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HomeMy WebLinkAbout0143 ABBEY GATE - Health 143 ABBEY GATE LANE, COTUIT A, i TM � d v�p p� J t � o a � O 0 1 o� G Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA_ 4/4/13 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General. Information ' on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway - T use the return Name of Inspector key. H.P.S. r� Company Name P.O.Box 151 Company Address Forestdale Ma- 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number, B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of- Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/4/13 Inspector's Sig re Date The system inspector shall sub it a c© y of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 4 �� . .I 3 R t5ins-11/10 Title 5 Official sp ion Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for 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: Tank, Dbox, Pit all working properly 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool � ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ .E Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•1111u Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4l4/13 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility.with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or''no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 ..Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i f - Commonwealth of Massachusetts W Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings,if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 1 month ago Date Commercial/Industrial Flow Conditions: Type of Establishment:, Design flow(based on 310 CMR 15.203): Gallons per day(gpa) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes 'El 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-11/10 Title 5 Official Inspection Form-Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is COtuit MA 4/4/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 3/13 Date Other(describe below): General Information Pumping Records: Source of information: none Was system pumped as part of the inspection? ❑.Yes ❑ No If yes, voiume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: r ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit -MA 4/4/13 required for every page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1982 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: 20+ feet Comments (on condition of joints;venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 811 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)' ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth:. 3„ t5ins-11/10 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle .31„ Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 12„ Distance from bottom of scum to bottom of outlet tee or baffle 5„ How were dimensions determined? sludge judge tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): good cond. no cracks or leaks 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: Leach pit has 8" of water in bottom. staining 2'4" below invert from clean above that line t5ins,11/10 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 ,M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology:_ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth=top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11H 0. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 A. Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotult MA 4/4/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately vi 0 Sa, 33 A t5ins"11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. City/Town 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: 12+ 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: Back yard drops of with min. 10' of el. change front yard is higher then backyard. leach pit is 1' in ground Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o�M 143 Abbey Gate Rd. Property Address McNamara Owner Owner's Name information is Cotuit MA 4/4/13 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 DATE;__9/26/00 PROPERTY ADDRESS:--.