Loading...
HomeMy WebLinkAbout0026 SYLVIA LANE - Health 26 SYLVIA LANE, CENTERVILLE A = 189 078 I UPC 10259 No.H_ 1_ , NAYTINOS.UN I Commonwealth of Massachusetts M fio ' 10 -07 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville V, Ma 02632 4-27-15 page. Cityrrown 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your C! cursor-do not Brett Hickey use the return Name of Inspector Y Excavation Company Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 Citylrown State Zip Code (508)477-0653 S113747 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 4-27-15 Insp or'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 e c n itions of use at that time.This inspection does not address how the system will perfor in t e utur - nde the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. CityrTown 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): i 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name ' information is required for every Centerville Ma 02632 4-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection 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 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013-74,000gallons 2014-64,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form x o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is Centerville Ma 02632 4-27-15 required for every 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: pump truck driver Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank size Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'8" Depth below grade: 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.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 1 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: 1000 gallon Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts L . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. Citylrown 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 30" Scum thickness 8 Distance from top of scum to top of outlet tee or baffle 6" 8" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,baffles present with no sign of back- up.Liquid level equal with outlet invert. Tank was pumped for maintenance after inspection. 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 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 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 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 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working order with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 16 infiltrators 11 x25 ❑ 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 time of inspection leaching appears to be in working order with no sign of hydraulic failure. Infiltrators were dry with no high staining 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 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `< 26 Sylvia Lane Property Address Marc Israel Owner:. Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. Cityrrown 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: Z .hand-sketch in the area below ❑ drawing attached separately AY. . nk ` � ; ��t� rY 40 :t0 r is 3.3+ Fi - l M t5ins•3/13 Title 5 Official,nspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 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: No Gw 120" 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: Feb-21-2013 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: plan on file 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 0119 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Sylvia Lane Property Address Marc Israel Owner Owner's Name information is required for every Centerville Ma 02632 4-27-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 13 J as I Town of Barnstable P 3 g7c cF IKE tqk Department of Regulatory Services BMWSPABLE, : Public Health Division Date / 3/ 1Z MAW. t63q. `0�A 200 Main Street,Hyannis MA 02601 Date Scheduled J/ Time 1 Fee Pd. 0/0 0 Soil Suitability Assessment for Sea e Disposal Performed By: Witnessed By: 01 LOCATION &'GENERAL INFORMATION Location Address Owner's Name 2-6 �S'yl v l L , 4 e --Ls,0-a-e, C n�-'err/ v-�Je Address Assessor's Map/Parcel: �Q 9//a Engineer's Name V L'J✓-, oke!? NEW CONSTRUCTION REPAIR X Telephone 3 44) 7 Land