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HomeMy WebLinkAbout0050 REDWOOD LANE - Health 50^Redwood Lane e-r).....,, i Hyannis'-i F/R 288 088 Commonwealth of Massachusetts a88^088 p Title 5 Official Inspection Form "I Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentsso CJ(A/D 0 ' Property Address r�+µ, Owner Owner's Name information is required for every -- page. CitylTown 004State Zip Code Date of Ins ction i 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. Inspector Infor tion cS/# 13UGp�- filling out forms on the computer, use only the tab key to move your Name of Inspector /f cursor-do not L-A1110 7 4C,/T use the return Company Name / �Q key. 00 -x) Company Address City/Town State Zip Code rim �� Telepho umber License Number B. Certification certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection 1 have determined that the�Passs m: 1. e 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �o Cx $ Vinspect, 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. Sinsp.doc-rev-712&2018 ?iae 5 Ada;Inspection=or.:s:bsur,'ace sewage D:spcsal System-Page 1 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� nn dSo Ke 6✓o0d � Property Address / I 1N Owner Owners Name V information is IA / / required for everyA44R 41 / d ` O,p page. Cityrrown State Zip Code Date of Insp ction C. Inspection Summary Inspection Summary: Complete 1, 4 3,or 5 and all of 4 and 6. 1) S;�Ihave stem P ses: 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: C.007 -e- OF 2) 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 exf Itration 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): i t5insp.doc-rev.726/2018 `ite 5 otaai i,spacdo,=om:suosurace Sewage Disposes system•Page 2 of 18 Commonwealth of Massachusetts ,P Title 5 Official Inspection Form CY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments so 124t // Property Address R1111 N f Owner Owners Name information is required for every Al 41444 t O 6 0� � -,`llAy page. City[Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: ?aye 3 of t8 LSinsp.00C•rev.7/26/2018 we 5 Official.nspemon For,Suosurface Sewage Disposal System• I�, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form/-Not for Voluntary Assessments ' 0 CWOO o6 441 Property Address • 1 Kf Owner Owner's NamAA e information is A N h r f 11 Qd 6 0l /O ax / 3A required for every page. City/Town State Zip Code Date of Inspection C. Inspec ion Summary (cost.) ❑ 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 b. 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. c. Other: } 4) 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 Title 5 Offoal!nspectlor.FQ"`Suosu`ace Sewage Disposal System•?age 4 of 18 t5insp.doc•rev.7/25/2018 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is 1411c;o41j Ir Q60/ /olai required for every hy page. City/Town 42_ State Zip Code Date of lnspTctinn C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Li id depth in cesspool is less than 6" below invert or available volume is less han '/z day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tines pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ElAny portion-of cesspool or privy is within 100 feet of a surface water supply or �Ie<" tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply e(I. ❑ ny 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 nd chain of custody must be attached to this form.] ❑ e system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. �-, 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. 5) 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 C.4. I 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 I I of a public water supply well ?izle 5 Qf-Cal Inspec5cn=orm:SUbSur`abe Sewage Disposal System•Page 5 of 18 t5insp•doc•rev.7262018 Commonwealth of Massachusetts ,I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 So A4R el 10 a4c:�,�"o C/- Property Address Owner Owner's Name �All information is required for every page. City[Town State Zip Code Date of Insp lion C. Inspection Summary (cont.) If you have answered "yes'to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at Issue approximation of distance is unacceptable)[310 CMR 15.302(5)] I i 71te 5 otoai',nspe -=orn:Subscrface Sewage Disposal System•?age 5 of 18 t5insp•doc rev.7126/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � N Owner Owner's Name information is �r /411f go- /� required for every v V page. Cityrrown State Zip Code Date of I pection D. System Information .1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): 3 3a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /coo 6w 1 . / /` N i9cs4n,44 A o&n Soo Number of current residents: Does residence have a garbage grinder? ❑ Yes C1 No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes eeNo information in this report.) Laundry system inspected? [I Yes No Seasonaluse? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Ye No Last date of occupancy: Date Tice 5 5dai nspecor=cm.sccsu`ace sewage Disposai system•?age 7 of 18 t5insp.doc•rev.712512018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /I !� -C. Owner Owner's Name ' information is / �r f O4)6 O/ /O required for every A�/1 / p� page. CitylTown State Zip Code Date of Inspe ion D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: , Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.72612018 ':itle 5 offidal:rspecaor om:Subsurface Sewage Disposal System•?age a of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments sod641,00 �- ~`'� Property Address tNf Owner Owner's Name - /f -rQ information is ANh /� Q /�/ � Ste_ required for every State Zip Code Date of In pection page. CitylTown D. System Information (cont.) 4. Type of Sys 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): do A1#4+-oY-31Y Approximate! ,e of all components, date installed (if known) urce of information: OW� / ,w4e VA L S• /4 S Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5, Building Sewer(locate on site plan): // 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.): T;Ce 5 v'�oai inspection Form.sutsudace sewage Disposal system•Page 9 of 18 t5insp.00cv rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Rio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 /fiec!i✓� 9 C1 Property Address HI 114f Owner Owner's Name information is / / required for every N✓1!1 Q�y©/ (0Opole page. CityFro'm State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet I ?en construction: rete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I 2a If tank is metal, list age: I wears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Y ❑ No Gi 4— J x �� Dimensions: o� Sludge depth: l � o Distance from top of sludge to bottom of outlet tee or baffle Q � SC JM Scum thickness Distance from top of scum to top of outlet tee or baffle k Distance from bottom of scum to bottom of outlet tee or baffle "e v� Haw 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.): E G'vt �t-�¢S !✓1 ,9 60.1 1 o rt /l/0 G his ?age 10 0`18 t5insp.doc•rev.7/26/2018 '.IIle 5 of5aaj Inspecacn=o^n:Suosurace Sewage Disposai System• Commonwealth of Massachusetts Inspection Form Title 5 Official Ins P � p i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Plem N S Owner Owner's Name • information is H f ��4 a.)6 0 required for every page. Cih'/To^m State Zip Code Date of fnspec on D. System Information (cost.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 Tile 5 of oa'.inspecuon Fon;Subsurface Sewage Disposai system•?age 7 of 18 t5insp.doc•rev.'/26i2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SO jQ4 J_ Lor/ Property Address 14 1qn1 Owner Owner's Name information is y f �60 a A required for every page. Cityfrown State Zip Code Date of Insp ction D. System Information (cons.) 8. Tight or Holding Tank(cont.) 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 9. 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.): o q veld So 1� ?ae 5 01"08i S�osurtace sewage Dispose System•?age 12 of 18 t5msp.00c•rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Z,00V/ Property Address n Owner Owners Name , information is „� ///g 0�601 /Q � bl required for every page. City/Town State Zip Code Date of Insp tion D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 3 �`tu h C�t&# �,Q leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ! leaching fields number, dimensions: ❑ ❑ overflow cesspool number: ❑ innovativeialtemative system Type/name of technology: Page of 78 -iue 5 pY:aa�InspeC:�or.Fa',n:Suos�rface Sewage Disposai system• t 3 t5insp.doc•7ev.'