---, ------------------ _` 143 Abbey_Gate kAjie Cotuit. Ma. 02635 On the above date, I Inspected the septic ,system at the above address. This system consists of the following; 1 . 1 -1000 gallon septic tank 2. 1 -1000 gallon leaching pit 3. 1 -distribution box Based on my Inspectlon, I certify the following condltlonst 4. This is a title Five Septic system. ( 78 Code ) 5. The septic system is working order at the present. 6. Note; The invert pipe to the leaching pit is 12" below the the inlet invert of the leaching pit.Instaed of 6 ' Aelow the �� pipe you have 5 ' below the pipe. 7. Pit was installed to High. ` SIGNATURE;,, 8. Distribution box cover broken. 9. ReplacedName:_,Z,��.H9ssaktr-.yU-__.a..- p � / C3 Company: Joe!.ph_P _ Hacomb.r_6 Son , Inc . Address;_ Box-66---------- __Centervilleu Har_02632-0066 Phone:___ 20 z.!Z5_3978____ _ THIS CERTIFICATION ODES NOT CONSTIYVTE A CIVARANTY OR WARRANYY JOSUH P. MACOMBER & SON, INC. Tanks•C9s+poois•l.oichfl�lds pump4d L Instilled Town Sower Connootlons P.O. Box 6�75•J338erAlls,A 02632-0066 -ter � 12�pA t , 1 • COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVE) B. STRUHS Governor Commiuioaer SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION property A&*,. :1 4 3 Abbey Gate Lane Name of Owner John Bredice Cotuit Addre"of owner: same Dou of Irupection: 2 0 Name of� �Der: ( {.,s. �ose h P. Macomber Jr. I am a DEP approved system Inspector purul&nt to Section 16.340 of TW* 6(310 CMR 16.000) c,,np,,,y N,,,,.: Joseph P. Macomber & Son Inc. M.&VAddre"' BOX b b enterviiie, Ma . 02632-0066 Tsaephorw Number — —3 3 3 CERTUICATION 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 dme of Lrupectlon. The inspection was performed based on my training and experience In the proper function and muntsnance of on•site s wage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Falls Inspector's SignaGue; , Date: v The System Inspect Wrall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)wttNn thirty (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 "it submit the report to the appropriate regional office of the Department oK-nv{ronmerMW Protection. The original should,be sent L0 VW system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Past Ior11 Of Printed on It"ted Paper SU53URYAC9 SEWAOE DISPOSAL$YSTEU INSPECTION FOFW., PART A C£NTViCATWN (oontLtsred) r,opo Adra„: 143 Abbey Gate Lane, Cotuit Owrwr: John Bredice Dou of V"P*Vdi : 9/2 6/0 0 eys►ECTION furawvtY: Ctwck A. B, C, " O: A. sYSTDA PASSES: _ I have not found any information wNch lnd Wes that &ny of the f&Auro condldow described In 310 CMA 14.303 •List. Any taa�k uttoria not evaluated are In, sted below. Cowaxrs p�;Note; The inert Ai t b t P 1 ear'h i n Ai_t is 1 2" byloa��h rTivu t of une eac in i of noIU-1—ng capacity. i. SYSTEM CONDMONALLY PASSES, AldOne or more system sompononu u described In the 'Conditions!/aces'section need to be replaced or repalred. The eyetom. vp• compledon of the roplacomont a rop&U, as approved by the Soard of HoaJth, will paces. indcate yes, no, or not determined(Y. N, ce NO). Doscribo bass of detwmLtadon In aJ!butanoes. If 'not determined', exa aln why not. ko rho •optic tank Is metal, unless the owner ce opwator Itas p wAdod the system tnapeator whh•Copy of a c4c"Seto or CompUancs fottschod) Indcating that the tank was lnataUod wlWn twenty(20)years Price to Ose date of the trvpecVon tho sopdc tank, whether or not metal, Is crooked, strveturaUy unsound, shows subotantlal ktf4Y6don of sAY60VOdon, o+ t. Ialluro Is Imminent. The system wW pass Irupoction If the existing septic tank Is replaced with a Complying sopdc taro approved by the hoard of Health. 