surface water in the basement was clear and no oil sheens were observed. Unknown if oil tank is full or empty as it would require swimming over to the tank. Photos linked below. DS called the office of Barry Holt on 3/18/08 and left a message to have Barry call or stop by Town offices to go over the project. There may be issues with other departments that need to be addressed (building and conservation) before work commences on the project. I Bldg #: 1 Card 1 of 1 Print Date: 12/15/1999 FOP 16 10 1 f 16 UBM .._ __._ 1 16 F ``� la-l"I� 2 10 17 3 ?0 � I 14 v .......... ie CA 1 op Av t .i it ,r t'i ' •�� a' i R � if 1 l , ;.' i . �' 3.. ;� :r �� � .. . , ,- E �., F T • ' ,.t _ - � :. � f .. �, •. • � _ I .. -'� _ � - u� � - - _ - ..�._._. i ,� s � �: �� , • ' � «- fit` '••a'•• �''�' `'!• •••+t'•R a • • i LT OL Vs • ob # • 40 Am •ti 16 - .;•;. .,' ••y e t •; ,. �. . is • •�. �S 'R It , 146. R♦ R • i • R 46 TtK i. — � t No.AF400V e `r��f THE COMMONWEALTH OF MASSACHUSETTS FEE /� BOARD OF HEALTH LT&Vyw H APPLICATION FOR DISPOSAL SYSTEM CON TRUCTION PERMIT Application for a Permit to Construct ( ) Rcpair ( ) Upgrade-(Abandon ( ) - CYCOMpletc System ❑Individual Components � k/p 12A o cA Lobityx-3 Owner's Namc Map/Parcel# Address Vq "'et"','ne S �/�t Installer's Namc Designer's me Address Address,7 Lh 2s Telephone 9 Telephone 1 Type of Building: Lot Size 100_?(D Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder ( ) Other—Type of Building No.of persons (,P Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. required) 5 gpd Calculated desi n flow330 gpd Design flow provided' CSC, pd Plan: Date 3-2-6-0-0 Number of s eets Rev' ion Date Title C 1 ' rn Description of Soil(s) a CtA�. y 3Zu A X Soil Evaluator Form No. Name of Soil Evaluato Date of Evaluation 3—q-L C, DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 aArnot to place the system in operation until a Certificate of Compliance hass been issue d by the Board of Health. Signed Date d V ?OOC2 Inspect .•r ✓ FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 1 ; No. V loop- �✓ THE OMMONWEALTH OF MASSACHUSETTS FEE / �r✓vr BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: � C AgLTv - • at 1 O eZlk p �iJ'TtR has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as uilt plans relating to applicationrToO40- dated JF'�� Approved Design Flow, pd) Installer 41 D V Q Designer: Inspector d/ Date 06, VA I /i ' The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 r / No �D�" �'��< THE COMMONWEALTH OF MASSACHUSETTS FEE 0:0 BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby ranted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at �(9) 1,"7N2�i�.1� �� Cr--PZTe—PQ1LLG as described in the application for Disposal System Construction Permit No.2ll 0i`d dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date l 3 ac) Board of Health ��FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN'" PUBLISHERS- BOSTON