Loading...
HomeMy WebLinkAbout0087 LOOMIS LANE - Health 87 Loomis Centerville 00 '1■■■■�■■■�■�■�r■■�■�■�■��■�r�r■�■fir■�■■■■��■r■■ 1■r■■■■■■■■■�■■■�r■■■■■■�■■■r�rr■■r■■fir■■■■■r■■ 1■■■■■■■■■■■■r■■■fir■■■rr��■■■■�■�■■■■r■■■■�■■r■ ilr■■ ■■■��rrr■■■■■E■■rNM■rMrr■■■■ ■r■MM■■rrrr■■ Ir■■■■ram■■■■■■■■■■■■�■■rr■■■�■■fir■r■■■■■■■■���� �1■r■�■■r�■■■■■■■■■■■■�■■r■fir■r■r■■�r�■■���■���■ 1■■■■■■■■■■■■■■■■■�■■■■■■■■■■r■■r■�■■■M■r■■■■■■ rs����■■■■■■■ ■■■■r■11■■�■■■■■■■■■�r■■■rrrrrrrrr ■■■■■M■■■■■■■■■■■■LALL ""Lim srrr�rrrr��r■r■rv■■■�c����■■r■■■rr■■r■■�������� rO■■■■■■■■■r■rrrrrr■■iQ3 �r�r������■rr����■■r■ �eee®�®®®®®e�■®ee®■re■■r®■■■■■■®■■r■rr■err®®®re® 1■■■■■■■■■■�■■■■■■■r■■�■■■fir■■■■�■■■■■■■■■■■■■■ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 87 Loomis Lane ' o Property Address Barbara Mackay f11 Owner Owners Name information is required for every Centerville Ma. 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection f.. 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 A. General Information 2 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere key the return Name of Inspector Y Cape Septic Inspections W A Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Citylrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/23/2016 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �V .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 page. Cityrrown 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. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. 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 x Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�' 87 Loomis Lane Property Address Barbara Mackay Owner Owners Name information is required for every Centerville Ma. 02632 10/18/2016 page. City/Town 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 '/z day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 .` , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•°° 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 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): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •�° 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,• 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 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: Mike Bisienere 508-280-3356 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity Drivers Est. q y pumped determined? Reason for pumping: Cesspool 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): Main cesspool with a precast leaching pit. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leaching pit installed in 1987 Permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"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: 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: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 87 Loomis Lane Property Address Barbara Mackay Owner Owners Name information is required for every Centerville Ma. 02632 10/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °( 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 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 copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.