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Home My WebLink About0010 ABBEY GATE - Health 10 Abbey Gate; Atu it P _ 123 I ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate _ Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for every 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. Impotent: A. General Information When filling out J� forms on the (' computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell _ cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. _ Company Name 189 Cammett Road _ Company Address Marstons Mills MA 02648 Cityrrown . State Zip Code 508.428.1779 SI 12855 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: � —� o ® Passes ❑ Conditionally Passes ❑ Fails 03) ❑ -n Needs Further Evaluation by the Local Approving Authority n �2— AA 0 August 18, 2010 Job# 10-= Inspector's Signatur Date tV tJt7 w r— The system inspector shall submit a copy of this inspection report to the Approving AutMrityfMoard of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner, and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 . 11 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for 9 _ every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Recommend pumping tank in next 12-18 months, leaching chambers had no standing water or sidewall stains. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 10 Abbey Gate _ Property Address Chris&Carrie Shanahan Owner Owner's Name information is required for Cotuit MA 02635 August 18, 2010 - every page. Citylrown State Zip Code Date of Inspection B. Certification (coat.) 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): i ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh e5ins i 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Abbey Gate _ Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for — every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of'Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 El 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 les8 than_day flow _ t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Abbey Gate — Property Address Chris&Carrie Shanahan — Owner Owner's Name information is required for Cotuit MA 02635 August 18, 2010 every page. Cityrrown 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 legs 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 analysils 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. 4 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 El El 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts. r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 10 Abbey Gate — Property Address Chris&Carrie Shanahan _ Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for — every page. Cityrrown 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? ® El available 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): 4 Number of bedrooms (actual): 4 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts r Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Abbey Gate Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for — every page. City[Town State Zip Code Date of Inspection — D. System Information Description: 4 Number of current residents: — Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? if yes separate inspection required] ❑ Yes ® No . s Laundry system inspected? ❑ Yes ❑ No i Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Irrigation g ( y g (gP ))' System _ Detail Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate Property Address Chris&Carrie Shanahan Owner Owner's Name information is required for Cotuit MA 02635 August 18, 2010 every page. Cityrrown 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: Tank last pumped 12716 months ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool _ ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate _ Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for — every 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: Compliance date: 3/30/00 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' 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.): Septic Tank(locate on site plan): ' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metah, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal. 411 Sludge depth: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 7 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'l 10 Abbey Gate — Property Address Chris&Carrie Shanahan _ Owner Owner's Name information is required for Cotuit MA 02635 August 18, 2010 - every page. Cityrrown State Zip Code Date of Inspection — D. System Information (cont.) Septic Tank(cont.) 2811 Distance from top of sludge to bottom of outlet tee or baffle — Y Scum thickness — Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" 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.): Liquid level was found at bottom of outlet invert and tees were intact and clear. Recommend pumping in next 12-18 months. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 AL Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 10 Abbey Gate _ Property Address Chris&Carrie Shanahan f _ Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 _ required for 9 every page. Citylrown 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): i Depth below grade: — Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate — Property Address Chris&Carrie Shanahan — Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for — every page. Cityrrown 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.): No solids or high stains present liquid level at bottom of all outlets. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate _ Property Address Chris&Carrie Shanahan _ Owner Owner's Name information is Cotuit MA 02635 August 18, 2010 required for 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: — ® leaching chambers number: Three 500 gall drywells. ❑ 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.): Interior of chambers had no standing water or sidewall stains. 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 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate _ Property Address Chris&Carrie Shanahan _ Owner Owner's Name information is g required for Cotuit MA 02635 August 18, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,; etc.): Privy (locate on site plan): Materials of construction: Dimensions — Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts - ."S Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Abbey Gate Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA _02635 August 18, 2010 required for g every page. City/rown 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 Ito at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawim.attached separately Abbey Gate f? M l 4 t � K \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 39 \ \ \ \ . \ ♦ \ \ \ ♦ \ \ \ . \ . / ! , , / / / , f / /•/ r / / / / / / r / / / / r /NNNN/ f / f / / / / / / • / / / / %r / / / / / / , , % ! \ \ \ \ \ \ \ \ \ \ 30 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Abbey Gate Property Address Chris&Carrie Shanahan Owner Owner's Name information is Cotuit MA 02635 August 18 2010 _required for g , every 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: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: River and wetlands on opposite side of road are considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Abbey Gate Property Address Chris&Carrie Shanahan T Owner Owner's Name information is g required for Cotuit MA 02635 August 18 2010 every page: Citylrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 d 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE ONIVED DEC 2 2003 TOV�N OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 Abbey Gate �22 Cotuit. MA 02635 MAP ,.,,. .2 Owner's Name: Jim McWilliams PARCEL Owner's Address: LOT • ._�.+. nmero Date of Inspection: November 4, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 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 Fai Inspector's Signature: 4 Date: November 10, 2003 The system inspector sh\suba 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. 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 6/15/2000 page I Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Abbey Gate Cotuit, AM Owner: Jim McWilliams Date of Inspection: November 4, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ 1 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. Answer yes, no or not determined(Y,N,ND) 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 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. ND explain: 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 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 ND explain: 2 t i Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Abbey Gate Cotuit, AM Owner: Jim McWilliams Date of Inspection: November 4, 2003 