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HomeMy WebLinkAbout0059 POINT OF PINES AVENUE - Health i9 Point Of Pines Avenue Centerville A = 210 108004 1 r u �Esse/te 1521/3 ORA 100/0 P2 I 4 - alo- iog Oa Commonwealth of Massachusetts "M W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��M I {'/ -7L Property Address - Owner Owner's Name information is �1 ? required for every 0a 6 ?a page. City/Town State Zip Code Date of Aspecti6n 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:Ing outfA. forms When General Information c �a9s fillin out f J� 9 on the computer, use only the tab 1. Inspector: key to move your / cursor-do not Q r use the return Name of Inspector key. E/I/ O 7 _ I Company Name wo Company Address Cityrrown (fin �J�J 9i� State [�' f)* Zip Code Telephone%tember License Numbef'° B. Certification 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 C R 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspecto 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 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.doc-rev.6116 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal Syste Page 1 of 77 '. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M /poi n` - o-71-' Pyres AOe Property Address Owner Owner's Name /� 49� .7.2 3 information is PH � , � a� required for every � / page. City/Town State Zip Code Date of nspec on B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) SysKeases: Ihave 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.doc•rev.6/16 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 �l✓l� D� �'t"-ej � Property Address Owner Owner's Name eA information is 4 CeM h-s-i 11 dla— page.required for every y d�City/Town State Zip Code Date ofinspeiftion B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 _ N, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM J 9 f 0*1 - o�' I"t Nef lT V'e— Property Address Owner Owner's Name AX information is required for every y� page. CityFFown State Zip Code Date of I spectio 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: f You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 5�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 El �r clogged SAS or cesspool iquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 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 Property Address Owner Owner's Name information is Ce„ I_ v`/l� �/� Q�� Q1 3 /.PAR required for every �F-G�/ I � d�L page. City/Town State Zip Code Date of nspec' n 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- ❑ 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r9 AV6- Property Address /Owner / yj •L/— r N " Owner's Name information is / required for every � �Q✓1 �� C 4 page. CityFrown State Zip Code Date of Insp ction C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No [IL/ P moping information was provided by the owner, occupant, or Board of Health ❑ I� W n of the system components m y y p pumped out in the previous two weeks? ❑ he system received normal flows in the previous two week period? ElHave 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? L�J' LI Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? ;---- LJ 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): Number of bedrooms(actual): / DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 - vE Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage D iiss9posal System Forrrm0-Not for Voluntary/ Assessm///e/'��nts / 01 Property Address J_Q I �o4 Owner Owner's Name /� I information is / �`� 3 p� required for every l� •y � � /" page. City/Town State Zip Code Date ct Inspe tion D. System Information Description: 0 /_WM 6+ l/vo , ,G �✓ l 4i itAa, <eO ,� Sofl � Il��► C��� ws-� b Number of current residents: Does residence have a garbage grinder? ❑ Yes Ei, o Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes to Laundry system inspected? ❑ Yes o Seasonaluse? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? s ❑ No Last date of occupancy: 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address .Le r G,4-o(,1 Owner Owner's Name f/� . information is H `�! 1V �6 3� 3 a� required for every page. City/Town State Zip Code Date of Inspe tion 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 n No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Ty:;Oof S m: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage QDisposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every C-e4-41tlillt d J}I v��� J? page. City/Town State Zip Code Date 9f Inspeftion D. System Information (cont.) Approximate a of all components, date installed (if known) d source of information: �A 544 Ke a�os C're_-�- �G4e"J Were sewage odors detected when arriving at the site? ❑ Yes E: ' o Building Sewer(locate on site plan): Depth below grade: feet Material of construction: Elcast iron 4 PPVC ❑other(explain): Distance from private water supply well or suction line: feet /0 Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Mater 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: r10 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments g Property Address // " Owner Owner's Namee"'4 information is Name Ile- A4required for every y 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 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 o le Ka vac 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.): PL4!M I N �✓ Ar► -C /h S o o CoHC/rAM . 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 i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments *M ST PIP44 y� Re&1-5 /fklip-1 Property Address Owner Owner's Name information is �v ! A/t n /� required for every /T Vd-!e✓a'� page. City/Town State Zip Code Date o Inspe ion 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): Dime nsions: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Ia--m ¢.. u. _ e. _m" .. —- . - e.cy.tso= -, a,..........s.-. - -'.. .. _ .• . 1 G�„ __ s.+ e .3 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form l-Not for Voluntary Assessments nes Property Address Owner Owner's Name /�/� information is Iley1v` / //� o�6,� 3 a7 required for every page.- City/Town State Zip Code Date of Inspitction D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): A 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.doc•rev.6/16 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 Property Address Owner Owner's Name information is Coe N_1WVt6 required for every page. City/Town State Zip Code Date of Inspectio D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): D off �� � �►'1 �� nc J ;oV" o . S, � !? lac.., 46 • 14.*r 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is � '`d � 4 � required for every h"'wGY /_/, (/�` _ page. City/Town State Zip Code Date of 6specti0fi 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments Property Address / Owner Owner's Name information is Name information I- /✓ Ile required for every f�/'T�✓ page. City/Town State Zip Code Date oAnspectfon D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least er nent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate jhand-sketch y pu water supply enters the building. Check one of the boxes below: in the area below drawing attached separately G le" t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 a -.4 COtY -n �^�' �a 'n of Massac 9C35et$S -- Tits 5 07 ic!M inspection Form - Subsu acc Sey�::�a Disposal System Form -Not for Voluntary Assessments yY 59 Pcin*Of Poncs nve. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerviiie Ma. 02632 09/30/2014 page. Cityrrcum State Zip Code Date of Inspection D. Si stem _.n�' U (cont.) S,c cn Cf Sev.