•° 87 Loomis Lane Property Address Barbara Mackay Owner Owners Name information is required for every Centerville Ma. 02632 10/18/2016 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 N/A 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.): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 87 Loomis Lane Property Address Barbara Mackay Owner Owners Name information is Centerville required for every Ma. 02632 10/18/2016 page. Cityrrown State ZipCode Date of Inspection pectlon D. System Information (cont.) Type: ® leaching pits number: One ❑ 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.): At the time of the inspection there was apex four feet of ponding water and two feet of head space Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration One round Depth—top of liquid to inlet invert Appx. 8" Depth of solids layer 1211 Depth of scum layer 1" Dimensions of cesspool 6 x 6 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Loomis Lane ,p — Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 page. Cityrrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Loomis Lane Property Address Barbara Mackay Owner Owners Name information is required for every Centerville Ma. 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ��- �j- Ji I � �sor� �l,z �:� �-1�.!!e� v.✓ i'h� nJefi �`,5e. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 W W.LVWuv1UGlllbtdUIC.Ub/ASsessmginiv►aispiay.asp'!mappai=2... TOWN AP IIAI NSTABLE � �L `Pw AmmQII o MAP 0 I,A _ INSTALLI RIB NAME a PHONE NO. -- SSP=TANK CAPACITY_C>e-7�iJl y� lit*6�fo'�L �y�&R LEACHING PADILIT'4tm) NO,AP IIWRQAM6-_aPRIYATU3 WALL Of FITPLW W 817ILDI;II A��W�I��,-„- ►� � Kam-�i-_. ._ - --- DATE PERMIT ISSUED;- DATA'.CAuPI,IAIICE II3oIIED: �. . ► - VARIANCE DII.ANTEDc vas i fin PRt •C-wi PIT WET(,pN.9 w(2�.�2STCNE �f 1 Commonwealth of Massachusetts 101 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 page. Cityrrown 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: 18 plus feet 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: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Loomis Lane Property Address Barbara Mackay Owner Owner's Name information is required for every Centerville Ma. 02632 10/18/2016 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 j P1 vs F-eer Feel No zo t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # -e� VILLAGE ��v�;1� Yli� I�`�._ . ,ASSES SOR'S MAP LOT INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITYj� K-0l ems ' LEACHING FACILITY:(type) �Y (size) /OZ7) NO. OF BEDROOMS ' PRIVATE WELL PUBLIC WATE)t BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: - VARIANCE GRANTED: Yes No , / 11�,1S1i"�• aid °1k�� <,�. . �'; �3-0 • G� 4 ,l� �N rn� v2,31 D 1,:P - ©O.� Fas.... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratiun for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( VJ an Individual Sewage Disposal System at:._........ l......-----•--- -�-c......•.............._.... L t'on-Address or Lot No. -- ...................V�........... .._... W � Ow er � � A�`+e� i - - S feet Installer Address Type of Building Size Lot................ q. U Dwelling—No. of Bedrooms..... Expansion Attic ( ) Garbage Grinder ( )�+ -•........................•-- '4 Other—Type e of Building No. of persons ................... Showers G.� YP g ------•-•-------•------._... p ( ) =-Cafeteria ( ) 04 Other fixtures ................................. d .................. ............... WW Design Flow........ .....................gallons per person per day. Total daily flow.. .. .....