NOt THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH I . OF - UUALL LL APPLICATION FOR DISPOSAL SYSTEM CON TRUCTION PERMIT x Application l'o'r a Permit to Construct ( ) Repair ( ) Upgrade"(((Abandon ( ) Complete System ❑Individual Components i Lm . �`a Luc lio wner's Name Map/Parcel# Address # "I'cicPhone It Installei'sNamc 1_ Designer's me Address rAddress�2 Telephone It - Telephone# fr �, Type of Building: Lot Size {tUl-1 LD Sq.feet j Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of.Building No.of persons LIP Showers-( ), Cafeteria ( ) Other fixtures 'Design Flow(min. required) 65 gpd Calculated desi n flow 330 gpd Design flow provided t�gpd Plan: Date _3" Zb-U- , Number of sheets Revision Date Title . Ci` M Description of Soil(s) �`- , "-3Zu tta�� Lt`-1w ` t`1'la ll j Soil Evaluator Form No. Name of Soil Evaluato " Date of Evaluation o; DESCRIPTION OF REPAIRS OR ALTERATIONS >. 'W The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furt r gree's not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed WA4- Date + y ,?000 ' Inspect FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 1` h � TOWN OF BARNSTABLE �* LOCATION f,VA IZa( SEWAGE # dddo-- 34 VILLAGE C&A 4wt 11C- ASSESSOR'S MAP & LOT Ate �©6 INSTALLER'S NAME&PHONE NO. d 6 Gt.v\ Qcz(40 SEPTIC TANK CAPACITY f 5 0 J 6 j/�- ,,/ LEACHING FACILITY: (type) _��5 d J b i9 C ( G nt�• (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private`Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by sg��A � Oaa �� fs� r �• o�� y FIT q Gt a , t/ I US� ��. , S' TOWN OF BARNSTABLE LOCATION ka4A !t v-Z R-1 SEWAGE # o7d00 - 31/ VILLAGE GA -k t v t I1 C ASSESSOR'S MAP & LOTk�UO '0� i INSTALLER'S NAME&PHONE NO. oI a SEPTIC TANK CAPACITY f�--0 J 14 z / o LEACHING FACILITY: (type) a/S d J b f9 L dWfYJL. 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C,1OW A J - A.Or- 1.411ae x / zl rilz_ aNS AJd f�(1L� /A/�G'D/!Z 12' o Bath First Floor [1462 Sq ft] Porch 34' 12' 1-7-- Master Bedroom N 4' Dining E 1 ~ CO iKitchen Closet r" < Full Basement N i 1 Car Att o Family [252 Sq ft] u Cl Bath 1 Living 1 �! 1 Cl 12 15' iv Bedroom ^ No bsmt 20' Cl 15' Family Room could serve as 3rd sleeping area Living room and kitchen have cathedral ceilings WAL sketch by a La made,In. Area Calculations summary F Living Area Calculation Details First floor 1462 Sq ft 12 x 12= 144 30 x 15 = 450 26 x 20= 520 15 x 21= 315 11x3 = 33 Total Living Area(Rounded): 1462 Sq ft Nonliving Area 1 Car Att 252 Sq ft 21 x 12= 252 Form SKT.BIdSki—°WinTOTAL"appraisal software by a la mode,inc.