420 Sowago backup or breakout or high static water level observed In the distribution box Is duo to broken or oba vcud pip• or duo to a broken, sottiod or uneven distribution box. The system wW pass Inspection If(whh approval of the Board of Health). broken plpole) are replaced f obawcdon la removed dlsvibudon box is levelled w replaced • The *Mom foQuhsd pumPMginar+dtanlow oted pipe(s). The iy*tsm wfrywe^ Inspection It (with approval of the hoard of Health), broken plps(el are replaced obstruction is removed revised 9/2/98 ncelorlt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART A CERTIACATION (contirxiod) /,opwtr Addreu: 143 Abbey Gate Lane, Cotuit Owrw: John Bredice 00" 'f 1ri°ecdon' 9/2 6/0 0 C. FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evalustion by the Board of HoWth In order to determine If the systam Is h1iing to protect the public health, safety and the environment. 1) SYSTEM WALL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CL R 16.303(1)(b)THAT THE SYSTEM I3 NOT FUNCTIONING IN A MANNER WHICK WLLL.PROjECT THE PUBLIC H AALTH.AND$AIM A D THE BsfZRO MEWL• Cesspool or privy Is within 60 feet of surface water Cesspool or privy Is within 60 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)DETERUSU3 THAT THE SYSTE3e is FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVLRONMEXT: 10 The system has a septic tank and soil absorption system (SAS) and the SAS Is wltNn 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS Is wltNn a Zone I of a public wet- supplY wou. The system has a septic tank and aoll absorption system and the SAS Is within 60 foot of a private water supply wall. The system has a septic tank and loll absorption system and the SAS Is less than 100 feet but 60 feet of mwe horn a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds Indlcatas Mat Vw well Is free horn pollutlon from that facility and the presence of•mmonla Ntrogen and nitrate Nvogen Is equal to or less than 5 ?pm. Method used to determine distance (approzimatfon not valid).- 71 OTHER revised 9/2/98 Pate3of11 SUBSURFACE SEWAGE DISPOSAL A YST9A INSPECTION FORM PARTCERTIFICATION (cortdnu*d) ProvwtYAd&*": 143 Abbey Gate Lane, Cotuit Owner. John Bredice Dou of y„pect—: 9/2 6/0 0 D. SYSTVA FAILS: You must Indicate either 'Yes' or 'No' 10 each of the following: 0 of I have determined that entifiede of mOlbelow. ThetBoardhe f iof Health owing lshouldure nbedcontacted to deteons exist as rirnl eiwhatt will be n ceuary to W fa`k' determination Is Ida Yes N 0/ BAS or-c esa}oal. �.• ,i/ Backup o4 e.weye Into fsclNty�or•�Tel+r^�^tPonHtedae�to en overio�d�d or^oMg4� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. Static liquid level in th dlstrlbu on bpx,rlb��)e�utiet Invert due to an overloaded or clogged SAS or cesspod. Liquid depth In-soeeA�"�+Tless than 6' below invert or available volume la lase than 1/2 day how. Required pumping more thaA4 times In the last year&U due to clogged or obstructed plpe(al. Number of times pumped Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fast of a surface water supply or tributary to a surface water wpDIY Any portion of a cesspool or privy Is•wlthin a Zone I of a public well. Any portlon of s cesspool or privy Is within 60 feet of a private water supply well. a cesspool or privy w th Is lase•than 100 feet but greater then 60 feet from a private water ppiy weu wlt Any portion o1 n acceptabl ewater,qty ualitlle or lysis. It the well ha& been mmonla nitr 9entandenJuate nluiogen.ach copy of wall water analysis to -c o - E. LARGE SYSTUA FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system Is a Significant"veal to ,fi _ o health and safety and the environment because one or more of the following conditions exist'- yes the system is within 400 teat of a surface drinking water supply ar �s eurl-oa drk+kiw9 w+Nr wl►fIY the ayatem•i�wlt 200 feetol+-M ►t Y Zo II of e D the system Is located In a nitrogen sensitive area(Interim Wellhead Protection Area IWPA) or a mapped M '— water supply well) slnfor ationl upgrade t he system In accordance with 310 CMR 16.304(2). The owner or operator of any suchPlease consult tt+e IoW rK offlce of the Department for further !n Pa{r 1 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART 9 CHECKLIST Propeety Adya„: 143 Abbey Gate Lane, Cotuit own«: John Bredice Data of 1nspectson: 9/2 6/0 0 Check If the following have boon done: You mutt Indicate either 'Yes' or 