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.:...................Total leaching area...............0...sq. ft. 3 Seepage Pit No........./......... Diameter.....f.. ...... Depth below inlet....JC'.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1--4 Percolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. 1................minutes per inch Depth of Test Pit......:-............ Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ x .......................................................... O Description of Soil......................... U ..... - - -•-•••-------------------------------- - ....... - ------..... W U Nature of Repairs or Alterations—Answer when applicable........d-VV,........ • ..._.%. �-_---- cx,� ' ' �H' 'S — Q.. .�. ................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL U 5 of the State Sanitary Code—The undersignq4 further agrees not to place the system in operation until a Certificate of Compliance h ued by the board o It Signed............ ...... ��7,� ....----------- --------•---- .. .. .... Date Application Approved By--•.........................................•--•-•-------••..- -•- .... ----•-----------^ ........................................ Date Application Disapproved for the following reasons:...............•.........................................................................................._.... .............................•-•-----.........--•-----------------------------------------...------...._.--•-------------•-....---•--.....--•--•-•-••-----------------------•-.....--•---•....-•------- Date PermitNo.......IV.Z..-I-6.7....................------. Issued..-------•----••--------•---........................._ Date I'll _----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `�W.. ..........O F.........,I„G, t�.. �t, •��-*� ........................... :,. (Irrtif iratr of Taamphand THIS IS TO:CRR._IFY, That. the Individual Sewage Disposal System constructed ( ) or Repaired ((�) by -- •- 1 ...........�. ....-• ----••--.......-•-••...............••---------•••------•••-•----...--••-•-•-•••......•................... -- =-� Installer 5r at -----.------•------------------------�- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... .......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............�:� - I�_"-3--? ------..... Inspector--...� .� ,,� lam-*-r-�-- ........._ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD` OF HEALTH( No.. .7:.�:7 FEE.. %Vvsa1-1Vvrkq-Tvnstrurti an prrmtt Permission is hereby granted............. ................................. ' to Construct ( ) or Repair .( ) an Individual Sewage Disposal System at No r�- Street as shown on the application for Disposal Works Construction Permit No.37 S, . Dated.......................................... ........................... .............................. J Board of Health / DATE..................................................................... No._ 1.... 7 Fss_..... THE COMMONWEALTH OF MASSACHUSETTS BOARD �7OF HEALTH li.,-:....OF.?.......1 ................................ Appliratiun for Uisposai l Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: .«......« _..«`;.06 i4!L_1�S ._ .f::: .................. .......... � 2c.�, � --.............«......«....-- rt� Location-Address or Lot No. ................