—1-800-ALAMODE t r✓ a Town of Barnstable P Deoment of Health,Safety,and Environmentaievices o�TR Public Health Division Date 02 hoo d, 367 Main Street,Hyannis MA 02601 entuae BU& �r� Date Scheduled , q-oo Time `�y I� t 60 Fee Pd. /O J a 60 Soil Suitability'Assessment for Sewage Di osal Performed By: �l1x�J`a W r�-t- Witnessed By: ��'��4 /� � �•� LOCATION&'GENERAL INFORMATION Location Address (�C 1_ - . _ P � . Owner's Namel � -1 O J11J1 t•fi i h--Q� Address Assessor's Map/Parcel: Engineer's Name ,/y�C�� q4� NEW CONSTRUCTION REPAIR Telephone Q i Land Use r %ofc CA— Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way R Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) Q. .�. z IUot Zo r 'ice 15W Parent material(geologic) 0 7f°1"-� Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETEYtMINATICINTOIt SEASONAL IIIGH WATEI 'TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date 3 4:!41tme Observation Hole# Time at 9" y�. « Depth of Perc Time at 6" Start Pre-soak Time Q Z o Time(9"-6") End Pre-soak Rate Min./Inch d L Site Suitability Assessment: Site Passed L= Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-� Copy: Applicant DEEP.OBSERVATION HOLE LOG 70le Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) YiZ I/i y"-32y B fp..of YA sly S.ae/ �OY/t S74 `DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munscl!). Mottling (Structure.Stones,Boulderes. Consistency,%Ora'. I DEEP OBSERVATION HOLE IOG Hole# Depth from Soil Florizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.°o Gravel) Flood Insurance Rate Map: Above 500 year Hood bvunda:y' No_, Yes Within 500 year boundary No Yes Within 100 year flood boundary No v Yes Depth of Naturals Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Ye f If not, what is the depth of naturally occurring pervious material? Certification / 1 certify that on y!9S� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above,analysis was performed by me consistent with the required training,expertise expertise and experience described in 310 CMR 15.017. Signature i- Date 3 : . ..... E,. �8 .� S Yll. TOP FNDN. x EL . FINISH GRADE c �� 's' FINISH GRADE OVER 't ;i''i•;'; SEPTIC TANK ao aA O°.aoCp C! �p 12" MAX. 9 .m ro►q �G Ss Aor�• • ' a` 'b+ ' .C�.;4�.D� e'::Q•e�y�s;0 o p7.b�6'4Irb.- !-ij A 1 V. r 10 } ....... pl'O.O•. Q 3 •a. :P.OoO p da C. I. OR P VC TEES ►p � -�� o ro 1500 R esMr. FL . GALLON b' EL . y �; 90 AA PPECA S T CONCPE TE ° a H-*/ 0 REINFORCED ., ��b�o v`ibo••o�,�pr o 4••p'b.':p sQ d.a °l�'i;oDpa.eq;.a-�°. SEP TIC TANK INSTALL ON LEVEL BASE 23,w =:1 • ' . 6�, • . _ AKA,THERINE ROADi ALL f. ,� ` o�, �F✓ /� �_ 2. `ALL L`•X ,x - ".-- 100.00 — OR /G 97 r 3. THE HEM TO I 4. ANY L_ I BY o; o o SUR 9c ry° 5. MA TI COMI CODI N W o ,' o° I N �0.oo I 28.10 ^ ,°0 6. NOR IS I hEXISTING : 7. •FL OI DWELLING B. WA Tt 0 ' I S 46.00 Ll6.90 M•d W/ c/c-.s.. •S.cp..r/ r --a--- 100.00 — S 06'18'51"W E/, G 7. .7 ... Z rf/ /1T ^# I♦1 .. S YS TEM PROFILE NIT TO SCALE . TOP FNDN. FINISH GRADE FINISH. GRADE OVER EL . G �, H FINISH GRADE OVER OVER TRENCHES �% .'`i' FINISH GRADE OIS T. BOX SEPTIC TANK G_o 00 Grp•.. � j a p �e,v/`... 