Use W Slopes(%) G - Surface Stones No h oL Distances from: Open Water Body Z�/G ft Possible Wet Area �ZGG ft Drinking Water Well Z00 ft H Drainage Way Zoo ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Al /GG,06 ' ® /0 N ��•C t -r g =- �s CO � 0 , S OY G� T Parent material(geologic) \-I f e Depth to Bedrock 00 Depth to Groundwater: Standing Water in Hole: +•A /A Weeping from Pit Face /✓/,4 P. Estimated Seasonal High Groundwater —All A DETERMINATION FOR SEASONAL HIGH.WATEI TABLE Method Used: Depth Obsc.,,cd standing in obs:'hole:- in—Depth to soil mottles" Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date.Z/ U Time WOO Observation ((// ►s Hole# I Time at 9" i(D Depth of Pere ,1U ,4 Time at fU•Z� Start Pre-soak Time @ 1 Ue :� ' Time(9"-6") 3,10 Y)j n ., � End Pre-ak e 't✓" Rate Min/Inch' 4 Site SuitabilityAs§essment: Site Passed, Site Failed: Additional Testing Needed(YIN) V > " Original (Public Health Division ;�,• Observation Hole Data To Be Completed on Back----------- ***If percolation'fe'.sttis `o`be`conduct d within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. . - ♦ iT..� ♦.'• C• _ �i It A'4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency_%Graven SL IovRI/z k-z0 L 5 IGYR 20-7 Z C, 11ki 5 IoYR 14 72-�ZG DEEP OBSERVATION HOLE LOG , g"Hole#= Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel L IoYR /Z �°-2 q t L 2v-,72- c , 145 10 6tAl ��-IZo cz �I/�S IoyR 6/3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency_%Gravel)_ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No Yes !� Within 500 year boundary No V Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the r' area proposed for the soil absorption system? V'C 5 If not,what is the depth of naturally occurring pervious material? k " Certification I certify that on 5/1 / Z (date)I have passed the soil evaluator examination approved by the , Department of Environmental Protection and that the above analysis was performed by me consistent with x the required training,expertise and experience described in 310 CMR 15.017. 4 Signature Date Z/20/� d ' Q:\SEPTIC\PERCFORM.DOC TOWN OF BARNSTABLE , LOCATION a'G Su I u;o— LIJ SEWAGE# 07013 - 0 G G VILLAGE Cr_nacr u i 11C_ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. EXCaya—)t O� SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) yn.r. -Ira-jo1'S (IG� (size) j 1 x 2 S NO. OF BEDROOMS OWNER_Marc- ZSRAFL PERMIT DATE: 2-2 8= 13 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 1 FURNISHED BY Al- aO.q y A7- Bz- I A3- 36o 6 3 ,63— 17, rJ O A4- ,By - 9 I: q � rcn.4 No.2,o 1-3 —0 G(o Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -YOWWOF BARNSTABLE, MASSACHUSETTS Yes ZippYiration for Misposal 6pstem construction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No. y 1/I(� {l� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel J A 1 (g `-3(a — 12 install 's me,Address,and Tel.No. / Designer's Name,Address,and Tel.No. �"A U WVO hon 66Y-/4- �-�-3 DqYqn EM6 -6c)�/3&2-4fq1 Type of Building: ` Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.require ) O gpd Design flow provided gpd Plan Date -21 W `1 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.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 Certificate of Compliance has been issued by this Boar alth. �f Signed Date D� 27 113 Application Approved by Dated Zo rs Application Disapproved by Date for the following reasons Permit No. Za(3—06 6 Date Issued 66Fee No. THE F MASSACHUSETTS Entered ncomputer: COMM(ONWEALTH I, PUBLIC HEALTH DIVISION -"TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLatlon for -Mispoeial *pBtrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 26 5ylV Iq Lo n C Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Mor —f5 ro e I .50g - 4,Lj Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. E)4cnv LfIOn 6oy-tii7-t&b3 Dpyvn EM6 5o�-362- 4j�41 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 30 gpd Design flow provided gpd Plan Date 2,Z I (� _Number of sheets ( Revision Date i` Title Size of Septic Tank Type of S.A.S. j Description of Soil I Nature of Repairs or Alterations(Answer when applicable) y 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 Certificate of Compliance has been issued by this Board.o alth. Signed Date A 27 Application Approved by DateZ Z9�� i__ Application Disapproved by Date for the following reasons Permit No.Za 1 Date Issued ! - -- ..