_ !f C/` ...;.,/........._..........._............_...... ........ ..............^ .�V! :. .........__--..-------....««....«..... Owner _ 4 —� Address rw.a 1Lc � r YGv � rat. .S ........ i��?C1:'............... Installer Address Type of Building -17 Size Lot................ Sq. feet ,.. Dwelling—No. of Bedrooms.........:..................................Expansion Attic ( ) Garbage Grinder ( ) P-4 Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------•------- -, WW Design Flow.._.....`�_a_. ..- .--. .._3................gallons per person per day. Total daily flow. 'I-_a.....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length....... ......... Total leaching area...................sq. ft. 3 Seepage Pit N,o.__....._;.......... Diameter......e-?..... Depth below inlet....A52 ...... Total leaching area.................sq. ft. Z Other Distribufion box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... .. P�+ ----•----------------------------------------------------------------------•••-•-•----•--•-•.._.......•--.....----•----••----------•------_-..-- ODescription of Soil...------•-•-•----------------•--••--------------•--•-----•----------------•-------------------....---•----•---------.........-•-•--------•--•-•----•----••-......--... W •••••...---•----------•----••---•-------------------•-•--•---................---------•••• ...-----•--------•---•----••---•-----.......... :..._....•-••••:••-------..................--•-••----- U Nature of Repairs or.Alterations—Answer when applicable ��l'a-0......_(?A :•z:........!MM...... s:_ ._.........7 ...... ............... .....................v...... .. .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hastbeen_isssuue^d� by the board of Health. Signed........ •._.._.se:_._\_ _ C I 5\ 1 o�7' J- -----------------I-------.....••--4• ........ .�........_. ./ Date Application Approved By--•••••-••••...............••••••••••--...........-•••-•••••-•.....-•••--••-•--......•-••-••--•« ,...., ........................................ Date Application Disapproved for the following reasons:...............i......................................................................................... ................................•----.......................-----......--•------.......-------------•---.--•-...............------------......----------------...-••--••••--.....-------•...•-•••-•---- Due PermitNo..=••-F.?_-. -5-�--••----------------«--.. Issued......................................................« Date AsBuilt Page 1 of 1 TOWN OF B.ARNSTABLE LOCATION L/ 7 L,rx�y�►S ��' SEWAGE# 7- VILLAGE ASSESSOR'S MAP & LOT_ INSTALLER'S NAME SY PHONE NO. SEPTIC TANK CAPACITY_ 'X'`2�:� l ✓"G Cs aiC'.y+yr rK •h; LEACHING FACILITY:(type) �� (size) NO.OF BEDROOMS PRIVATE,WELL*PUBLIC WA BUILDER OR OWNER _ I A DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No j Gr�hz1 ISp} �xShSTUv(y /A �� CEEaS�1(� J` Ly �o+ F fvXly P(?t ^CASi PIT http://issgl2/intranet/propdata/prebuilt.aspx?mappar=231018002&seq=1 11/3/2016 a g WOOD TRIM• 5 CROWNOWNER TO SELECT ALL AND BASE,WINDOW CA9NC,DOOR CASING, NIR]iEt�j CABINET/APPWNCE/FIXTURE LAYOUT IS FOR REFERENCE (CRT EW WINDOW IN PREVIOUAL US OPNG) ^ e CROWN NOULDING,ETC ANO FINISHES FOR EACH. ONLY.OWNER TO SELECT ALL CABINETS/APPLIMCES/FD(NRES AND L.L 11 CREATE FINAL DESIGN LAYOUT.MECH/ELEC/PLUMB CONTRACTORS TO § VERIFY WITH OWNER