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 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 triggered. A copy of the analysis must be attached to this form. 3. Other: i 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: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/2 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 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.] No (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 System: 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 3 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4, 2003 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: 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 C is at issue approximation of distance is unacceptable) [310 CMR 15.3.02(3)(b)]. 5 r Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No. Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied 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 system (yes or no): Water meter readings, if available: Last date of occupancy/use: ` OTHER(describe): GENERAL INFORMATION ` Pumping,Records Source of information: Pumped a couple months ago-per owner Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: gallons--.How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Mar. 30100-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4,2003 BUILDING SEWER(locate on site plan) 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 below grade: 16" 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: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. -The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (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 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.): 7 ' i Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Abbey Gate Cotuit, AM Owner: Jim McWilliams Date of Inspection: November 4, 2003 TIGHT or HOLDING TANK: None (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/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)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was level and clean. No solids were present. The cover was to grade. Speed levelers were present. PUMP CHAMBER: None (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 appurtenances, etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-500 gal leach chambers- 12'8"x 34'(per as built card), 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.): There did not appear to be any signs of failure. The bottom to grade was approximately 5. CESSPOOLS: None (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 or no); Comments (note condition of soil; signs of hydraulic failure,level of ponding, condition of vegetation,etc.): ° I PRIVY: None (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 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4, 2003 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. A p a GAM6L .4 a C- C 3 a 3�` 3a 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Abbey Gate Cotuit, MA Owner: Jim McWilliams Date of Inspection: November 4, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35 +/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 35'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION # �mg 5 r VMLAGE �� ASSESSOR'S MAP&PARCEL rg=W-�S NAME&PHONE NO 0/1 0-l. a� i Z SEPTIC TANK CAPACITY I.9UG LEACHING FACILITY:(type) (size) S`b� NO.OF BEDROOMS OWNER S awl ct✓) PERMIT 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 h \ h h h h 4 h h h h \ h h h \ h h 4 4 h 4 4 4 h \ \ 4 4 \ \ 4 4 4 h 4 4 \ 4 4 h 4 \ 4 4 4 h 4 4 4 4 4 h h h 4 4 4 4 4 \ 4 4 4 4 4 f f ! f f f f f f f ! f f f f ! f f f f f ! f f f f ! f h h 4 4 h \ 4 4 h h 4 4 h h 4 4 4 4 4 h \ 4 4 \ 4 4 4 h 4 4 4 4 4 4 \ h 4 4 h 4 4 \•4 4 4 4'h 4 4 4 4 4 f f f f f f f ! J f f f f f f ! f f J f f h h \ \ h 4 h h \ h h h f f f f f f f J f h h h 4 \ h h h \ \ 30 r ^ TOWN OF BARNSTABLE 'LOCATION' �C) /1� �'I C�/� SEWAGE # �� 9 VILLAGE COT i+ ASSESSOR'S MAP & LOT o'*- 113 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l SW S� LEACHING FACILITY: (type) S�b S41. C4AMLees (size) x 3y NO. OF BEDROOMS BUILDER OR OWNER �/Z/YAs mC ty IliAMS PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi g facility) / Feet Furnished by �il S,OeG�i0�1 �orCl A GA�g6c. —8 30 3I 3 3a 3 as a� Y ao 3�j TOWN OF BARNST BLE G VOCATION' %6 IJ b�ev, a '� SEWAGE.