- gs -Disposa' System: Provide a view of the sewage disposal system, including ties to a least wyc �&-rn.anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wrare p jai e :F.a.er sucp!y enters the building. Check one of the boxes below: ,and-SK8tC.. lin the area below C dravdin,- .2i ac�ec separately I �S9 3 3-T.,.,� c �•` to a � 3 'M rza-� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S 9 �014+ Property Address 4e-/ w�to Owner Owner's Name information is required for every A4 page. City/Town State Zip Code Date of II spectio D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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 ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checkef j ith local Board of Health-explain: // ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must de cribe how you established the hi h grOlLed water elevation: �'J O wv� Ql'✓` 4;4 /0 f�✓ �• �405?0 9:r-7 C-� C/ 17'--' TL114 cf* i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 - o Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voll{/unntt)ary Assessments �M I ��� • D� I �1�/ Property Address Owner Owner's Name information is �Q`��Y { A,4 O 4� ✓ required for every page. City(Town State Zip Code Date of specti E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Syst Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn n g p y o page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 MAY-04-2005 08 :56 AM DOWN CAPE ENGINEERING 5e8 362 9880 P. 03 Town of Barnstable Q Regulatory Services = Thomas F. Geiler, Director Public Health Division Thomas McKean, director 200 Main Street,Hyannis,MA 02601 Office: 508-862.4644 Fax: 508-790.6304 Installer& Designer Certificati®n FoM Date:S Sewage Permit# c-4 -9-7 esser's MaplPat cel -�o 0', Designer: Address: Address, On _ �� _ -- was issued a permit to install a '(date) (installer) septic system at 5 1 a u o , based on a design drawn by (address) dated - i X. » G Sr (design ) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordar:ce with State & Local regulations. Plan revision or certified as-built by designer to follow. pA oxems, ARNE h! cy k(Installer's Signature) OJALA CIVIL ,0 No, 30792 - N (Designers ignature) (Affix Dest er's Stamp Here) PLEASE ,$Lj=___TU BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CRZdPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:ReakhMeptioNsigncr Certification Form 3.26-04.doc ' Commonwealth of Massachusetts Title 5 Official Inspection Form SubsurfactAewage Disposal System Form -Not for Voluntary Assessments cs 59 Point Offs Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 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. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, �I use only the tab key to move your 1. Inspector: 4 b q cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Q Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town 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 CMIR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority f.� 4 09/30/2014 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 Fo t: s wage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 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 . Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The`system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. City/Town State Zip Code Date of Inspection B. Certification (coat.) 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 ❑ 17 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 N 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. City/Town State Zip Code Date of Inspection B. Certification (coot.) Yes No z 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. ❑ u 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. ❑ ,1 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L� 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.] ❑ z The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ IN 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) Larne 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 ❑ 11 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Point Of Ponds:Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma 02632 09/30/2014 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 ❑ 7 Were any of the system components