PRIOR TO ANY ROUGH-INS. (NEW DOOR IN PREWOUS OPNG) (NEW WINDOW IN PREVIOUS OPNG) (NEW WINDOW IN PREVIOUS OPNG) y/ INTERIOR PRTIRONS: (J)3o60C 10880 SLIDER (3)2842C Q^0 -- BATHROOM (3)306OC w B 2X4 0 Ifi'OC WITH)'GYP BD FA SIDE(TYP) --1 ® ® � �L 2X6®16'DC WITH(•GYP 80 EA SIDE(PIBC CHASE ONLY) BATHROOMS CABINET/FIXNRE LAYOUT IS FOR REFERENCE ONLY. '§ OWNER TO SELECT ALL CABINETS/FIXTURES AND CREATE FINAL EXIST FIREPLACE TO RE,WN U §z DESIGN LAYOUT.NECH/ELEC/PLUMB CONTRACTORS TO VERIFY WON 6'-10' OWNER PRIOR TO ANY ROUGH-INS. NEW KRONEN O AI PROVIDE WATERPROOF ENCLOSURE AROUND MASTER BATH SHOWER CABINETS AND LF WIDTH BE 36'MIN CLEAN ABOVE HANDRAIL, WITH CUSTOM BUILT SHOWER PAN/BENCH SEAT. PR3fi80 LIVING ROOM APPLIANCES BY FRENCH DINING ROOM g § WIDTH ON TO BE MINI•MIN CLEAR OWNER g VERTICAL RISE 147'MAX BETWEEN FLOORS/LANDINGS ALIGN KITCHEN BREAKFAST Z y RISER MAX OF 7)'Q'MAX DIFFERENCE BTWN TALLEST AND SHORTEST `l 3; RISER). PORCH PATCH FLOOR WITH FLOOR JOLSTS AND (•FLYWODO WHERE STAR WAS REMOVED§ TREAD MIN OF lo'. Nf]�I yF�;; SEE STRUCr DINGS M HANDRAIL REDO ON ONE SIDE WITH HANDRAIL RETURNED 1D WAIL OR PROMOS D ED/MUDDED/SANBED CYP BD FINISH FOR ALL INTERIOR NEW PARTITIONS yE NEWEL POST. WALLS AND CEILINGS. SEE PARTITION NOTES OWNER ro SELECT PANT COLORS AND OTHER AM WALL FIND AL. co g awNER ro$F1ECf AL CARPET,VINYL CERAMIC VICE AND ALL arxER c 8 EQUIPMENT NOTES. FLOOR FINISHES AJGN p 5 ALL APPLIANCES,FURNACE NR CONDITIONER CONDENSER,WATER c o ¢ HEATER,SUMP PUMP,SEWAGE PUMP,ETC.SHALL BE INSTALLED IN N as ACCORDANCE WITH THDR LISTINGS AND MFR•S INSTALLATION L?ccpm. f— o 9� INSTRUCTIONS PROVIDE A COW OF NFR INSTALLATION INSTRUCTIONS EAST SHELVES 3280 ALIGN fA N o yp ON SITE AT IUFE OF INSPECTION. OWNER ro SELECT ALL DOORS WITH ASSOCIATED HARDWARE AND ro REMAX " \// o 5 a FlNISIES c sE I_0 0 3280 t0 ag UDROOM 9 3680 ¢rno in E g OWNER FINISHESM SELECT ALL WINDOWS WITH ASSOCIATED HARDWARE AND �' - EXIST ROD/SHELF �1880 i ( PR1880 -1 CIR MI0. N 3 5 a-I 3 ��"' - z ro REMAIN. I ss �•2> v H e a ^ I EXIST ROD/SHELF Iz GUEST BEDROOM I To REMAIN FOYER NEW LAUNDRY BY 0 v w a Imi GENERAL NOTES I O OWNER Paleeo I LIES Q(1) N x$ BATH }� _ (2)PRI��& GARAGE Z M & 1. PROVIDE HOT RAUDr TYPE X/MOLD RESISTANT GYP BD ON WIDE OF WALL AT SEPARATION BETWEEN GARAGE AND LIVING O and ❑ M y SPACES. n ^S 0 . j 32600H 32600H I 12Z8AW(T) NEW PIRG FIXTURES CV 3 3128AW SEE PLBG TONGS 38 2 SPACES. ENV50PESHALL COMPLY WfIH 3015 ROEENAIONA BNS(ir CON1T3wAa0N CODE RH7UIREMBJI$REGARDPG - — O K THERMAL INSULATION AND AIR LEAKAGE AN ASP LEAKAGE TEST"ALL BE PERFORMED BY ATHRD PARTY AT THE CONIRACTORS I S EXPENSE IN ACCORDANCE WITH ASIM E 779 OR ASIM E I8271 TO VERITY THAT AR LEAKAGE 005 NOT EXCEED THREE AR CHANGE I}I LED EO f- i r z PER HOUR. OFTHEI5fi0 BESUBMITIED TO ME VILLAGE FINAL MSPECIION. gam• y._2. NEW PIRG FIXTURES B'-2• �„ o SEE PIBC OWCS Q Q y 1 STARS SHALL HAVE EOUAL BEERS(RBERS NO[TO IXCE®7)7 ANDIREADS OFIPMPL WITH 6'd'MWNffADR00M CLEARANCE KN TH F--_________- 3 y PROVIDE HANDRAIL IMN 17 DIA-MAXT ON ON ONESIDE MOUNI®36•ABOVERAIRS. PREVIOUS DPNG I I NEW DOOR IN I I 4. ALWWD.WINDOW SHOWN NEED TO E NEED FROM WINDOW PREVIOUS OPNG I I Q Eg SEIECIEO.WMDOWS LABELED AS EGRESS NEED IO MELT MIN EGRESS REONREMEMS. � I y°y S. ALL WINDOWS AND DOM TO HAVEHEAD HEIGMOF 6'FAFFUNO. I I L Z W L I I W J 6. ALL WP100W5 iOHAVEMNIHVAWE0F032 