--------- - --- - - - --, - 7 _- - - _ . . . ------ ------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( v) Upgraded( ) Abandoned( )by } at e n 2 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer ghQ r-i ��— 11 U Designer () r/'t�nP r(1/1 i e(71_ #bedrooms Approved design flow I �� gpd 'j The issuance of this pe it sha not be construed as a guarantee that the systr ncf� de igned. j Date Inspecto't —No. go I — � Fee ff� 1 aJ . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem ConstrUttlon Permit Permission is hereby granted to Construct( ) Repair( 4 Upgrade( ) Abandon( ) System located at Z C) 6 N I f w.T!-12 1I III and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 7 I Z£3 I Z o Approved by — FROM :down cape engineering inc FAX NO. :150e362seeo Mar. 13 2013 11:57AM P1 /3 0 r • T'�1'•;ti�7i E���Jf ._�':31i'k.P.��il: 'L'�l.�,`. '�-Ei4�tl_L•4p�r}�:\ '�:.�'.:yyT�F.l"�F.(tl�h°•,pT i_::a4'•1��. r. 'a;♦n-E- �1, n�r�s. �e..� i"1!REa11!G: ER.rlb,�ilt[iA '.r0[eIl{iP�Y ;rid?.:; T—hcjLss PAPJFa-can,nAua+e�.�m E • �'•tbCU��;:iLrtll�sdR'Q:C;I--��[.!["9rillLuPJ.A.^;11��. �d�✓fsQ.1 ff c.Lc:r-: `i0F•362-�61-1 i'N70 �02 '790-6104 �„0.71�1Cdt���A•C4. 2P�se�i_E��$nfi!�s�.lfn:um II+'rtua->m Date: 3 1 13 C%rage. ZA1.3 � 04 Qom}�1 rL@.24 lusPll_a r: J6 I / WLi:,1:.i`_i'CLCA fa pe.Ttl it'to im-aP_ll.a (,lsrl:ej (II1St�llC:I') sp Lil:, ste!n aL /Ilf fit- L—Ant �Lt;r;,l Call.a aesicrr d,a-non b_, p sY l.. 5 (�l�lr_1rC:ss) �. .��� fit"•• G P�., Pis ���tl,�� . _ _ I certify that the wpiiu vs1e111. Mfej.•e ccd above was austal.led. suh.,�Lan:taally acnordin,g Lv t.)_Le design, -otich ma;r izr:lrtrlr. •cu-LLto.r. ATlitmved c.hange.S saza;.0. as keral. re-ICIE;,41o:u of tile• i ianih111rm bo.s.nli /ur u:T-41C la.vk: _ f. certi�' tbat the' s'.ptir, system. -rei'eren.Ce.d LibOV(.', N1g5 1C1.-lalled with CI'l nigeti rve�atel• [li'm 10' latel-Ld rc,,loeariou,Ate Sk"," OT MYvulti("a reloc_�1don Ulu .Inv c..QfY7.1 on.E.' it c11.'In septic n le,.In) but M.auxide ic.l: 'wifLi :tare & T.ncal RGgu.lation.s- Plan re-visictx q,r cen�l.i i.ell as -ills-It by to foll,nw_ nF-A 17J !.A ^ jns(a11eT's 81 Tnaluri,) CIVIL r, No.413502 1 •�(i.�Ccr. C� t4' k®' �SS/ONAL Tie::;'gLax'5 �t;ijir T-T-ru) A �8 RTTJ K t a� ,^►i�C f+a:3:cl�ii l�,_, _7jd T[ 11EA.Q,111 € 1 V l'31L9rq...... �:i11vAc'6,➢�A[[+a1:A+ L, id+�`e' Y&� Y33iJ➢1JD 'Ll!`jR'9l, .r34Z'k']fT 'Ftll.la KNR A!°lL9 d'4RD R: ]�,d_4+,firF`)<2 b3if_9'IYiC)<?�A.A,1'4.C'v`l7'./l�lb1G�'9.i�P.�9.•'tnl";.fl,l',`A'�-9 T�lf`�'TroE�DI`]._'1_���33C�f0.AUJ, r. rr .,.,.rig_.:..�r•..,.,....,.-n.,rG- •,r�r.n Lnnn 41)fJlri.rl„r . ','TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAG s ASSESSOR'S MAP & LOT �n��c-forS L 1 " SoB�y�K- ga.Co NAME&PHONE NO. � SEPTIC TANK CAPACITY /'000 LEACHING FACILITY: (type) / r/i)' (size) U®® NO. OF BEDROO k BUII.DER OWNER O PERMITDA COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of,leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by l y g ib L6 `o SIT 9 da COMMONWEALTH OF 1VLASS ACHUSETTS ExECUTIVE OFFICE OF EN-VZRONMENT.AL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t RA Kr-Lrl - TITLE 5 OFFICIAL INSPECTION.FORM -NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. Al IVA.A;,�-�� 11114, Owner's Name: c ' Owner's Address: �E� !a� � r Date of Inspection: T Name of Inspector: (please print) 9f d�> l, Jul Company Name: �es4nlc OARNSTABLE Mailing Address: i� TO OWN OF TH KEPT' i Telephone Number: ;csq - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete.as of the time of the inspection.The inspection.was performed based on nay . training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEB approved system inspector, pursuantZpasses ection 15.3.40 of Title 5(310 CMR.15.000). The system: Conditionally Passes eeds Further Evaluation by the Local Approving Authority . . Fails ; Inspector's Signature: r Date: fa � f.The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heaill or- DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of I0,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent'to the system owner and copies sent to the buyer, if applicable, and the approving _ authority. Notes and Comments *" "*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 inspection Form 6/1-5/2000 page I Paoe 2'of I 1 t r i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A` CERTIFICATION'(continued) 'Property Address: C;?