pumped out in the previous two weeks? ® Cl Has the system received normal flows in the previous two week period? ❑ 1Z 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? ® C Were all system components, excluding the SAS, located on site? Z ❑ 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? ® Cl 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: ® J� Existing information. For example, a plan at the Board of Health. ® C 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)1 D. System Information Residential Flow Conditions: Number of.bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): >440 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. City/Town State Zip Code Date of Inspection D. System information Description: Number of current residents: 4 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: .� l C201 /g/lv.J5 cyere vSCcA4 Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commerdiaili;ndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of.design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. Cityrrown State Zip Code Date of Inspection D. Syste m. 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 i 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): Lt5,ns3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewacae Disposal System Form - Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Approximate age of all components, date installed (if known) and source of information: 07/01/2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 33"feet Material of construction: ❑ cast iron, ® 40 PVC ❑ other(explain): Distance frorn private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 23" Depth below grade: feet Material of construction: Z concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard 1500 gallon septic tank Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachuse9.ts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. CitylTown. State Zip Code Date of Inspection D. System information (cont.) Septic Tank (cons.) Distance from top of sludge to bottom of outlet tee or baffle 39" Scum thickness Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Field Instruments Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner have the system pumped based on the future use of the home.Regular pumping will extend the life of the leaching. The board of Health has a list of local pumping cc. 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts U Title 5 Offolcial Inspection Form Subsurface sewage Disposal System Form - Not for Voluntary Assessments 59 Point Of Ponds Ave. Property Address Cathy Leighton_ Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. Cityrrown 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 Flo\&,: gallons per day Alarm present: ❑ Yes ❑ No Alarm level Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Point Of fonds Ave. Property Address Cathy Leiahtor Owner Owner's Blame information is required for every Centerviile Ma. 02632 09/30/2014 page. Cityrrown State Zip Code Date of Inspection D. System lin ormation (cunt.) ®is-ribution Box (if present must be opened) (locate on site plan): 0ff Depth of liquid.level above outlet invert 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.): At the time cf the inspection the flow appeared equal and there were no signs of solids carryover or leakage. Pump Charnbrer(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 W Title 5 Official Inspection Form a Subsurface Sewage,Disposal System Form- Not for Voluntary Assessments ye 59 Pain.Of Ponds Ave. Property Address Cathy Leighton Owner Owner's!dame information is required for every Centerville Ma. 02632 09/30/2014 ---- page. City/Town State Zip Code Date of Inspection D. System information (coot.) Type: ❑ leaching pits number: leaching chambers number: Three ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: 17 overflow cesspool number: I! innovative/a!ternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonweaf&h