/26/20118 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p G(�✓Od Property Address r �l Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Insp6ction D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4 f 4t.4 CJ �o'I G? Q r! r—i /�O S �s o� 1 • f�� �u� 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): I r ' we 5 07f.,ai mspacc, em:sucsurface Sewage D,sposai System.?age 14 of 18 t5insp.doc•rev.726/2018 Commonwealth of Massachusetts :. P Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessment G� s so Property Address / � vl Owner Owner's Name information is required for every _ Ay page. City/TownState Zip Code Date of Insp tion D. System Information (cont.) 13. 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.): i I t5insp.doc•rev.726/22018 Tore 5 Offiaa;nspecon;on`,.scosudaae Sewage oisposa System.?age 15 of 18 Commonwealth of Massachusetts e Title 5 Official lnspectio.n Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments so Property Address A JC Owner Owner's Name ` information is -squiredd for every G ✓11 V/)d601 �1 � p cage. City/Town State Zip Code Date of insp ction D. System Information (cons.) 14. Sketch Of Sewage Disposal System: Provide a viev j,eflhe sewage disposal system, including ties to at least two permanent reference landmark Kr benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the b ' mg. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately / I J i i 1 L LpbGI r1e,/A� I ' Covey / 1 Ta n I✓ � i � t i c � I r7 nl - /-9 3,0 1S 3 0 q3 - 317 � I I i t5insp.doc•rev.712512018 Title 5 inspecuort=orm.Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo rm Not for Voluntary Assessme nts Property Address Owner Owners Name ` H information i e _ ap`b Q required for every G page. City(Town State Zip Code Date of Inspecion D. System Information (cost.) 15. Site Exam: U Check Slope Surface water Check cellar Shallow wells Id �m�Estimated depth to high ground water: 'A/V 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: pate ❑ served site (abutting property/observation hole within 150 feet of SAS) Checked with local rd of Health - explain: Checked with local excavators; installers - (attach documentation) Accessed USGS database- explain. You must des e how you e ablished the high ground water elevation: u4 k �� !aN , 42�f A , is A ffok 1 yaw Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.6oc-rev.725,20,a -iUe 5 5aai irs en=a-:Sucsurace sewage Disposal System•Page 17 of t8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments az Property Address AAC Owner Owners Name Oa 60/60 information is required for every — page. City/Town State Zip Code Date of In pectin E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. ertification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4X'UreCriteria)and 6 (Checklist) completed System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t6insp.doc.rev.7/26/2018 `ue 6 C'.`oa,:rspec-jon Four,.Suosutface Sewage Disposal System•Page I of 18 TOWN OF BARNSTABLE ,rc LOCATION SI-0> SEWAGE # o, (- 31® VILLAGE 'lc/ann i s ASSESSOR'S MAP & LOT ' INSTALLER'S NAME&PHONE NO. L✓''" (% `t�ib�n4,r 3c2�{tc;SetJKC 775�7?(0 SEPTIC TANK CAPACITY /oao Coal LEACHING FACILITY: (type) 3)( S"bo cA,-- E1%,c1ts (size) x NO.OF BEDROOMS 3 BUILDER OR OWNER ` 5+�►on� PERMITDATE: Go 21-6LI COMPLIANCE DATE: -7— t-614 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 ,o , r r ?5 0ON 41 39V--J) V5 / 4. NO. lJ Z/ '3 ICE , F4 5 0.0 Vees / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(ppYication for Migogar *pgtem Conotruction Permit Application for a Permit to Construct( . )Repair(X )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. 50 Redwood Lane Owner's Name,Address and Tel.No.7 9 0—1 5 3 9 Hyannisport Eileen Desimone Assessor'sMap/Parcei 288/88 50 Redwood Ln, Hyannisport Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 9 8—8 31 1 Wm E Robinson Sr Septic Craig Short PO Box 1.089, Centerville PO Box 1044, S. Dennis Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other 'Pype of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install new Title 5 leach system to plans of Craig Short, #1 -1020 . 