& 5J lrtrh, 1 Owner:. ° Date of Inspection: >inspection Summary: Check A,B,C,D or E/ALWAVIS complete all of.SectionD A.lystem Passes: i i found an information which indicates That an of the failure criteria described in 310 CMR I have no fo n y y 15303 or in 310 CMR 15.304 exist.Any failure criteria nbt evaluated are indicated below. i Comments: B. 'System Conditionally Passes: i One-or more system components as described in t I e"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. i The septic tank is metal and over 20 years old' or.1he 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 Ix tank is replaced with a complying septic tank asapproved by the Board of.H.ealth. *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. i ND explain: Observation ofsewage backup or break out or high static water level in the distribution'box due to broken or obstructed pipe(s)or due to a broken; settled or uneven distribution:box. System will'-pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is)ev eled or.replaced i ND explain: • i , The system required pumping more than'4 times alyear due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):. i broken pipe(s) are replaced obstruction.is removed ND explain: j 2 i Page 3 of I'] OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: 2 s`7/lljF< Owner:J& Date of Inspection:. ugh/ & 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,wiii protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water — Cesspool or priory is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is,functioning in a,manner that protects the,public health,safety and environment: _ The system has a.septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply- - The system has a septic tank and SAS and the SAS is within 50 feet of a private.water supply well. _ .The system.has a septic tank and SAS and the SAS'is less than 100.feet but 50 feet or more from a private water supply well".Method used to determine distance "This.system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria,are,triaaered.A;copy.,of.the analysis must be attached to this form. - 3. Other: 3 Paae 4 of 1] 1. OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ��_},i/ ;1' Owners 1 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or.clogged SAS or cesspool _✓ Discharge or pond.ing 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 titan 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS, cesspool or privy Is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50:feet.of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but,greater than 50 feet from a private water supply well"wiih no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the.presence of ammonia nitrogen and nitrate:nitrogen is equal to or less than 5.ppm, provided that no other failure criteria are tri;'eyed. A copy of the analysis must be attached to this form.] A/0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of 'Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large:systern the system must serve a.facility with a'desivn flow of 10,000 gpd to.15,000 gpd,You must:indicate either"yes"or"no"to each of the following: (The following criteria applyto large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to.a surface drinking water supply —..the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area,—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the,-large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`F.ORM PART D CHECKLIST Property Address:; Owner r, Date of Inspection: a ,' _ n r Check if the following have been done. You must indicate"yes" or."-no" as to each of the following: Yes No L7.