6 ;o,Qa� 12 MAX. ...._.7�ia IsfR ��/y.. d o,4 I• •� ••'e'! ✓e� .Q.l sD '?o'.,0•?y�•p••v. o�~d��i�L•• •s'ti•br.r l� , - __. "ell Ca ✓ v d TOTAL LENGTH OF TRENCH z-5 OUTLET PIPE LEVEL 3 ° FOR 2 FT. MIN. - a�' •. : o.. .,o. , ..D: .e ':d• b' I;�;,:p• a1 �0 .�. 6" Q :P: ,Y 'Ali ve ;t :�,eoo66d66d�o C. I PVG TEES �° %o •0 7 o � 0 0�0� �e o OR ro _67 of 1500 Goa L L ON DISTRIBUTION BOX y y- 0 .a.1 b': BSM T FL . EL . o °'.�o_a o °� o� INSTALL ON LEVEL BASE ��500 GALLON ORY`✓ELL S �� PRECAST CONCRETE lei b H 0 REINFORCED •, p. p bo. •I tv�oao,�bQ:';n�o a .'�b.':D a ►:�.0°P::Ae� '9 'o` P: SEPTIC TANK p TRENCH SECTION INS TA L L ON L E VEL BA SE NO TE: EXCA VA TE TO EL E V. �1,4 OR LOWER TO REMOVE ALL IMPERVIOUS MA TERIA L BE TH THE LEACHING AREA 4" Or aM 12" MIN. REPL A CE EXCA VA TED MA TERIAL WITH l 3" OF 1/®"-1/2" r- :O'a.:•0'. .v o.'p o c' b � b .o;'. dr.}ti CLEAN, CL A Y FREE SAND a2, A i.° A . �;.o,..:p. o. . WASHED PE STONE 3/4" - 1-1/2" WASHED a \� CRUSHED STONE � ��'• G �'' — KA THERINE ROAD GENERAL NOTES s 3 '! TRENCH WIDTH � ". -.-✓ , � �_ - .Ex sue... liY.o l�.r. .7'✓t . F . t�/C / p. 1. ALL EL EVA TIONS SHOWN ARE BASED ON ASSUMED .NUMBF R O e PE ,ES 1 , / 6'24 0o E 2. LL P.'PGS °Iiv Tr,�c SYSTEM MUST BE LAST :YROl1i NUMBER OF DRYWELLS 2 zG, `� 00 i 1 a . OR SCHEDULE 40 PVC. I 06'SEIgVA TION PIT Y14E BOARD OF HEALTH MUST BE NOTIFIED P-9693 WHEN CONSTRUCTION IS COMPLETE PRIOR TO BA CKFIL L ING PERCOL A TION RATE. , 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <5 MIN./IN. ® _ I WI TNESSED B Y.- a s; BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS , SURVEYING CO., INC. MATERIALS AND INSTALLATION SHALL BE IN — DONNA MIORANDA BARNS. BRO. OF HEAL TH DESIGN DA TA COMPL IA WI TH THE STA TE SA TA DA TE: MAR. 9L2000 CODE - TITLE V - AND LOCAL APPL ICABL E 14.20 ' `N RULES AND REGULATIONS - - T.-s 6 W NUMBER OF BEDROOMS 3 o N oo 6. NORTH ARROW IS FROM RECORD PLANS AND o m, IS NOT TO BE USED FOR SOL AR PURPOSES H �� . o o � 28.10 ^ o 0 5 ^ a GA RBA GE DISPOSAL 330 GAL o c EXISTING o :� 7. .FL 000 HAZARD ZONE C (NON-HAZARD) r.a A.� s DA IL Y FLOW DMELL ING o `m� B. WA TER SUPPL Y TOWN WA TER e r _r%_ SEPTIC TANK RECJ 'D. 1500 GAL . � GAL . �o SEPTIC TANK PROVIDED 1500 46.00 LEA CHING REGUIRED 330 GPD. (,2 SIDEWAL L AREA = 152 S.F. �►� _i© .. _ 152S. F.X 0. 74G/S.F. = 112 GPD. BOTTOM AREA LEGEND 329S.F.X 0. 74G s.F. - 243 GPD LEACHING PROVIDED = 355 .GPO 100.oo PROPOSED ELEVA TION fi s 06•.re•si Nw --G � -- EXISTING CONTOUR oesERVA rroN Pr T SEP TIC UPGRA DE C PROPOSED A DDI TION ❑ DISTRIBUTION BOX 7c, , L G ' PROPOSED SENA GE DISPOSAL S YS TEM 4-11 <a r_=---, TRENCH PREPARED FOR y o o sEPrrc TANK a 74- PADGET T BUIL DERS L O T B '(HIE. N0. 9B) KA THERINE LANE —._! RESERVE AREA u ,{., CEN TER VIL L E—BA RNS TA BL E—MA SS. C Gaya PIPE INVERT ELEVA TION ��, ,;-IL - i--' rr1 •�l;;b(� ,! DA TE.�_kf�r�ti 20 .20a d d'.q PLOT PLAN ' CAPE 6 ISLANDS ENGINEERING zy-� SCALE AS NOTED 800 FALMOUTH ROAD — SUITE 301 SCALE: 1 0 MA SHPEE, MASS. c p- MA p SFr PC I- ! 0 T 1 MSF