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 be ssued • o oa f Health. Sig ed Dat Application Approved by Date a ti �✓ Application Disapproved for the following reasons Permit No. 3 Date Issued v`� -.._.w-_.:......�_ -..-. +'F+s'•+.:. .:,, w,.,r..: -, ..,yn » -rd§"^.-+�.t....� _ .y.,.y .....4 _ -"e' .-�'. Sri'3,wvF � •-. .r No THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es ZlppYication forr�Dizpozal *pztem Con5tructioft, Permit Application for a Permit to Construct( . )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 5 0 Redwood Lane Owner's Name,Address and Tel.No.7 9 0-1 5 3 9 H annisP ort tileen Desimone. Assessor'sMap/Parcel 288/88 { 50 Redwood Ln, Hyannisport Installer's Name,Address,and Tel.No, 7 7 5 8 7 7 6 Designer's Name,Address and Tel.No. 3 9 8—8 31 1 Wm E Robinson Sr Septic Craig Short PO Box 1.089, Centerville PO Box 1044, S. Dennis Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other Type of Building -No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install new Title 5 leach s_ystPm to plans of Craig Short, #1 -1020. x. w 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 sued by thi Boar of Health. Sig ed .�, '.�' Date Application Approved by —~� Date 1-19 5 Application Disapproved for the following reasons - Permit No. - ^3 Date Issued f 5 _1 Desimone THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm E Robinson Sr Septic Service s at 50 Redwood Lane, Hyannisport has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 110 L dated 6 bL/ Installer Designer /A \ The issuanc of ' 's ermit shall not be construed as a guarantee that the sy a wiil f�In�c�tion as des wed. Inspector- h Date 71+��) - ...... -- ---------------- ----------------- No. Feet 5 0.0 0 Desimone THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS liopozar *patent Construction Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 50 Redwood Lane, Hyannisport 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 off pe Date: 7 / Approved by TOWN OF BARNSTABLE �c c LOCATION St!� SEWAGE # VILLAG ASSESSOR'S MAP & LOT RE" INSTALLER'S NAME&PHONE NO. 315*i1 S—MLct j SEPTIC TANK CAPACITY • LEACHING FACII.ITY: (type) 3 S'Zb A& Z n1v r-% (size) Q X NO.OF BEDROOMS 3 BUILDER OR OWNER 'S�,nno�►N - PERMITDATE: Co- aS-dy 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 QJ n� 0 1 • r Town of Barnstable 'THE �Df'tio Regulatory Services Thomas F. Geiler,Director + Beaeisrast.K MASS. Public Health Division 1b39• �0 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: -7 Designer: Craig Short Installer: Wm E Robinson Sr Address: PO Box 1044 Address: PO Box 1089 S_ Dennis Centerville On Wm Robinson Septic was issued a permit to install a (date) (installer) septic system at50 Redwood Ln, Hyannisport based on a design drawn by (address) Craig Short dated 06/22/04 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such ash 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. s OF ret�s9 CRAIG (Installer's Signature) a6 CIVIL ti No.274M G2t::: L E� (De 'gner's Signature) (Affix D.si Stamp Here) " =PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BOLT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF_A.IRS DEPARTMENT OF ENVIRONMENTAL PrP& -T3--QWD FAILED INSPECTION Nov 11 Zoo3 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP eL�� Property Address:: ,. ;t, ;�� C'ARCEI� -Owner's Name- R•' ' '� SOT ' Owner's Address: rr7 9, Date of Inspection: 3) ri JLLI�b. Name of Inspector•, pleas print') 1 Company Name. `��� . ' / - 7 l X-C-,, Mailing Address: ' ey s n� Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rtponed below is true, accurate and complete as of the time of the inspection. The inspection was performed based ora 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 Needs.Further Evaluation by the Local Approving Authority Fails Inspector's Signature: DaLe: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I3ealuh 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. /� and CommentsIP- ����`' PO— Notes12?YD�� ****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 6/15/2000 page 1 Page 2 of I 1 " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ~`CERTIFICATION (continued) Mv Property Address:.,t J Owner: ( tOhl^v Date of Inspection: ( 0^71, Awe , 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 m 3 i`0 CMR'1 304 exist.A y 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. a: 3 Answer yes,no or not�determined`(YAND)in the' for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or"the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *.A metal septic tankwill pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewacc backup or break out or high static water level the distribution boz 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 leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed 1;1)explain: 2 Page 3 of 1'l OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: , 1 A Owner: ' Date of Inspection: C7G 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 15i303(1)(b)that the system is not functioning in.a manner which.will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 pptn;provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. 3. Other: j 3 Page 4 of I l OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:r , Owner: 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 _ Back-up 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 around 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 %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V 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 cesspoof 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. riv is less than 100 feet but greater than 50 feet from a private— P P y g p water supply well with 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 triggered.A copy of the analysis must be attached to this form.] Jb(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 system the system must serve a facility with a-design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to 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 ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM RT CHECKLIST Property Address: _ Owner: 6)f1PP,1, Date of Inspection Check if the following have been done.You must indicate"yes"or"no" as to each of the following: _ Yes No Pumping.inform'ation.was provided-by the owner;occupant,or.Board of'Health —L—//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 ? —Z- 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 o tf lie baffles or tees material of construction dimensions depth4 P of liquid, depth. 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 the Board of Health. - _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: , Owner: Date of Inspection: a) FLOW CONDITIONS RESIDENTIAL�� Number i a of bedrooms(design):' . --3. Number of bedrooms(actual): DESIGN flow based on 310 CM 15.203 (for example: 1 I:0 gpd x#of bedrooms): _ ,Number of current residents: Does residence have.a garbage grinder(yes or no): r ,.. "! Is laundry on a separate sewage system es or n�.(if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no) (,Qj-.. _ Water meter readingsAii.fvaiilable(last 2 years usage(gpd)):Sump pump(yes or nLast date of occupan COMMERCIAL/INDUSTRIAL 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 s stem es r V /y o .no): , - b J \J 1 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 inspe tion_(yes or no): If yes, volume pumped: gallons How was quantity pumped determined? Reason Torpumping: t TYPE OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP.approval �Other'(describe): Approximate age of all corpponents, ate installed(if known so rce of info at'On* Were sewage odors'detected when arriving.at the site(yes'or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan)'J - Depth below grade: Materials of construction:_cast iron _46 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) yL�R Depth below grade= �- Material of construction:-v6oncrete_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: 's� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness-r W Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bTatins, A outlet tee or baf e'. Z How were dimensions determined: Ana P Comments (on pumping recommen nlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert,e i ence of leakage,etc.): of Ox •� e, 0 GREASE TRAP._ ocate on.site plan) 44j ,/xg 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 baffle: 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.): r , Page 8 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: 03 TIGHT or HOLDING TANK�nk 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/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 ;f present must be opened)(locate on site plan) 1 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.): F, PUMP CHAMBER (locate 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 appurtenance-s, etc:): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: pwjw6 U&'Aly ,09 Owner: 1.8'X.