— Pumping.information.was provided by the owner, occupant, or.Board of Health. /Were.any of the.systein components pumped out in the'previous two•weeksb? I-las the systeni 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 ? t/ 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: Yes no Existing information. For example, a plan at die Board of Health. _ Determined in the field(if any, of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page-6 of I] - OFFICIALINSPECTION�FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: • tl) Owner Date of Inspection: . (� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(:design):3 . Number of.bedrooms(actual):.-- DESIGN flow based on 310 CMR 15.203 (for example: 11:0 gpd x# of bedrooms): Number of current residents: Does'residence.'have a,garbage grinder(yes,or no): Is laundry on a separate sewage system (yes or no): ;[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):. Water meter readings, if available (last 2 years usage(gpd)): Sump pump(yes or no):�?C Last date of occupancy: &t COMMERCIXUINDUSTRIAL ' Type of establishment: Design flow(based on 310 CMR.15,203): gpd Basis of design flow('seats%persons/sgft,etc.): . Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title-5 system*(yes or no) Water meter readings; if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION. Pumping Records Source.of information:, &c, Was system.pumped as part of the inspection.(y s or no): [� If yes, volume pumped: «allons--'How was quantity pumped cletermined?. Reason forpumping: . y TYPE OF SYSTEM _ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool _:Privy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP,approval _Other(describe): A oxen to o all of irts date.installed if knownZ. rmation. and source o PF co, ` P y ' Wae sewage odors detected when arriving at the site(yes or no):ILU i Paae 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C \ SYSTEM INFORMATION(continued) Property Address: Owner: ' c Date of Inspection: ,z " BUILDING SEWER(locate on site plan) rJ� Depth below grade: Materials of construction:_cast iron _40 PVC other(explain):, Distance from private water supply well or suction line: Comments (on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK. locate on site plan)- Depth P ) Depth below grade: Material of construction:_✓concrete_metal_fiberglass polyethylene —other(explain) ` If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):-(attach a.copy of certificate) > Dimensions: X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ) Scum thickness: ����5�` �1 Distance from top of scum to top of outlet tee or baffle: Distance from bottomof scum to bottom),of outlet tee or baffle' How were dimensions determined: J';r-7 Comments(on pumping recommendation ,inlet and outlet tee or baffle condition, structural integrity, liquid levels . as,o ated to outlet invert, evidence of leakage, etc.): ' , GREASE TRAPV, (locate on site plan)/ Depth below grade:_ Material of construction: _concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Doc, Owner: Date of Inspection: &.J) , TIGHT or HOLDING TANK:t (tank must be pumped at time of inspection)(locate on siteDian) P P P )( Depth below grader Material of construction: concrete metal fiberglass Polyethylene other(explain): Dimensions: ` Capacity: gallons Desi-n Flow: gallons/day Alarm present:(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float.switches, etc.): DISTRIBUTION Box, if present must be opened)()ocate on site plan) Depth of liquid level above outlet invert: U�> Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of le 'age into gut of box;et ): � ' n � PUMP CHAMBER:_140cate on'site plan) Pumps in working order:( yes or no): Alarms in working order(yes or no):. -Comments (note condition of pump chamber' condition of pumps and appurtenances,etc.): M Page 9 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):Z- oocate.on site plan,excavation not required) If SAS not located explain why: Type :/-"leaching.pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number; length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, c 'I 2�-4o/_ ell N �, _ A�i• ,. 'tom Ci CESSPOOLS:A16) (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 laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of Groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of 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.): 9 Page 10 of i l i . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P�RT C SYSTEM INFO2MATION(continued) Property dress: P ert Ad Owner Date of Inspection: j 02`" SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includiri"ties to at least two permanent reference landmarks or benchmarks.Locate all,wells within 100 feet. Locate where public water supply enters the building. • i 71 f �- j '1 10 IPage 11 of y 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Property Address: r> AIA Owner: -�16fL Date or inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to around water-ate feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: _1Checked with local excavators, installers-(attach documentation) V Accessed USGS database explain: You must describe how you established the high ground water elevation: !`t/wy e,l°' �L /'/Pll4�lr`lJ� SL1/ J�!L�' 9� 1�/ t�t✓� r doses ✓�fF.^F/Dr'G'�'C61.'`�� Il Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTA T ION Site Location:-- Z� �/ l e!/ �Ile— Lot No.. c Owner: L�� !` CTt?�:/G? / F_;; �iL�lr' Address: �tT 5��� rya✓��, Contractor: dry _ C-l1s�i,r Address: � t�✓ fSi°' Notes: ST_C,D 1 Measure depth to water table to nearest 1 10 t+L. ........................,....................................................... .Date rz�!r month/day/year STEP 2 Using Water-Level Range Zone. and Index Well Map locate site and determine: O'Appropriate index well.................................................... ................. 10 O Water-level range zone ................................................... ._J STEP 3 Using monthly report "Current Water Resources Conditions" i determine current depth to , water level for index well ........................... //G l Z month/year STEP 4 Using Table of Water level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 23) determine water-level adjustment ............................. STEP o Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) Figure, 13.-199Dro`dUCibi9 COMputation form. 15 n i TOWN OF BARNSTABLE LOCATION Lc., -Q_ SEWAGE # VILLAGE ASSESSOR'S MAP & LOT/� INSTALLER'S NAME & PHONE NO.g::4 SEPTIC TANK CAPACITY I ©UU LEACHING FACILITY:(type) P17- (size) 7 fLEO NO. OF BEDROOMS PRIVATE WELL OR iMj C WAT BUILDER OR OWNER �r�-yc DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t , J i ` i De. cs � �odasl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH APMOVED TOWN OF BARNSTABLE �Q�D-= Apphratiou for Diripoonl Workri Cnottotr�tr toy '. �..'. Application is hereby made for a Permit to Construct ( ) or Repair (L,,<an Individual Sewage Disposal System at: - ............. ^-� - Locmi n- \ddress or Lot No. !1..... ....... . � 4..S�•-••--••--•--•-•-•--•- .+1 a G�C .... Owner . r� � Address A ,� 'I __._.4C9_ ---................... . �. ... ._...._._......._.._ Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...3____________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow........ ...................... per person per day. Total daily flow....7.3<::)........................gallons. WSeptic Tank L-Liquid capacityS.GOV-gallons Length------T------ Width....5S_.___. Diameter... ............ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. r Seepage Pit No......../............ Diameter...../i?.._...__: Depth below inlet..... ............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________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........................ a _____________•--------------.._-___._._••-...----•..__.••--••-••••._._•-•••-•--•--•---•..._....--•••............................... -:... --.... ____.... •...... 0 Description of Soil........................................................................................................................................................................ x w ---------------------------------------------------------- ................................--••--•-- .................................................... Nature of Repairs or Alterations—Answ� when applicable.....: '(�` <----lOZ1?7_�-�a.�_'�u --- ....6 b�..._..1 �/J�� �� G`- ......................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o health. 1, Signed --- :....E7..'.--... .... .. ........ �l e Application Approved _-- : ............ ..../ ; Application Disapproved for the following reasons: ..................................... . ............................................................................................ ....... ....................................................................... . ................ ................... . ..................................------........... ........... Permit No. ��..... J��-./--------------------- - Issued ...... ...:.n�. ................. Dace ------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#iftratic of Grapliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ---)"-" by ...........................................( 4 ._1fLP.. ..C-sew .... ........._..........._... ... - `� Insr.Jlcr at . -1 .......��. �.v1.S'y-....L: •-4_,............................................ . ........_... ......... ..................................... ...... has been installed in accordance with the provisions of TITLE 5 oJ,The State Environmental Code as.described in the application for Disposal Works Construction Permit No. _..._� _.._"- dated ,�.. '��lf L.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. ......................_ :!1... � .-:- -------.. Inspector ... t/ �L/ - { ....... ,�, t e ` p ' - - -- --._--- _-------�_,_— ��. �-,1-_._.,-----•-------------------- -- __ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. 2. TOWN OF BARNSTABLE FEE. , . _..... Permission`is hereby granted •=---- •----�---•-�-------------------•---•-...._._..-----•. ,.... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo. ( ...................... '«z -......................................................................... Street i as shown on the application for Disposal Works Construction Permit_Np_ �__��__�9__ Dated........ ......:Z. ........ .......................... DATE. �_ Board of Health j cl � FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS f-._.,�.r:�,,_ 'r ,..-'�r..e��,+... �.,,..-.�•...,,,_r-+.Y,.�,.`.. n._ :..•.,::�."vaf.�.:'^..L�u.,�,-1,.�9:.4't..•.r"`-., a - v�..'4..i �.r+r:._" �..�'�=..,� .. .� ,-- � t . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Alipliration for Diripwml Htorlw Tomitrurtion "rrnttt Application is hereby made for a Permit to Construct ( ) or Repair (t, ) an Individual Sewage Disposal System at: .....................�.. -_.... . -------.._..... ................................................... Locati n-Address or Lot No- os„er Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.-----?------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 14 Other fixtures ------------------------------ W Design Flow_._.__.__ -.....................gallons per person per day. Total daily flow._. ............_...........gallons. WSeptic Tank A-•Liquid capacity.k_�(,?.gallons Length__-._-�----- Width..__S-------- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/............ Diameter-----/b..._.__. Depth below inlet...._lp�_._______ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by..............................•------••----------------•--------------•--- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit................'__ Depth to ground water........................ G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ...---•••-•--•.................•--------••------------------•-•----•------•---------..........----...._._.__....._..---......----••-•----......----••....... 0 Description of Soil........................................................................................................................................................................ x x --- --•------------------- -•---------------- -----..._...--------------•---------------------••-------------------------------------•••----------------•--------•...._._........-•-----•---•--......... U Nature of Repairs or Alterations—Answer when applicable-----:37(Y-5.A_p ______________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed;. - - -- ------------- ----- ..1 .`....�. Application Approved By—�- Lam__� G y Application Disapproved for the following reasons: ........... . ... . .. . ...................................................... . ......................... ......................................................................... . . .................................................. .. . . . ...... ...:..