'No' as to each of the following: Yes No A y Pumping Information was provided by the owner, occupant, or Board of Health. None of the systemcoa*oaar"Ls,"jman paw►p*d4*;satJaast:two•wwke&a64 -Vystsm haib "vecolaassgesaeoi A rates during that period. large volumes of water have not boon Introduced Into the system recently or as put of ws inspection. ALI As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The ske was Inspected for signs of breakout. _ All system component a:mfudinp the Soll Absorption System, have been located on the Nts. 2/ _ The septic tank manholes ware uncovered, opened, and the Interior of the septic tank was Inspeoted for condition of bar or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The site and location of the Soll Absorption System orr the site has been determined based on: Existing Informstlon. For example, Plan at B.O.M. Determined In the field (If any of the failure criteria related to Part C Is at Issue,approximation of distance Is unaeeeptao. 116.302(7)Ibll The faclOty owtw (anC.�+�=+■.Jf dlHuaot frorn ou sx),viara.prayidarf wWt IaLaLm doc6an. mgj: ta..., _ ,. SubSurlsco Disposal Systems, n, revised 9/2/98 Page$of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECMN FORM PART C SYSTEM LNFORMAT10N PropwyAddreas: 143 Abbey Gate Lane, Cotuit Owr►..: John Bredice Dea of Inap.cdon: 9/2 6/0 0 ROW CONDITIONS RES084T AL; DosJgn flow:_aA0 9•p•d•roodro M. Number of bedrooms 1 eal nl' J Number of bedrooms(sctut+l)� Total DESIGN flows � Number of current residents: Garbage grinder(yes or no): _ Laundry(separate system) or� I}yes, eepuaielrup+ction-requited �P•� �� �� Laundry system InspW* (y0j/or no) /Cje)'67 f3%0(aocry"Ila?S. ' Seasonal use (yes or no): 1 y99::W L�L�acz Water motor readings,If available (last two year's usage Will: Lri------ Sump Pump(yes or no): Lost dais of occupancy: ' D CQsAL4 NCtALANDUSTRLAL: Type of establishment: Design flow: d ( Sped on 16.203) Basis of design flow ' Greese trap present: (yes or no) Industrial Waste Holding Tank present: (yes or noWl� Non-sanitary waste discharged to the Tide 6 systo : (yes or no)&d Water meter readings, If available: Last date of occupancy: ZO— OTHER:(Describe) AA Last date or occupancy: ' GENERAL INFORMATION PUMPtNQ PACORDS&no agylce of fo . tjo r Systed pumped as part of Inspection: (yes or no) If yes, volume pumped: _ 9sllons Reason for pumping: TYPE OF YSTEM Sspdc tankrdlstrlbudon box/soil absorption system Singlo cesspool Overflow cesspool Privy Shared system (yes or not llf yes, attach previous inspection records,it any) IIA Technology a c. Attsch copy of up to date oporatlon and maintenance contract Tight Tank Copy of DEP Approval Other APt ROXIMATE AGE of all componenu, data Installediif known)-and source 044-formation: Sewage odors detected when-arriving at the alto: (yes or no) revised 9/2/98 Psee6orit SUBSURFACE SEWAGE DISPOSAL•SYSTFaA INSPECTION FORM J, . PART C SYSTEM INFORMATION(contlrwd) progeM Address: 143 Abbey Gate Lane, Cotuit own«: John Bredice Dau of klspectlon: 9/2 6/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade:j� Material of consvuction:Nbcost Iron 20 PVCNUother lexplaln) Distance ho rivals water supply well or suctlon Diameter Comments: (condition of Joints, venting, evidence of taakage,rtc.) No evidence of leakage , ys em i ve SEPTIC TANK: (locate on she plan) Depth below grade: �—� g �� y Material of construction: concrete/Wmetal Flber tas Pol •thylen ther(ezPlaln) If tank Is fnetal. list ape 0 ls.age.conFwmed by Certificate of Compliance o0f (Yes/No) r f� r� Dimensions: Sludge depth. Distance hom top o ludge to bottom of outlet tee orixsffl Scum thickness: Distance horn top of scum to top of outlet tee or bsMe r � Distance hom bottom of scum to bOnOT of outlet to or baffle:.2ka-1- Mow dimensions were determin9d: Comments: (recommendation for pumpinHmiD thl Inlet and outlet tees or•baffles, depth of liquid level In role Inletd andoutletrei-K+tegrrty. evidence of leakage, etc.) 1Y' 1 One tees are in lace iqui eve inc es evi ence of leakage, GREASE TRAP: (locate