I I F$ N I I V� J IRS Bn ® 2 F T FLOOR PLAN ya•=,•-0„ 30'DIA FIXED(ABOVE) > ea EGRESS WINDOW NOTES coVJ IY �. W° w AT LEAST ONE WINDOW LOCATED IN EACH BEDROOM SHALL COMPLY WITH THE FOLLOWING EGRESS 5 s REQUIREMENTS: B a B B np NOT LESS THAN 5.0 NET So.Fr.CLEAR OPENING(BASEMENT AND FIRST FLOOR) !PH H HE Q € NOT LESS THAN 5.7 NET SO.Ff.CLEAR OPENING(ABOVE FIRST FLOOR) 20 MIN.WIDE OPENING __ ___ �� � i -HE S w W -�___ 24'MIN.HIGH OPENING I I L If I I I > U B OPENING SHAH HAN BE LOCATED NO HIGHER T J6•A.F.F. III I I III >X n0 I O 11 L_�1 II W �$ LIGHT/VENTILATION SCHEDULE Ili —J i`�n11 W § ROAN NAAE AREA REQUIRED NATURAL MECHANICAL LIVING ROOM YV 'VII 1 3 DINING ROOM I I I 1 B J Z S1 1 LIGHT VENT SUPPLY RETURN EXHAUST t II 16 r (1 FOYER 131 NR NR 315 CFM III e 7 e 9 1011 _n KITCHEN L- BREAKFAST j j J Z Q ;g 11V1NG ROOM 173 28.0 14.0 JIS CFM _ I I Q J �B DINING ROOM 17} 1}.8 6.9 I60 CFM PORCH 111 14 75 10 ga KITCHEN 220 17.E 8.8 Z00 CFM NOTE 3 ,3 BREAIffASf 188 I5.0 7.5 170 CFM zsMUO ROAN 36 NET NR 35 CFN - �` C_ _ --- N.N r-_---_--_- GUEST BEDROOM 605 16.4 08. INS CFM - - I \ I r T7-TNT-E- -(-rrr�}Jy� T r--1 r---�— ��IT-- � _ s GUEST BATH 60 NR E-fi0 CFM 55 CFM NOTE 1 BATH 1 54 NR E-60 CFM 50 CFM - NOTE 1 yc HALL Ile NR NR 110 _ \ III I II \ - 2 MASTER—BEDROOM f IL I I I I I`I I I \ ja FAMILY ROOM 235 18.8 9.4 220 CFM - - � I I I I III \ e 201 16.o e.o Lao CFM - VIVID JJ_LLL.L I -- -� z MASTER BATHROOM 1 \X�I I \ a BEDROOM} 170 12.0 6.0 140 CFM B 5 BEDROOM 4 170 13.E 6.8 155 CFM - L h / \ \ W \ �__J 1�__ILL.—� J BATH 2 60 NR E-60 CFM 55 CFN - NOTE 1 \ -r/7- � 1 B O ` r1. P= 9 L PRPALE EXHAUST FAN L,IN MR IMCF RREI4RNQ1 64IRIADON BWMiCm WECRY m WORM WiIX NV,,R TE JILT(R-3 III BEDROOM 1 \� II L PRDMRE EXHAUST I MfX MN IOOCHI w3RumDN WtmuATxlx DS.YIARGm OBEGILY N EXTERIOR Nim 0N6DIAlm[RICE(R-]YN). BEDROOM 2 z I'XOVIDE ImD1EFI How EMMNST xmH WIN ns C,I TwwlSf. _ /%J g B rr11 LLJI r � FOYER —fi -- 72 g' P BATH�I GARAGE 3 A P s e nne p FIRST A $§ FLOOR PLANS �s '4/111/2017 N ® (,-)FIRST FLOOR DEMOLITION PLAN 2761 v4•=ra' �� Al w ffi (CIR ON WINDOWS BELOW) ��------ k (CIR NEW WINDOW IN PREVIOUS UAL OPNG) 3,_4. EQUAL EQUAL < U (3)2842C (2)2842C ———_ (3)2842C O gF a 32�NEW CLOSET ORGAN2EH SYBIEN IN ANSTER CLOSESBY if OWNER L 9 MASTER `��l( i PATCH FLOOR WITH FLOOR JOISTS AND BEDROOM C-6 FAMILY ROOM 3'PLYWOOD WHERE WSEE ADS� ^———— m g _ m Amc SGY1/R£NEW TO Ram —J ATTIC ISEE MECH DWYS T 32BO NEW PARTITIONS Q SEE PARTITION NOTES m�` E ii 3280 �y q a ALIGN ==LJ i e _ pi c� 3'-0' a ..' CLR MIN I Q C/) N § PRIB80 I r {& NEW RD0/SHELF I E%ST IELF I\ Z BEDROOM 3 i 2,_B• BAUCH ELOW BELOW n I J 0_ N gg OPEN TO O ° PR1060 2,1 6' BATH 21 j SLOPED PARTIAL I MASTER g g I HEIGHT WALL 3'-6' I Z. BATH O Q Q ASM STAIRS "'�25 I NEW PLBG FIXTURES 32480N(T) 3D'DIA FTAED 324BDH 1 n MANIOH(1) SEE PLBG DINGS coI..IJ 3248DH 32480H vm. .M .^ fi CTR ON DOOR BELOW) NEW PLBG FlXRIRES ED ED O 5-8` 9 2' l SEE PLBG OWLS B'-2` Z z w w J �$ N 2 SEC FLOOR PLAN > =r-OND o^ � B O w wz ww F- i , �x 1! s 6f 6 6 w w J z Q Q � J 6' II u) II 11 a st0 U— ,s,a O 1 _ s� II II 11 II II 11 13 w O z O W J a§ I I I i'I T T i? OFFICE O F_ z 00 $ MASTER I I mECFr 7 Ik II 1�IT BEDROOM I L----I .3 ,Iw11 4 / MASTER E Ly III BATH O M =�= =�= _g—�— —�— SECOND 6 FLOOR PLANS 6 6 04rowie �n i1l2017 8 N 2761 SECOND FLOOR DEMOLITION PLAN - ,r4 Al .2