of Massachuseftts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 59 Point Of-Po,:ds Ave. Property Address Cathy Leighton_ Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 _ page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Cornments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (ioCatc 0r i site p!ar): Materials of construction: Dimensions Depth of soi ds Comments (,note contrition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Co �f��e�n e _ �T iMassachusefts Title 5 OfflcW Inspection Fora SubsuE pace Sew-ago L9sposat System Form -Not for Voluntary Assessments y� 59 Point Of Poncs Ave. Property Address Cathy Leighton _ Owner Owner's Na ne information is Ma. 02632 09/30/2014 required for every Centerville J page. Cityfrcwn State Zip Code Date of Inspection D. System ',ntfor afian (cons.) Sketch 0,�SavJagv Oisposa System: Provide a view of the sewage disposal system, including ties to at least;wc cer,nanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pubitc ,rarer supply enters the building. Check one of the boxes below: Iand-SK8tC%i i:,'ire area below C drawing 21t2&ec separately 13 t9 s ___. g-T�.,,r c,�/•t /� aye Al -- d � a3 Pj.:Yf 0? P.. i q✓{ Cor> molrruveal-th of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Point Of Pcn:ss Ave. Property Address Cathy Leighton__ Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. Cityrro-wr,, State Zip Code Date of Inspection D. Systern ;nforinatsc n (cont.) Site E�aVn: Check pope Surface`Water Check cellar F1 Shallow vve!ls Estirnated depth to high round water: 10 plus feet g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 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) L ,`,ccessed USCS database-explain: You must describe how you established the high ground water elevation: I augured a `oie a a lower elevation and shot it with a transit to show five plus feet of seperation from ground water. Before filirip this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 . COM.Mionwea!ih of Massachusetts Title 5 Official Inspection Form Subsurface Sep}gage Disposal System Form - Not for Voluntary Assessments w 59 Point Of Fonds Ave. Property Address Cathy LeiGl.ton Owner Owner's Name information is required for every Centerville Ma. 02632 09/30/2014 page. Cityrrowr.. State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspe.;ticn Summary D (System Failure Criteria Applicable to All Systems) completed System information— Estimated depth to high groundwater E Ske-ch 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 i i0 Of Sc� POW LOT 8 20,143t SQ. FT. i CONC.- "��o Of°S FNDN. rycb�— TF —49.5 �S• JOB# 05-031 FOUNDATION PL 0 T PLAN FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT ONLY PREPARED FOR: LOCATION ; LOT 8 POINT OF PINES AVE. CENTERVILLE, MASS. ROBERT SA WYFR SCALE : 1" = 40' DATE : APRIL 26, 2005 REFERENCE PLAN BK. 325 PC. 33 ASSESS_ MAP 210 PCL fO8-4 1 HEREBY CERTIFY THAT THE STRUCTURE _ f<t SHOWN ON THIS PLAN 1S LOCATED ON THE GROUND AS SHOWN HEREON. r� off. 508-362-4541 fax 508-362-9880 wA�S down cape engineering, inc. CIVIL ENGINEERS LAND SURVEYORS Z ,s 939 main st, yarmcuth, ma 02675 DATE REG. +LAND SURVEYOR 1.9/6"X II 116"MIGROLAM 2'X 10"-Ib"O.G. X 5USFACIA CONTINUOUS 90FFIT VENTING 2 \101 / 0 4/3'X 2'AWNINb 2/2"X 4"TOP PLATES ap WINDOW5 2/2"X 8"HEADERS VINYL 5101" / TYVEK HOUSE WRAP 1/2"0.5.13.SHEATIN6 5/8'PLYWOOD \ 2"X 4"STUDS-16"O.G. 2"X 10"-I6"O.G. 2"X 4"BOTTOM PLATE 5/2"X 12"BEAM / 2"X 6"P.T.SILL SILL SEALER-b' 10"ANCHOR BOLTS-V O.G. ' O I I/2"LALLY-T'b"O.G. o r-= - COMPACTED GRAVEL 8".POURED CONCRETE WALLS 10"X 20"SPREAD FOOTIN& IE PR0P05ED GARAGE - 5EGTION A ROBERT 5A 1 YFR 5r-9 N t1 0 T Y�Ines C?