��Date of Inspection• ,t, SOIL ABSORPTION SYSTEM (SAS):4____00cate 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: Ifts'ching fields,number, dimensions: overflow cesspool,number:s?_ 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 ` , 0,q4l �.A17 CESSPOO cesspool must be pumped as part of inspect ion)(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 or no): Comments(note condition of soil,signs of hydrauiio-fai lure,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.): //////�J�LLr)����+((/��r,,(p.�.J� y///,�y�A�'''J f 1 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address:,6n abjv-(�/0,/� Owner: r Date of Inspection: SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. O 4/ /'t� '•r �j �a L 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property dress: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to around water feet Please indicate(check)all methods used to determine the high groundwater 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: n .� , / l 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: � q Lot No. Owner: Address: Contractor: J�/���� d� �' Address: 'Y J Notes: - .. �✓"Yrr�J`N�®�l.J.�t/�� -s`•7iT�"�O !� STEP 1 Measure depth to water table to nearest 1/10 ft. .................. p month/day/year i STEP 2 Using Water-Level Range Zone I and.1ndex Well'Map locate I site and determine: A Appropriate index well.............................. ....... B Water-level range zone ..,...... S T`P. 3 Using monthly raport'."Current Water Resources Conditions determine current depth to r----� water level for index well .......:................... �p®✓ !' i month/year =° " Using .Table of plater-level Adjust Hems I or index well (STEP 2A), current depth to water level for index.well ('STEP 3)., i 'and water-level zone (STEP 2B) determine water-level adjustment•........... :......................... . i 'STEP 5 . Estimate depth'to hi.gh'water by subtracting the water- le.vel adjustment (STEP 4) from'measured'depth to water level at site (STEP 1).......... Figure 13.--ReprC•dudble pompu aiion form. i 5 .< i.v ,yam y _ } i 4 i t y (a • � 4 i I I 3P yy t 3 � ' . S e : f s Kin aNA . '� 'tom, • two i "1 LEGEND: BENCHMARK TOP OF FOUNDATION 20'C:T. MINIMUM FROM CELLAR SOIL TEST EXISTING SPOT ELEVATION . . . x0.0 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST 1. .L4 EXISTING CONTOUR . . ----00---- ELEV. _ � ,a 10 FT. MINIMUM CLEAN SAND SOIL TEST DONE BY 0-99 13,5H �.E. FINAL SPOT ELEVATION . 070 (ASSUMED) CONCRETE WITNESSED BY - ]b�ON. SR. FINAL CONTOUR - Q�Q}-- Tp COVERS LOAM AND SEED SOIL TEST_LOCATION , . . . 0 4" SCHEDULE 40 PVC PIPE OBSERVATION HOLE 1 ELEV.- 011.o UTILITY POLE . . . . � MIN. PITCH 1/8" PER FT. 2" LAYER OF PERCOLATION RATE _< 2 MIN./INCH AT 54-66 INCHES TOWN WATER ---W W 1/8" TO 1/2' DEPTH HORIZ TEXTURE COLOR MOTT. OTHER CATCH BASIN .� " L 9 9.'•'.1�,.�,,a WASHED STONE GAS LINE c ---c 4" CAS? IRON PIPE ,�,� ����� UNSUii GAS METER . . . .® (OR EQUAL) MINIMUM GAS VALVE . . .9� PITCH 1/4" PER FT. ¢ z 0- 2" A LOAMY SAND iOYRS 3 O M�r i- CESSPOOL . . . . . . . �► DD ZABEL FILTER CLEANOUT . . -�C•O• FLOW LINE ELECTRIC BOX . . m "� qla.S�% a, PLUMBING TO BE RAISED ELEV. _ it 10" C1 ❑❑ ❑ D C? ❑ ❑D o 12-30" B LOAMY SAND 10YR5 6 NO P•L " 4.S'O ELECTRIC LINE,. E-E-E -7-MIN. ELECTRIC`MANHOLE . . . . 0 AND RE-PIPED BY A ( LEV. 9L.GT - ��V�Y�Q�`-I o ° ° o p ELECTRIC METER . . . . . NEEDED LICENSED PLUMBER AS ELEV. - 1Y�� GAS = '�C 6" SU P ELEV. Ito. /' o o ❑ C3 O ❑L�C7❑D❑C]t7 FLAGPOLE . . . . . . . . . .r BAFFLE EEV' o ° ❑ ❑L7 O ❑❑D O O❑D o 2 0 o MEDIUM SAND ' w COAR SAAND HYDRANT . . . . DISTRIBUTION ELEV ° ° ° ° VEL 10YR7/6 NO LIGHTPOST . . )� LIQUID OUTLET _ BOX 7s' o o° t� ❑ ❑ D L7❑O❑©❑❑ ° o ° o ELEV. _ 93.7J' r C A MANHOLE . . . . . . 