on site plan)Depth below grade:/—/0 �&PoIyethylanar&other(explain) Material of construct! n:Aj/cortcrete/(g/ metsl4RFlberg Iss Dimensions: ff Scum thickness: Distance hom top of scum to top of outlet tits or_4Y too o Distance hom bottom of scym to bottom of outlet tee or bafffe:� , Date of lost pumping: ��► Comments: (recommendation for pumping. condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet Invert, structural Integrity. evidence of leakage. etc.) reas Psae 7 of I1 revised 9/2/98 SU93UR.FACE SEWAGE DLSP03AL SYSTEM WSPECTION F01" I MAMN (cond wow , SYSTEM WFOR 143 Abbey Gate Lane, Cotuit o.rrM•: John Bredice Dwo o+ lr,a�: 9/2 6/0 0 TIOW OR HOIDWO TANK:d'&9(Tank nwot be pumped prior to' or at dm• of Inapecdon) 1104010 on 0II plan) Oapth below prods: ans�othsrlIXP1&ln) McIIAN of c w on► ctlon-/J_4 oncrets mat���Flbarpla►st���dYs�Yl Olmon►Ion►: Clplclry: gallon► Deoign AOw: p►Ilon►IdoY Alarm prI►ont Alorrn level: Alarm InWorking otde►:Ys No� pate el prevlovt pvmpinot Aw Commenu: Iconddon of Wet tea. condtlon of ►)arm and Hoot switches,etc.) or ------------- OtSTRISUTION SOX:, llocele on Nte plan) Depth of liquid level above oudel Invert: comments: Id}ca(rYol(or, �(,�awe of J• kage Into or out of WI, eto l e I rod dlttrlbvtlon Is equal. evide8114f fateral. `1Vo evidence of IDONVFitution box h in o or 'u °on the o en cover. Pu Mp CM IA B EII:,6ve Ilocaio on Ott plan) /vmps In working ordof:(Ye+ or Nol� Alarm►In working order IYoe or No)� Comment►: condtlon of pump chamber, condition of pumps andf•DDvnenoACes' etc.) Inou am e hie/ofll revised 9/2/98 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA . PART C SYSTEM INFORMATION (cont mAod) Propa,ryAdclross: 143 Abbey Gate Lane, Cotuit Owns: JOhn Bredice Da,of ktson: 9/2�/0 0 SOIL ABSORPTION SYSTEM(SAS): (locale on slit plan, If possible: excavation not required,location may be approximated by nonantrualve methods) If not located, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries,number: leaching trenches, number, length: leaching fields, number, dlme Ions: overflow cesspool, number: Alternative system: IEIAp Name of Technology: ! O Comments: ' ote condition of s II, signs of hydraulic failure, I of ond)n dam s II, c nditio of vep atip etc.) Loamy sand to dead sand. W6 919n6 of �ydraurlic �al�ure or ponding. Ol s are cry. Ins a t 14A4 Rip *;he invert CESSPOOLS: (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 (cesspool must be pumped as part of Inspection) Cesspools are not, i recant Comments: (note condition of soil• signs of hydraulic failure, level of pond)ng,condition of.vegetation, etc.) esspo0 s are not present PRlVY:� (locate on site plan) Materials of conatruc on: Dimensions: IV Depth of solids: 109 Commenu: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) r1VV is not nragant -- revised 9/2/98 Pa¢s9orii SUi3URPAC9 SEWAOL OLS►OSAL IYIT1Dd INS►Wn0N►OKU PART C '. iYITVA WnR"I'low loondr� f.,pomy A,a, 143 Abbey Gate .Lane, Cotuit o.T«: John Bredice SKETCH Of SEWAGE DISPOSAL SYSTEM: Inclwdf d#i to �t I$&#%two pgrmanlnt rnleranc•Iandmuka or benchmauks locate ul wells wlWn 100' ll.0cat1 when publlo water wpplY OM48 Into hW&I) M � \ 10 301 / I II revised 9/2/98 ncrworli • 3Ui3URFACE SEWAGE DLSI93AL 3Y3TFAA WsrecnoN FORM , PART C s SYSTOA WFORMAT10N (condn+od) S NoptyAd&&": 143 Abbey Gate Lane, Cotuit own«: John Bredice D.0 of 4upocdon: 9/2 6/0 0 NRCS Report name Sou Type_ Typlcal depth to groundwater USOS Date webslts vlalted Obaarvadon Wells checked Orovndwater depth: Shallow Moderate Deep — SITE EXAM Slope Surlace water Check Cellar Shallow wall Estimated Depth to OroundwatelG Feet please Indicate all the methods vied to determine High Groundwater Elevation: _ObtalMod from Design Ifni on record Observed Site (Abutting property, baervadon hole, baaemeot eump otc.) Detormined from local conditions Checked with local board of health Checked FEMA Maps —Zchocked pumping records Zchecked local sacswto(s,lnstallers Used USGS Data Describe how you established the High Otoundwstst Elavodon. lb!yld be completed) Used; Water Contours Map Gahrety & Miller Model 12/16/94 nEtllof11 revised 9/2/98 I i TOWN OF BARNSTABLE WARD OF IIBALTII ,SUI)SUNFACF SFHA(1F, DISMSAL SYSTEM INSPECTION FORM PART D — CERTIFICATION ••1nr1••.