��e� �� �)� 32'-0" - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - -- - - - -- - - - - - - - - 6 -4 ,6 6 -4 6 13 ,, 13/ n -4" 6'-4 ' ' i � X � i o ,I - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --- 10" X 20" 5FREAD FOOTING pet cs "At-0 RVVI- LING HCX/YC i - - - - - - - - - - - - - - - - - - - - - - - - - - - '-._ - - - I '32-0" I I I I _ I I I I I I I � I I I I I I i -- -------------------- ----— - --------------------------- --------------------------L------------------------ -- I- - - - I I 0 I ii o m � I I ii I I I I — 6'-6" 6'-4" 6'-4" 6 -4 6 -6 4 /5' X 5' WINDOYN5 I I i S 9 Pdt � ' �lo6 f i ROOF LINE ABOVE - - - - - - - - - - I I I I I i I I i I I I I I I I I I a I I i I I I I I I I I I - - - - - - - - - - - - � - -_ _ — ; - - — — — — — — — — — — — I _ I I ' I i I ' I i I I I I I - - — — — — — — — — — — — — — — — — — — — — — — — — — I - - - — — — - - - - - - - - - - - - - - - 6'-41. 6'-4" 6'-6" I GC C, e ® i Pa; n-e s l TOWN OF BARNSTABLE LCCATI..0 /� 'F' R:�•s ✓4 SEWAGE # 20P-1-.27, VILLAGE ASSESSOR'S MAP & LOT !�/0' 42 'INSTALLER'S NAME&PHONE NO. /119 SEPTIC TANK CAPACITY LEACHING FACILITY:'(type) 3` �oO,? ��a»+6��s (size) 33s�Xf��3Xa NO.OF BEDROOMS <B�UILDER)ROWNEI�_ 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 y 13 %isleqt ;?o ��/ ` •9 4_ 4 - No. z �, �t Fee i'� Entered in computer: THE C MMONWEALTH OF MASSACH6SETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for -Migool bpftem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. `1 ng Q�^ L n���QS Owner's Name,Address and Tel.No. Assessor'sMap/Parcel �! vO9)) 7 J�' Q e 3 Installer's Name,Address,and T ..No. Designer's Name,Address and Tel.No. ` v'v' ffic Down 3C a - 115Y/ Type of Building: Dwelling No.of Bedrooms_� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 9qo gallons per day. Calculated daily flow O gallons. Plan Date llhaW Number of sheets Revision Date Title �` o OIL, uI.hg- Size of Septic Tank_15-Od- Type of S.A.S. Z eAfl+ Description of Soil I a dAr, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue th' oard 9f Health. Signed Date�"�"®� Application Approved by 4v•, Date 7 1 2- Application Disapproved for the following reasons Permit No. 9002- 2- Date Issued No. ��)� ,, � @r ,,: J,, a Fee �M 4,✓�S� �1P �1 � THE COMMONWEALTH OF MASSACHUSETTS Entered n computer: r,. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2ppYication for Oilpaol bpztem Con.5truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( .)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ln� ^ �'�QS Owner's Name,Address and Tel.No. Assessor's Map/parcel j�t 1,/1l1 DT- !'ULI �I OA e f Installer's Name,Address,and Tel.No.' Designer's Name,Address and Tel.No. ffo TY/ Type of Building: Dwelling No.of Bedrooms L/ L sq.ft. Garbage Grinder( ) Other Type of Building 1No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow Ll gallons. Plan Date, 1 Number of sheets Revision Date�,A Title.'; �t� N,: m ,, u /o� Size of Septic Tank ` S' y Type of S.A.S. L Pack Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspecte Agreement: The undersigned:gr�ee�stonsure the construction and maintenance of the afore g described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue th' oar d o Health. Signed Date'f-,?`O 5 Application Approved by 4V- Date 7 / a -;x Application Disapproved for the following reasons Permit No. d'2 U 0,2- ?2- Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed()C)Repaired( )Upgraded( ) Abandoned( )by at has been construct d ' accordance with the provi ions of Title and the to Disposal System Construction Permit No. dated Installer ` _C.'. J� �� Designer ^%�,..J n CQ 11 K2 The issuance of this permit shall not be construed as a guarantee thatttthe sy�s°emsV1_:W1_j un,tion as designed. Date 7/,�/S Inspector-- _..L . ----' ---------------------------------------- No. .[W w Fee 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS i� ogacrpgtetottgtrutorYerrnit. }. Permission is hereby granted to Construct�X)Repair( )Upgrade( )Abandon( ) System located at o oCQA elf, 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 thi t. // c Date: n 7" � Approved by ermi /10. ALL:== i t No Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Zlpprication for aiopooal *p!gtem Con!5truction Permit Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. o TB Owner's Name,Address and Tel.No. ®O/-4 T of /�i„rE S ,q i,� C 144 2t E S C/4.