0 -144 OBS. WELL 4 FEET 14 INCHES TO BE WATER TESTED , SEWER NE. .r s s -s - 5 FEET 24 INCHES OOO GALLON IF MORE THAN ONE OUTLET 3' 500 GALLON 0R1'WEZIS WITH STONE ?�- " SEWER MANHOLE �}S 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) IN AN t)A33.5 < E TRENCH FORMATION G WELL o✓ / NO WATER ENCOUNTERED AT __12_.._ ELEV. - &7,4 TELEPHONE BOX . . . .m 8 FEET 34 INCHES SEPTIC TANK 3/4' TO 1 1/2" CLEAN ZONE WATER SHUT-OFF . . . EXISTING DOUBLE WASHED STONE SOIL ABSORPTION INDEX ADJUST DESIGN CALCULATIONS WATER VALVE , . . FREE OF FINES do SILT SYSTEM SAS NUMBER OF BEDROOMS 3 USES PROBABLE WATER TABLE ELEV. _ GARBAGE DISPOSAL UNIT NO. N01 ALLOWED ao.00� SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ELEV. TOTAL ESTIMATED FLOW NOT TO SCALE BOTTOM OF TEST HOLE ELEV. _ '7:O (110 GAL/BR./DAY X _3._ SR.) .,.330_ GAL/DAY (\, REQUIRED SEPTIC TANK CAPACITY _:I 5m GAL V ACTUAL SEPTIC TANK CAPACITY _.15M GAL SO4L CLASSIFICATION _ 1 Q DESIGN PERCOLATION RATE 5_:MIN./INCH TITLE VARIANCES REQUIRED: EFFLUENT LOADING RATE d74_ GAL/DAY/S.F. j�26, 97.? 1 SECTION 15.211 MINIMUM DISTANCES: LEACHING AREA 4 2'1, SQ. FT. (� <, 3��- , 98.7 DISTANCE BETWEEN S.A.S. AND CELLAR WALL ( 91x 33.s") +(2�Ass') �///-��QST�.//� <.t 99.2 �;s�;r `�M �_�`+�j A 4'�VARIANCE REQUESTED LEACHING CAPACITY .y48 ` GAL./DAY SL! TIC V \\ \ rw rs f• :,y y1�t�, f + J - T� \�\\, r',•'..",...�...,. r I -9 7i S X 0.74 N _ r:'1r.` � ���1'\ • , ` ' `, RESERVE LEACHING CAPACITY ;N/A GAL/DAY �\� y l�\ ti �. \ a 2 SECTION 15.211 \ a\ ;> .►, / DISTANCE BETWEEN S.A.S & CELLAR WALL C+?�Tw4 sf'•�N0TES`. i,i. 1 r , A �.Z6tVARIANCE REQUESTED 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF c, Q ' / SEWAGE. 2 /; FINISHED GRADE. WITHIN 6" OF 1• '�.,�u� tea'� � - 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO ` �.8. v V Ij •� , r 1 / 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE 'CAPABLE OF oD �'vER -�• �• j WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF 9.0 P1gT.�� / DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN (Q / 10 FT. OF DRIVES OR PARKING AREAS. / 4. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE'MORTARED IN PLACE. / 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR /2 ZONING REGULATIONS. OWNER / APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY, N PAG� , 8. l 6. UTILITIES SHOWN ARE APPROXIMATE-ONLY, EXCAVATION CONTRACTOR IS TO S � --....,,. : ( CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS PRIOR TO 98. 8.9 1 7 COMMENCING WORK ON SITE. 100,00 ,,....:. 9/ ,g 7. CONTRACTOR IS TO VERIFY GRADES AND. ELEVATIONS AS WELL A5 SITE _,-v ' CONDITIONS-PRIOR TO COMMENCING WORK ON SITE. ,ANY VARIA71ON 1S TO BE PATID r --•'M �� R� �J 8. PAR GRIT TO .HE ATTENTION OF<THE DESIGN ENGINEER IMMEDIATELY. GEL tS IN FLOOD ZONE C 9. LOT IS 'SHOWN ON ASSESSORS MAP _2W_ AS PARCEL 88 G1�S 10. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER, AND FOR A ORI 9$.5 98.6 `., MINIMUM OF 5 FEET FROM AROUND THE SOIL:ABSORPTION ;SYSTEM, AND -BE 1 EX1577NG 1 -� '@ 1 REPLACED WITH :SAND AS SPECIFIED IN 310'CMR 15.255: (3) (I.E. TITLE 5) IF 98.6 I (n ENCOUNTERED-BELOW .S.AS. PIPE INVERT. DWELLING ' J 11. EXISTING L r-ACH P>r TO 6E PUMPED AND FILLED WITH SAND'OR REMOVED: = 12.,A ZABEL 'A18DO FILTER IS'TO BE_INSTALLED. \ 13. CONTRACTOR'TO PROVIDE'SHORING AS NEEDED'TO PROTECT BUILDING AND PROPERTY LINE. CRAIG 97.0 .. SHORT �; g� , APPROVED: BOARD OF MEAL CIVIL J� I No. 2'A8S J#2636 DATE AGENT I LOF 55 ,f R • l 7 740 .�- S.F. l PROPOSED SEPTIC ��SIGN I / FOR x 98.3 / � � -o - .R`C7.BIXS0 DESIMCJ1Y.E' 1 / toe. 50 REDWOOD :I NE. & ,R ,�S'TIC .LANE / BARV,S',TAB E MA i 98.2 NOTCO 96.0 a NARRI RAID R. SHORZ P. E. 96.5 LOCUS n n5 GREA T WESTERN ROAD x $7.8 _ .,.,..-- ,..... _ - _ .._ ._. - _ - off P. 0 S1�X �'f744 ' - ? ,; 6 0 56a Jgq..&01 SOUTH DENNI.S ;MASS a2S6C1 �g8.1<os� DATE SCALE _` / A 10 CJ o rav o , ` . Sl PLAN ; to to : - _e ,BARNSTABLE,(HYANNiSP�Y4T�. MASS. IZEv. �oB No. f 96_4 SCALE 1 fNCH : 10 FEET ; LOCATION MAE REV. SHEET 1 OF :1 01-4020 R esi one.fl r» !�! 02004 CRAtG R. SHORT, P.E.