* VILLAGE �`�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE'NO.S C'- QA,' b C60S�` f/.oig'j 5?S SEPTIC TANK-CAPACITY so b i �-EACIHi'iG FACILITY: (type) 3/S0O`a J2o-e�i•ti� (size) ,r;:Id I x ,j7 � NO.OF BEDROOMS 'BUILDER OR OWNER PERMPTDATE: y• - COMPLIANCE DATE: Separation Distance Between the: t . Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Priv�ate Water Supply Well.and Leaching Facility (If any wells exist -4 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 facilib!);. :Feet Furnished by , � _ -- - :_ { __ _ - . ,. . .., Abb�. � t � a' � �' i � � s �o � � � � to D � a ,6 35 5 0 � �� .,,.�'a� 5 ►� 6 y � � o to � ! ,�,; � � � 33'� � TOWN OF BARNSTABLE �G LOCATION 16 A b�2 ley Ca 'L SEWAGE j � t VILLAGECc-�LA. ASSESSOR'S 1MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 150C> ;. qPJ- LEACHING FACILITY: (type) 3�$6O�a kO`� tea( e) NO.OF BEDROOMS I I BUILDER OR OWNER ► S��'``�`lZ 2. PERMITDATE: y'�y_99 COMPLIANCE DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table and 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 facili -. Feet i Furnished by p� 4� ------ orN .7--- No. FEE� r Board of Health, j3 AR N S=146 Lb7 , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(Zoolepair( ) Upgrade( ) Abandon( ) - Q omplete System ❑Individual Components Location /0 r4 ,C 6A T F Owner's Name I2 I L L s C H Ui_Z Map/Parcel# a Z e_e Address Lot# a 3 Telephone# Installer's Name Designer's Name A,uL'e,c Svrvc ;, we %G4 uts Address Address /o f3 Telephone# Telephone# ya8-0A S° Type of Building Lot Size/ / sq.it. Dwelling-No.of Bedrooms Garbage grW(� Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures L Design Flow (min.required) Z71"1 gpd Calculate^dd design flow Design flow provided 60 gpd Plan: Date1l/—a 3-9 'CY Number of sheets oZ Revision Date Title t 1 t S`e txs d4c�e /J L 04 N Description of Soils) �1,,t Soil Evaluator Form No. 9 J 3 Name of Soil Evaluat,9 Y'�ne ,/ yDate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date N No. FEE �- '�\uTf��i�. � i q Iqn\�'/III''/ \(\\\\(\\1\}/A\{\F �''r IT I�''t COMMO V V V Jl+.l II.I IH OF 1 JLASS ssCH�/SE Y TS C) Board of Health, l A N ST g , MA. APPLICATION,�F��P�,,,RIS�OS\AL' SYST'EM CONSTRUCTION PERMIT Application for a Permit to Construct(G4-KepairO Upgrade( Abandon( - 46mplete System ❑Individual Components Location Q A E _ (5-A T 67 Owner's Name /3 1 L L S C r7 UL Z 67 Map/Parcel# ��Z� «�L r Address Lot# 01 3 Telephone# Installer's{lame �(711t> Designer's NameYlq u Co S ue- IA OS Address Address '/0 8 4rvelt,S- )4 RS o N S /A 1 L L f Telephone# Telepliorie# /a8—po s u Type of Building Lot Size�al �-�/ 'f sq.ft. Dwelling-No.of Bedrooms 7 Garbage grief Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) 1 Other Fixtures ` Design Flow (min.required) 'L,/'v gpd Calculated design flow Design flow provided gpd 3' Plan: Date / /-.a 3-9 CI Number of sheets of Revision Date Title t 14°- + S-e -`j A & 0 �-I� N Description of Soil(s) c01/- L) p� Soil Evaluator Form No. / J 3 Name of Soil Evaluat, ✓o« I�UIy'��Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS [r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and i,. further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ITr�BYrs .-zr w.� • �' �t,,v,,; _ ,�'-�• / 2 K.-� °I � q g- No."// - ` COMMONWEALTH /� �T��]�' ¶` �� (` T FEE 'Ila SETTS Board of Health, +,a r v4� � l MA. i CERTIFICATE OF CROMPLIANCE Description of Work: 0 Individual Component(s) O<bmplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned,( ) by: at 10 A 8 8 E\/ 6-0-IT ' ,. has been installed i accordance with the provision of 310 CMR 15.00 (Title 5) and the approved design plans,/as-built plans relating to application No. —7 9 dated Approved Design Flow /K 0 (gpd) Installer Designer:VygP++''-e-9 Inspector: ( Date: .3 ` 3 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. v 9 9- 5�. �- No. ,(� �1��T¶"� ,(� �T FEE d�r LT14 OF SETTS Board of Health, ►Ja J Sa ��' , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby grantedto; Construct(l.�Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at /0 6913 6-)q TE -,g q as described in the application for r 1q Disposal System Construction Permit No. ` (/ ,dated l�' Z7 /4-11 Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 3 r It) a)./I&✓)Board of Healthy l_[aWl SpdCC U1 UaJC111C11L 1Uu111auU11 avaliaui'_, ro."A�� Price Category B Cream of the Crop One of our all-time best selling plans, this home is extremely popul: builders and consumers due to its easy construction, desirable squs and open, relaxed design with split bedroom privacy. And a sky.: ' room only increases its versatility and value. a;I BED RM. — ` 12-6 x 13-0 d;j .Ilk IW... ball r.uw °eYn BONUS RM. I 16-0 x 13-0 BED RM. 12-4 x 11-0 °i0- '10raN W:a .Ilk .IIk loyw _j SECOND FLOOR PLAN PORCH MASB RAM _ 13-0 x 13-0 d xun.r KIT. 1x. 6M6 Q 12-4 x 11-1 w .