- iE s Assessor's Map/Parcel Ow /O (P(v lv p f 0,,.A,-S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 3 C.2-_ Dwelling No.of Bedrooms_ Lot Size -20l 0 7J sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow _ !Vlyv gallons per day. Calculated daily flow gallons. Plan Date Y l Number of sheets / Revision Date i_/� Title /7iF_ 46 hge=g6 —� Size of Septic Tank Type of S.A.S. AgW cy ,9is,/3 S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued -- --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( /)Repaired ( )Upgraded( ) Abandoned( )by at ,. � has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Zj� dated /',----;7 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Miquar *pgtem Construction Permit Permission is hereby granted to Construct( ai ( ) grade( )A ndon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by lft No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Application for.Digpo�al *p.5tem tonttruction Permit r Application for a Permit to Construct(>O Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. „j o rJ Owner's Name,Address and Tel.No. i49.15 v e ( W.I.14-E 5 C .-4,",E S Assessor's Map/Parcel { oP O..4 $ Installer's Name,Address,and T�jel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size ©Z I sq.ft. Garbag Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures y -"'"- a----Design Flow y gallons per day. Calculated daily flow gallons. Plan Date i/ /lAfOr .' Number of sheets / Revision Date Title -- hJT , Size of Septic Tank 4;�2 - Type of S.A.S. 4,F,4c�l s,/-SZF,� Description of Soils I Nature of Repairs or Alterations(Answer when applicable) DaIE,last'inspected: %:P -� Agreement: g s . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and'not to place the system in operation until a Certifi- r cAe of Compliance has been issue t s Board of Health. Signed y : ' F. y'1 Date'i= ` ApplicationtApproved by # Date Application Disapproved for the following reasons Permit No. ' c_ Date Issued r THE COMMONWEALTH OF MASSACHUSETTS t BARNSTABLE, MASSACHUSETTS , Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( /')Repaired( )Upgraded( ) Abandoned( )by 3 fat has been constructed in accordance with the provisions:of Title 5..a Nic f r Disposal System Construction Permit No. dated XOInstaller t _ Designeri 'f r � . The issuance of this shall not be construed as a guarantee'that the s ste . `"u ction as designed. �. N. _,'Date Inspector: t -------------------=----------- No a Fee ' .: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1 ig o.ga[ *pgtetn Con.5truction Permit Permission is hereby granted to Co truct( p ' ( ) grade( ~ )A andon( ) - 2�. System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply.with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by ht - TOWN OF BAFNST. BLE ' •, LOCATION ��! /y °f SEWAGE# o2OAa"o7 72 VILLAGE Gp-i-le r Ile ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Wti LEACHING FACILITY:*ype)\3- Soa, --f (size) 3 3,dal IR.-3X a NO. OF BEDROOMS PERMTTDATE: �'/"©� 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 ii • V d .'° pv.-V oe MAY-04-2005 08 :56 AM DOWN CAPE ENGINEERING 508 362 9880 P. 03 Town ®f Barnstable Regulatory Services _ $ Thomas F. Geiler, (Director Public Health Division Thomas McKean, Director 200 Maly Street,Hyannis,MA 02601 Office: 508-862.4644 Fax: 509-790.6304 Designer gerteflcation Fg!M Date: Sewage Permit# i }o'�-`l essor's Map1Parcel,W, s�1 o e0c)L/ Designer: k&A w1ristaller: Address: �`� , Address. On /V was issued a permit to install a � ( ) (installer) septic systern at T a as of , based on a design drawn by (address) p datedg'- (design ) k I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local regulations. Plan revision or certified as-built by designer to follow. N OF 44,Y. ARNE H y (Installer's Signature) OJVIL .