•:n-t.ur..rrnw.►..vw•nnwww.w+.r.�,�.1w+�A�-+.w�rwOw.w.-w�w�� ..w v..r•T•r..�. _. I -TYPO OA PAINT C1.6AAI,Y- PItOPERTY INSPECTED STREET ADDRESS Abbey Gate Lane, Cotuit ' ASSESSORS HAP , DLOCK ANU PARCEL I OWNER' s NAME John Bredice PART D - CERTIFICATION NAME OF INSPECTOR _ Joseph P. Macomber Jr, COMPANY NAME Joseph P. Macomber &'-"Son, Inc. COMPANY ADDRESS Box 66 Centerville MA. 02632-0066 $tr#ct Tovn or City statq t P COMPANY TELEPNONC ( 508 ) 775 " 3338 FAX >�7101111 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ®rlecommendat' lons his address and that the Information reported is true , accurate , and omplete ns of the time of .inspection . The inspection was performed and any regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : System PASSED ' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public heAlLh or the environment as defined in 310 CHR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con acted has found that the system fails to protect the j)ublic. health and the environment in accordance with Title 5 , 310 CHR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature DataIV �9I rcopy of this certification must be provided to the OWNER, the BUYER re &pplloable ) and the 130ARD OV HEAL'I'lI, • If the inspection FAI.LL'D, thv owner or operator shall upgrade ' the system within one year of the date of the inspection , unlosa allowed or required otherwise as provided in 3.10 CMR 16 . 306 . partd . doc ifouxl�- 3 L C A-T ION � SEWAGE PERMIT NO. Rb J ,v ��a Ca 7v- 7 Ad 1#9 VILLATCE Ca' l s ,Mva � INSTA LLER'S NAME i ADDRESS Jose, j?T BUILDER OR OWNER T,ycl'/"C� c1fl'i 171° DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��, 0o g a,� LOCATION SEWAGE PERMIT NO. VILLAG i A E ERS NAME ADDRESS UIL ® OR OWNED e - - DATE PERMIT ISSUED DATE C 0 M P L I A N C E I S 5 U E D f .n ��� 00�-/ �Z o . . �� h� .%��� � � 0 Lh TOWN OF BARNSTABLE ,LOCATION 1 43 AbbeyGate Lade SEWAGE # VILLAGE Cotuit ASSESSOR'S MAP& LOT INSPECTED BY: J.P. Macomber & Son Inc775-3333 ME'S NA &PHONE N0. SEPTIC TANK CAPACITY 1000 gallon LEACHING FACILITY: (type)Leacing pit (size) 1 000 gallons NO.OF BEDROOMS OWNER John Bredice PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r IN Iv d No... �`.�!! 3 ✓'� F ,�?,.:°`..`........... ii THE COMMONWEALTH OF MASSACHUSETTS -;d") l, BOAR® OF HEALTH v ,.?i�,��r® .........-"". .. ...................0F..........................._............ ............._........_.. -................. �'�^ •,, �d�c�'�,* t�;l Appliration for Disposal Work, Tontrnstion rr'Ala nttI��,a� Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposaly System at: ........../-401..1.1A.... ...... ec ion Addres or Lot No. •---.. --&........A...... �1'1.e«''�..-----•--•---•-------... -•---..�.e.et.t 1�1�!.5►.....44 4......-.... ................. � Owner ` Address a1-`- .1�1. SivA�� ..................... ........ C� �5� - -t-Alt.......................................... Installer Address Type of Building Size Lot..Lsf__ Us?'d'v......Sq. feet �., Dwelling—No. of Bedrooms..._...___..........................__Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .............. No. of ersons.....................__._... Showers — Cafeteria A, YP g P ( ) ( ) a Other fixtures -------------------------------- . W Design Flow....... .2_.0.................gallons per person per day. Total daily flow....... ..........:.......gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No.'................... Width.................... Total Length.................... Total leaching area___•-----•-_..____-•sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil......................................................................................................................................................................... W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•. UNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'i LEE 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in P Y g g P Y operation until a Certificate of Compliance has been issue by the boar of 1 alth. Signed........ : ... . . .....A ------•----- ................................ /� ate Application Approved By.......... = .•.......... mod 04 Date Application Disapproved for the following reasons----------------------------------------•------------•.......................................................... .................•-•---•---...----•-••-----•-••-----------•--•-•-•-•-•-•--•---••...............-------•--I---•--------......••-•••-••--••----•------•-----------•--------•----•••----------••--------•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ..--' --......OF......................................... Appliratinn for Uhipaii al Works Tot titrnrtion ermi# Application is hereby made for a Permit to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal System at: ....•..... - --•• , Pca'on Addres or Lot No .... ... A :.........................••••............... . Owner /f t A d`ress •-••--•-• .t�►�f..1 �'.••{+�_�------------------------- t.-�i!..s�-j•+-••....................................... Installer Address Q Type of Building Size Lot... 4; a......Sq. feet U Dwelling—No. of Bedrooms_......_..3.............................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers YP g ------•---------•----------- P ..----(----)--- Cafeteria ( ) dOther fixtures ------------------------------------•-••----------------•---•--••-•••••. -•-•-- W Design Flow....... . .................gallons per person per day. Total daily flow....... . .. ..................gallons. WSeptic Tank—Liquid capacity....___._...gallons Length................ Width................ Diameter-_-__-__--__--- Depth................ x Disposal Trench—No. .................... Width_................... Total Length.........._......... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ P4 ------------------------------------------------•--•------------..----------------•-----------••---- ---------------------- -••-------------------- ODescription of Soil-•----------------•-------------------•---------•---....---•--••-•-----•---•----------------------------------------•--------•----•-------------••--------••......•----- x W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----•------•-----------------------••---•--•------------------------------.......--••---•----.......-------------------------------------------•-------------------------------------•--•------••.--••-• Agreement: t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the boa�a of Ivalth. Signed �`� � .. .. D to Application Approved By--••---- ' Date Application Disapproved for the following reasons:...........................---••-••-----•-------•-• ........................................................... --••------•---•••••••-••••••----•-----•-•--•-••••.....-----•••.................••........---•••--•---•--•'-•....---------•---•--•--•••-••-•-•••-••••---•--•--••••••••------•----••••••-----••----•----•-- Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS. BOARD OF HEALTH ..................................I.......OF..................................................................................... Trrtif irat a of Toutplianrr THISII TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby-------------- ' 'fit '- .. ...----•-------•-----------•------------------------------------•-•--..............--•---........................---------------------- I llet. .-• r . at..................... --•-•------------------------------------••-- ------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application foV Disposal Works Construction Permit ............. dated_............................................. THE ISSU N OF THIS CERTIFICATE SHALL NOT BE CONST S UARANTEE THAT THE SYSTEM1lYIL Fc/NOTION SATISFACTORY. DATE..... ............................................... Inspector.... ... ..... •--• ......