�r.1k N 6-0 � d ' DINING 14-4 x 11-0 `^I GARAGE 20-0 x 21-0 nYln{ GREAT RM. "FOYER 16-0 x 11-0 , 7-0 x d'; 'I 1w.x.4 1-9 cAWI I Ik.pl.c. PORCH FIRST FLOOR PLAN s3-o . .,DV1L.Vl_I II V i4y„�. f Uawi space or DasemenL LLURUaL1Ulr avanaUie,Pira�r ZlPrLiiy. - Price Category B t g BED Rna I FOYER DMNG n-e.Ire Cream of the Crop One of our all-time best selling plans,this home is extremely popular with both PORCH FLOOR PLAN builders and consumers due to its easy construction,desirable square footage, 70-4 and open,relaxed design with split bedroom privacy.And a skylit bonus room only increases its versatility and value. ai BED RM. n-e=u-o s 00 4T ti BONUS RM to-o.n-o BED RM ---------------- F-F O SECOND FLOOR PLAN .t _ 01998 DAG PORCH ATE BED RM _ -.. .. d__ Krr. o Plan 63-720 /The Grayson J 12-4.tl-e 011 6 Total living: 1893 s.f. First floor: 1370 s.f./Second floor: 523 s.f. c' = Bedrooms,2-1/2 Baths Du�N Bonus room: 354 s.f./3 GARAGE Crawl space foundation only. _---_: le-e=II-0 `--- � Price Category B GREAT RK le-o 17 FOYER - L' j 7-e= a: Size Does ,Vaffer At 1,893 square feet,this home's size is perfect for practically all of your prospects.. PORCH And the wrapping front porch gives it the appearance of an even larger home. Y— The master suite down with secondary bedrooms up arrangement is great ® FIRST FLOOR PLAN for empty nesters as well as growing families. � ,t-e Town of Barnstable P# `j A C.), Department of Health,Safety, and Environmental Services Publie'Health Division Date 367 Main Street,Hyannis MA 02601 eArwe'TABIL, puss. Date Scheduled Time Fee Pd. Soil Suitability Assessment for Sewage Disposal G. V/. "1t WitnessedB _00P&VA m A Ij Performed By: �2C� y: LOCATION & GENERAL INFORMATION Location Address / __ 'n Owner's Name S GI„ 8I.... I. 1 u fl b►bej'cfLC tC r ` e •�� Address •�� 7 C; Assessor's Map/Parcel: a I IA Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Le-,uu Slopes(%) Surface Stones N' Distances from: Open Water Body 300— R Possible Wet Area 11 Drinking Water Well Il fi Drainage Way It Property Line oZ0 Il Other tl k SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) NJ f V �tt � � 2 Parent material(geologic) ^ Depth to Bedrock Depth to Groundwater: Standing Water in Hole: N !1 ' Weeping from Pit Pace N r Estimated Seasonal High Groundwater tU DETERMINATION F" SEAS. AI.HIGII WATER;TABLE . .... Method Used. Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.ho in. Groundwater Adjustment - tl. Index Well# _ -_, .._. Reading Date:.__.--- Index Well level ___ Adj.factor Adj.Groundwater Level PERCOLATION TEST` Ar .. Observation Hole 9 Time at 9" Depth of Perc Lfd Time at 6" Start Pre-soak Time @ Time(9"-6") IS �� cvcsJttl+Q �a,�1ga,<<w� End Pre-soak Rate Min./Inch # Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant DEEP OBSERVATION HOLE LOG Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel) �� Sew y v- la /� 104M JOYA 37a V I OYA S� �e eQ k NO Wc;� DEEP OBSERVATION HOLE LOG <'Iiole# .: _. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. it SA 40. ` Consistency,°o Graver OYA I- t `Kati) I oyR DEEP OBSERVATION IIOLE LOG -_Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Con istenc %Gravel . DEEP OBSERVATION HOLE LOG Hole# :> Depth from Soil Ilorizon Soil'Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Cons•stenc %Gravel I Flood Insurance Rate Maw Above 500 year flood boundary No Yes L� Within 500 year boundary No L Yes Within 100 year flood boundary No L� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? \/ If not,what is the depth of naturally occurring pervious material? Certification I certify that on l&OU �l (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,ex ertise and experie described in 310 CM 15.017. Signature Date —�� ' Ro BARNSTABLE 9 OLD KIAcS, j 10 MENT. 77- 00 30 ,- ----- --- - , /� g%''�j.66, ---R= ' N64'32'50'E' ' . �z �' • BENCHMARKS ----- ---R 1.,2 --__,�- TOP. OF CATCH BASIN ELEV.= 100.0'(ASSUMED) , SAMPSONS -A MILL LOCUS AS/LOT 123 AREA =- 20,454fSQ. FT r LOCUS MAP '-- -------- 1: . 0 ASSESSORS MAP 22, LOT 123 t pis PLAN REF-- 271/56 & - 373169 % 3 -_-------- -- -- ---- 16 ZONING.