� CIVIL No. 30792 - N (Designers ignature) Affix esi er's Stamp Here) PLEASE RETJM-.__TO BARNSTABLE PUBLIC. HEALTH [VISION. CERTIRICATE OR QMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORAd ANI3 AS-BUILT CARD ARE RECEIVED BY THE BARNfaABLE PU$LIC HEALTH DIVISION, THANK YOU. Q:Reakh/Septic/Desiper Certification Form 3.26-04.doc t 1 l l ----- I y gun 3,' „PMIJ(O�Uenn5 can 'a LI'IX:Ll1 x►a '' Coin(-(Z TEC Yad 5 ZL ,a ep 8 x -ra Poo reJ Con(rel — `1 Q C 7� on I&' Xi " Concre4e F004'sny ,, 1(9 �-oo1 � GNP 66- C ovo,( 0 �Do RC p n � o0 :a.w Ile c i F ('NOa. �ac�3a c I f� T—7' —T! D E C I< - I Lo FRN\l Ly .VAu L_—TEO ,�— N cO a< i 0 { n UO i —-- f �l LI o I co AT _ ' 4 C M MASr'L L.SV1NG DzNrNG IN � I o - t , � N gyp- ..�_- 9' CoVERD POKCN G ARAGL I 35'- o L o T # i r7 10 ' --- -- —— -- ------------ — i i 1 '` i3CDRoorn QEui�ooM j I I ----3 cv—o -------- f Ga� '�_�_�a�s_Cdb-� -Vtni 3 b yr. --- t CDIP1y ' o , ' J L Pl 2 LO — 1 - Ll o �d A►I w�11 S #�9 S Vi �1 s► ��.ng oS�3 3 3r�1, A v"e00 R 2s (�G kis L PT Z (, - t cp"-d �� -� x.U ,T, - 3-��. 0.�. SQc, ohw,r-A-,frProo �y p __-- _..__------ ----------_______.__..__._._._.__�_..�.-- S "T.�9. C SS S4P 6 ct, �''y lie, 44,; 1,1';4 Al, Ali I M0061 0 -AT 1 47.5 SYSTE PROFILE 'pES.T-' H0LE ,'L0GS .,,.,.,, F,, L �ACCESS COVER T4 W1 HIN 6 OF FIN, GRADE, (NOT, TO SCALE) D T ENGINEER: M, FAPIA, ;$E, GHT) TO WITHIN 'OF"FIN. GRADE ;. E. BARRY R OVER SYSTEM (BOH)' 2% SLOPE REOUI ED. �44.0' WITNESS: DATE: EASTONE PUN PIPF 2, DOUBLE WAS14d) 0 10/22/99 LEVEL 44. L(=S FOR FIRST 2 < 5- MIN/INCH OPOSED PERC.. RATE, �PR 3', MAX, CALLON.SEPTIC '9574 4 2.8 3` -SOILS 4 3" 4�4.�05'�,,-- CLASS TANk�(H-x 10 �GAS 43.76' BAFFLE 43,93' E3 r 0 0 c:1 4' AR)UND 4 .0'(LL% SLOPE) -CROSHED STONE OR MECHANICAL 'GREA MARS:_� 90�6 4 0;01 7 m ED m F-1 177 0 m, 0 m LOT 9 COMPACTION, (15.221 [2]) ELL -3 F-1 m m m m 0 4" ED 0 .' 43,7' DEPTH.OF FLOW�- : 47.0' SLOPE) TEE SIZES: 3/4" TO 1, 1/2' DOUBLE.-WASHEID :STONE INLET DEPTH �10 O,1A O/A 141" �'MAP 'NO 'SCALE 6 6'0 LOCATION OUTLET DLPTH, - B Ls LS 12" SEPTIC TANK D' BOX 14' FOUNDATION— 10' LEACHING -PARCEL- .108 �4 FACILITY 1 OYR 4/6' 24" - '1 OY R ''4/6 A SSIESSORS MAP 210 5' 24" 41,7' 4 5.0'.8.3' , NG DI T D-1 ZONI ., YARD SETBA ks: ' ' TRONT C C �: ,SIDE 31.7 MED/COS REAR HIGH WATER LAKE EL. 35.0' MED/COS PLAN REF., 2 2.5Y 6/4 .'2.5Y,6/4' FLOOD Z( �NE­ C AP DISTRICT: , , 31.7' 168"' NOTES:­ NO 'WATER ENCOUNTERED ' BENCHMARK �LA! E PiT I C D F 1 G N: BASM 0 U y< ELEV 45-02' (GARBAGE DISPOSER IS DAIUM <E D NO I' ALLOWED .'AVAILABLE 4 440 GPD_ ESIGN FLOW, --- BEDROOMS ( 110 GPD) 2� MUNICIPAL, WATER IS , w GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO 6 C PER , FOOT 4. DESIGN LOADING F Ri�A R -SEPTIC TANK: 440 GPD 880 LL." . ECAST.� 1UNITS ,to- I 'SE �AAS06 H­'G 5. PIPE JOINTSJO' I�BE MADE WATERTIGHT, - LLON SEPTIC ,TANK 1500 USE A, A CTIO - D WASS ' 6,� CONSTRU . N &AILS To BE, IN 'ACCORDANCE WITH LEACHI 3 ENVIRONMENTAL CODE TITLE'V. 2(33.5 + 12-83),�-2 (.74) 137 7 THIS , - PROPOSED:WORK '.ONLY-,,AND-NOT TO,ZE" SIDES: — �PLAN IS FOR USED FOP, LOT LINE STAKING�11' 3 3.5 12.83 (.74) 318) P 'FOR�,SCPTIC .�SYSTEM TO SCH 40-4" BOTTOM; 8. PIPE ' 455' 615 , .9. COMPONENTS NOT ,10 ',BE', BACkF I L LED OR C0NCE:AL.E:D W I T40LIT TOTAL: S.F. GPD -13Y, 13OARD OF. HEALTW:AND SSION OBTAINED USE (1) 500 GAL, LEACHING CHAM13ERS W!TH 4 INSPECTION D OF �HEALTH, (-')F STONE ALL AROUND > 10.,�CONTRACTOR, SHAL.J_-� BE'.7 RESPONSI�LE FOR,�VERIFYING JHF-1 �.LOCATION ' OF ,ALL ,, NDERGROUND' ��,OVERHEAIJ UTILI TIES '.PRIIDI�' , F �WORK, si LEGEND" -AND SEVA TE AN P TION OF -AV N S::� LOT ,' 8 i,'P 0 T 100x0i EXISTING SPOT ELEVATION ' IN THEJOWN 'OFf- 100 N "BAR ' STA' e _( CENTERVI'LL�� 100 — EXISTING CONTOUR PREPARED FOR RONFq: LOT 8 0 2D 20,021 SF ' 60 , 20 'Feet PIOARD OF JiEAt:TH 6 2 ' ' DATE MA E N6'�tM iR"f APPROVED 44 Off -362-4541 folt 508 362-9880 14 kfj AF 'down engin eerink, H -w,4 via-, C^ 41�3 0t7 OR NI) F&tyo S R�Arfti6iith-., 02676 � rnain