---....................... . .. ............................... 5 Permit No. -.1... .......- 7,. ... Issued ......�.. . ........................................ Dare ALL TE LL SYSTEM PROFILE MARK17DS WITHC MAGNETIC TTAPEAOR BE NOTES NOT TO SCALE) p� PROVIDE MIN. 20" DIAM WATERTIGHT ( COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE INSPECTION PORTS TO 2. MUNICIPAL WATER IS EXISTING Q �Q`pe5 \ TOP FOUND. EL. 51.5' WITHIN 3" OF FINISH GRADE Greo MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 42.0'- 43.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. OW e orn orsh PRECAST H-io 4. DESIGN LOADING FOR ALL PROPOSED PRECAST RISERS TYP. UNITS TO BE AASHO H-10 2 ( , 43.4' 4"OSCH40 PVC �" Route 2 . : R t PROP. TEE PIPES LEVEL 1ST 2' 5. PIPE JOINTS TO BE MADE WATERTIGHT. d• Locus d Pos EXISTING 40.4 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Sur OI o 10' 14" u//r R . TEE SEPTIC TANK TEE 42 Of'* WITH 310 CMR 15.000 (TITLE 5.) (RE-USE) 40.0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND c GAS BAFFLE::` °o°o° NOT TO BE USED FOR LOT LINE STAKING OR ANY 40.20' 40.03 0 92' 39.08' OTHER PURPOSE. MIN. SUMP 6" 8. PIPE FOR SEPTIC SYSTEM To SCH.. 40-4 PVC. 12" MIN. INT. DIM. 16 HIGH CAPACITY INFILTRATOR UNITS �o`C COMPONENTS NOT TO BE BACKFILLED OR OVERALL DIMENSIONS TO OUTSIDE OF UNITS: 25' X 11.3' 9. � CP• 6" CRUSHED STONE OR MECHANICAL CONCEALED WITHOUT INSPECTION BY BOARD OF COMPACTION. (15.221 [2]) (NO STONE PROPOSED) HEALTH AND PERMISSION OBTAINED FROM BOARD 1 6.58' OF HEALTH. ( 15 % SLOPE) ( SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP LEACHING CALLING DIGSAFE (1-888-344-7233) AND FOUNDATION EXIST. SEPTIC TANK 12' D' BOX 5' VERIFYING THE LOCATION of ALL UNDERGROUND & FACILITY OVERHEAD UTILITIES PRIOR To COMMENCEMENT OF NOT TO SCALE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT BOTTOM TH 1 EL. 32.5' WORK. UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE ASSESSORS MAP 189 PARCEL 78 PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE To SITE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED CONDITIONS IF NOT SUITABLE SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. SYSTEM DESIGN: 2,6 52 ,� 52 GARBAGE DISPOSER IS NOT ALLOWED 4 S7 51 FENCE DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD So 0,4 49 USE A 330 GPD DESIGN FLOW 48 TEST HOLE LOGS C + 4 100 46 4547 48.9 SEPTIC TANK: 330 GPD (2) = 660 44 43 RE-USE EXISTING SEPTIC TANK** q1 + 43.8 42.5 ENGINEER: DANIEL GONSALVES, SE 2.4 + 4 .3 �� 456 LEACHING: WITNESS: D. DESMARAIS, IRS __4.73 SF/LF,_x 6,25' LENGTH = --29.56 SF PER _ DATE: FEBRUARY 20, 2013 2.4 ,o _ HIGH CAPACITY INFILTRATOR UNIT < 2 MIN/INCH 14" oA LP 330 GPD/0.74 GPD/SF = 445.9 SF LEACHING PERC. RATE _ ��� REQ'D N + CLASS I SOILS P# 13872 s3.2 150.9 T N 445.9 SF/29.56 SF/UNIT = 15.1 UNITS O+ 43.7 ELEV. ELEV. Z THEREFORE, USE GRAVELLESS SYSTEM OF (16) v J H-20 HIGH CAPACITY UNITS IN FIELD 0" 42.5 0" 42.5 LOT 2 BLOCK B + 4748 D'eox covER? CONFIGURATION OF 4 ROWS OF 4 UNITS A A 11,598E S.F. 1 ,4 EXISTING SYSTEM SHOWN AS PER HEATLH SL SL 1 � 3.9 2 DEPT. RECORDS (SEPTIC TANK AS 16 UNITS X 29.5 SF = 472 SF > 445.9 SF +)45,ti �` LOCATED IN FIELD) 472 SF (0.74) = 349 GPD (OK) $» 10» 10YR 3/2 10YR 3/2 BECK 4•0 � � EXISTING SEPTIC a TANK** B B 1 ,2 LS LS 51.5 20" 10YR 4/6 40.8' 24" 10YR 4/6 40.5' EXISTING DWELLING 2.1 MA / TOP FNDN. = EL. 51.5' 5 APPROVED DATE BOARD OF HEALTH 4 43.6 BENCH MARK - SILL AT C 1 C 1 51.31 31�•6 WALKOUT DOOR. EL. = 44.5 PERCV MS MS 50.9 TITLE 5 SITE PLAN „ 10YR 6/8 » 10YR 6/8 / PAVEO 72 36.5 72 36.5 44.3 42.5 OF � /� DRIVE 3 o 5 4431 5 26 SYLVIA LANE c2 c2 / 50.10ENTERVILLE F 50.7 = M/CS M/CS PREPARED FOR 10YR 6/3 1OYR 6/3 42 B&B EXCAVATION/ " " 32.5' \\\���43.1 42,7 120 32.5' 120 41A ISRAEL 40.6 NO GROUNDWATER ENCOUNTERED j S+Y -0.1 FEBRUARY 21, 2013 91 4 v'� 39,9 + 48,0 14 a` o��s�J S1H OF i ASS off 508-362-4541 4 N� \,ry w q I fax 508-362-9880 DANIELA. �� D 1q�JIE G `•. m downcape.com down cope engIned9IIII iac. tip.GO 550 2 � ' No. 13380 411 90 �/STEF. �, Fp civil engineers Scale: 1 = 20 , / r� o , �a�. q �Ems' land surveyors 6 14 y g., 939 Main Street ( Rte 6A) 13-024 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675