• »RF" FLOOD ZONE »C" 38.2 4 LEGEND D) III EXIST. CONTOUR O TOP OF FND. - 2p- PROP. CONTO UR 114 EL. = 116 ti 0 -la, AS/LOT 6 ' - - 18 - - }11 SITE AND SEWAGE PLAN � � ,'� i �'• � � `s`9.2'; � -proposed O' -__�� 8 - C4-bedroom house �' PROJECT LOCH T/ON 10 ABBEY .GATE O BARNSTABLE, MASS. . o j APPLICANT. BILL SCHULZE GAR O TP' I��N OF 0 o PAU NR L TAN TS � a YANKEE SURVEY CONSU o + N P. O. BOX 265 UNIT 5, 40B INDUSTRY ROAD rF, MARSTONS MILLS, MA. 02648 1 114 o TP'�' PH.(508)428-0055 - FAX(508)420-5553 116 �-� -- r� `-------s?- tA !------ SCALE. 1" = 20' =DATE.. 11 23/99 171.17'(BY CALC.� �,' i N6112 47 E �, +, REV 176. 59 (BY PLAN) FRE ------------------------------=-=---------- ------- ' ` `. AS/LOT 122 JOB NO. 52085 SHEET I OF 2 , , =_116' gs ti TOP OF FV UNDATION "MIN ell 10' MIN. - 'A. CONCRETE CO ktW. F 4- SCHEDULE.4.0:P,.V,C. MIN..PITCH 1/8-.-PER`FT r 2"LAYER OF 12 _ . _ i i i ♦ i . � i w —T .T CONCRETE. COVER - WASHED IS NE�- - B MAX " _ EL: 114. 4' CAST IRON PIPE - ' (OR EQUAL MINIMUM PI71CH 1/4 PER F7' _ CLEAN SAND, 1 FLOW LINE —_ .25 9 '4. 4 w , :^ n 10 s . m INVERT l . •, a ,,, ,;; _ _ •o o _o o O, 1 = o.. - :,_ E 11 ' MIN. y- - 2 •�- o o° _ = = _ _ = = = =- = oy °8° INVERT # :y LEVEL °° , o Cl o = = = = = o = = °0 -- 14 1` ° m BAFFLE INVERT -r oo° ° o = _ _ _ __ __ _ o =; = O°000 8 75 IN EL:=11,2' 6 SUMINVERT o° =10 's - --- °o '�- `:- _ _ 4 o 0 0 0 ._ = o 0 0 EL.=112 25 E — r ° DEL' 11.Z�.25_ ,, 4. < ra (3) 550 CAL LEACH/NC CHAMBERS " DISTRIBUTION (7t7'BE PLACED, ON FIRM BASED. ;.- � t ,z. ,.P .' r MECHANICALLY COMPACTED OR 8 .OF S717NE G > ;, -EL.—'110. . V � 8011 1500 GALLONS ;. �, J u - '.- ---:-----. '"':12,B' X'34' TRENCH MRMAT/ON TO BE WATER TESTED'. - ° �lF MORE-.THAN ONE OUTLET_'. , € "3 v a SEPTIC .TANK -_ PLACE: ON. STONE � r � . n 6• S: , y a m l ,r " 14 3/4 1 S2 PROFILE OF . .,..` •- - DOU WASHED STONE O w �_ � �SYSTEI�r 4(SAS) $. SEWAGE. DISPOSAL SYSTEM ' 3 BOTTOM OF. TEST :'HOLE OR USES PROBABLE WATER TABLE ELEV.=_109____ 1 NO OBSERVED WATER TABLE (11/17/99) EZEV,=109 OBSERVATION HOLE ELEI!= 2_ NOT. TO SCALE ti. OLD KINGS ROAD ELEV. 9/9/99 ELEV. 98 PERCOLATION RATE �2l MIN./ INCH AT _4 '-INCHES R ` ' OBSERVATION HOLE 2 - ' ELEV.=_120_ x DEPTH HORIZ ' TEXTURE .COLOR OTT, OTHER DEPTH ORIZ TEXTURE COLOR MO TT OTHER 12" A -.•r — — — — — 4 0— � , ' SANDY LOAM � IOYR 3 2 - `- 0 l2" A SANDY LOAM.,. IOYR 3 y- 2.. 3, — 2 3' - - — _ Y 1 B LOAMY SAND IOYR 5 6. LOAM SAND IOYR 5 TL' - 3 —1 GENERAL NO S - - BY K 0,. CI ._z �MED.'• ND 1 s'R 6 4 , `3 11 1) ALL WORKMANSHIP AND MATERIALS SHALL .CONFORM TO D,E,P s� TITLE 5 AND THE TOWN OF _�ARN�TA_BLE____ RULES,AND NO WATER ENCOUNTERED F=x f �' ' NO WATER w ENCO UNTERED REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE ONE COVER ON SEPTIC TANK SHALL BE BRO UGHT TO a ,µ . 'Y - ' SOIL TEST WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" r DATE OF SOIL TEST. 9/9/99 SOIL TEST DONE BY BRUCE G. MURPHY, R.S. 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF i, WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN'. WITNESSED I3Y: '' . DONNA MIOANDI , 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE P#. 9530 DESIGN, CALCULA TIONS.' USED UNDER OR WITHIN 10. FT. OF DRIVES OR PARKING AREAS. 4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL INSTALL (3) 500 GAL NUMBER OF BEDROOMS . 4 BE MORTERED IN PLACE. LEACHING ,CHAMBERS GARBAGE DISPOSAL . . . . . . . . . NO 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH WITH 4' S2'ONE'SIDES TOTAL ESTIMATED FLOW AND ENDS GAL DA Y a DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO ( U!2__GAL 1BR,/DAY x 4___ BR,) 440 OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. A V X 5'i * EXCAVATE 5'�BELOW, 'LEACHING REQUIRED SEPTIC TANK CAPACITY 1500 GAL 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR CHAMBERS TO'tl E'LEV. 103. 75 TO SOIL CLASSIFICATION . 1 IS TO CALL "DIG— SAFE" AT 1—800—322—4844 AT LEAST 72 HOURS VERIFY MEDIUM:-,SAND. TO BE DESIGN PERCOLATION RATE < 2 MIN./IN. PRIOR TO COMMENCING WORK ON SITE. WITNESSED BY YANKEE SURVEY. EFFLUENT LOADING RATE . • 74 GAL/DA Y/S,F. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. • CONTACT YANKEE .SURVEY 24 HOURS LEACHING CAPACITY (AREA X RATE) 460 GAL/DAY 8) PARCEL IS IN FLOOD ZONE___.C ____. PRIOR TO INSPECTION, RESERVE LEACHING CAPACITY . • • 460 GA,61DA Y 9) LOT IS SHOWN ON ASSESSORS MAP __22 AS PARCEL _123 _ (25XL2,8X, 74)+(25+25+12.8+12,8X 74X 2) 52085