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF...........................: .......................................... FEE..... '}............ Disposal Work.5 TDonatrn.rtinn ami# Permission is hereby granted........../,.--` -t .. s:r=' ......----------•----------------•-------------------......-----•---.:..-----= ...........•. to Construct ( k1lor Repair ( ) an Individual Sew� Disposal System, w.:= t.�, yf.::_-�-. _—_---Street .--------•----------^--------•-•-• 41- wPP `P r DatedZ-_$as shown on the a lication for Di, osal Vl orks Construction Permit No.__._._... -=' i' el •••... r----------------------------•.-•---.---------- Bard of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS o. y 2 MFT I LGT LOT \ 1 2� f �. , 1 j j C .4?D,r:>0s 4=- ,D /000 a _ SO/L TEST \ } I TEST 412 O 4 TOn ..OF l 7-r0,47Ns.. )Jo EXh/�/ S/Oi✓ T' Cp eok, )*/ - j8.3 TE M&NSTA"LE CU vSCTVA;lr1� ,EX/ST%wG' /9w1� /T 144 RICNARD RlCHARD\' I o )AMES LAMES c O'IiEARN O'HEARN i ClST E� Ep/5T`. 'g. - swNtTAF1P�� Z'O ;.�yD y L"EGEND - EXISTI":G SPOT ELE ✓AT10N-S 0,0 EXISTING M . CONTOUR - - - 0 - - - - FINISHED . SPOT ELEVATIONS f�yo -- FINISHED CONTOUR 0 PROPOSED PLOT PLAN APPROVED; BOARD OF HEALTH DATE AGENT ���r // ' - /� /wC;S C�O�'.a/�; I CERTIFY THAT THE PROPOSED Rr ✓r 0.7HEARN.. 11VC., RLS, RS BUILDING SHOWN ON THIS PLAN I348 ROUTE 134 . CONFORMS TO THE ZONING LAWS EAST DI.NNIS 1 MASS. OF z��°�!�r.9G': t: MASS. DATE JOB N O. �� '-_�'f l <` ' CLIENT-Lam,,. U;Tf- f'.t_GIS TE_`,(-.J I ,,P' ) �lli,\'E YC)F2 (:; (;'� ! ' ' . :.I;F. I: T - .- OF �._._ TEST - INVERT ELEVATIONS NOTES: SOIL TE �) ALL` . WORKMANSHIP AND M►_ 5g INVERT AT , BUILDING /7 0 FTDATE OF SOIL TEST �c - /E FT. ALL CONFORM TO D.E.Q.E. 1►. WITNESSED BY �i�/%1���'^! �� INLET SEPTIC. TANK' AND THE TOWN OFi59,eti' Rom_ PERCOLATION RATE Z MIN./INCH OUTLET. SEPTIC TANK. /6 3 FT AND REGULATIONS FOR , ,SUBSURFA,CE I INLET DISTRIBUTION BOX �G•.o FT DISPOSAL OF. SANITARY .: SEWAGE OBSERVATION HOLE . l OBSERVATION HOLE 2' " OUTLET DISTRIBUTION BOX Z-5 8 FT. 2 yvATE� . TAI3GE .EGEV. 3. z ELEVATION = 17 .,� ELEoVATION= 20 3 INLET LEACHING PIT LS S FT. j — a T�ETE�M/N,En %�20� ' soi TFsr '� BOTTOM LEACHING PIT 9.5 FT. GN L0T // "9 . • 1 073 ,O c .U13 sai� S DESIGN CALCULATION NUMBER OF BEDROOMS .. . . . . . . i GARBAGE DISPOSAL UNIT:. M cz 6- N rzE D TOTAL ESTIMATED FLOW ( //O GAL./BR./DAY X 3 BR.)... 33 o GAL./DAY ' REQUIRED SEPTIC TANK CAPACITY. . .. . ... . . . . . - %S GAL. ACTUAL SIZE OF SEPTIC TANK TO BE. INSTALLED... . /00 o GAL. LEACHING AREA REQUIREMENTS. BARwsrat�CF SIDE' WALL AREA - GAL./S.F. CONSERVA.;'. I 2�11•a - /44 F` - 2• BOTTOM AREAS GAL./S.F. Corrirdl►ssioN 1/.'/-'TES /vfJ Yi/�r �(, : LEACH. ING CAPACITY ( BOTTOM SIDEWALL ).. .... . . . . . . 64 %� GAL. o t s. i 4.X X to y'z. S. 54 . 7 GAL. I RESERVE LEACHING CAPACITY. . . . . . _ . . . . . DEC TOP OF FOUND. F.r ��,,. AI 4 SCH. 40 CLEAN SD j ELEV.= 20 �'- CONCRETE PVC PIPE Ii COVERS MIN. PITCH CONCRETE I/8 PER. FT. _P`t77� 2% MIN. PITCH *�l' OF y�r E�`tK G 12 MAX. _ I 4 RI:HAZ - R0a RDIrAHMAERSCV OF /8" 1/ " JA5� a CA y I FLOW LINE - WASHED STONE '" wNi�eiN ,p �rbEa9iKo �i _ 0 Z I9" o D 3/4" 1 1/2" ��,�GISTEQ 10 rC'tSTf��v 4 CAST IRON - g �- w 7a WASHED STONE O - 70 `S�gV PIPE- MIN. PITCH ° ° L >2 c n PRECAST LEACHING ' DIST. � • 1/4 PE.R FT. BOX " `Lk Uw A a BASIN 'OR EQUIV. J) V w n ' °_ n w � /coo GAL 5 ��/c'��S'T.913� F MASS.. v `-�-I '. 4 �.r R. J. O� HEARN, INC., RLS, RS SEPTIC TANK /O .•Cr n/,,; ���..�. . . 1348 ROUTE, 134' EAST DENNIS, MASS. PROFILE OF GROUND WATER TABLE F4 = 3. 2 JOB NO. 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A!;,z 1L i,°t° _ - ___" - __ +Ml Nt bit' V; 6'4�5 4 e o CO C p X Co r T.A m> 41,CC: 7 nl Z 7 nz The Abbey Gate Nominee 1- by GTrust Residence Ae ARCHI _TECH ally°the 6 school street t 508.420.5335 f508.420.53 .I- 0'aA 4 tIIIIII- � IIII'Ii Ooa rl 143 Abbey Gate Road asT:lcrhaarA°y,Ih°:nl aicf t;.;nA°nnnin�oe�°wr5ra°endrl,cA.i oa°mil,n-a II ch•,�t."-_'-�.Il ASS0CIATESAcotuit, ma o2635 einfo@archftechassociates.com Massachusetts tbggncprioroa _ hi Plans ala;'e ° O°°mI architectural design architechassociates.come arg