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0012 ANCHOR LANE - Health
12 Anc hor Lane u Cotuit - A= 024 - 060 TOWN OF BARNSTABLE LOCATION / A„c-1.or Lane. i SEWAGE#,V007 -o7SS VILLAGE Co-f U�� ASSESSOR'S MAP&PARCEL �?, 5/ - G O INSTALLERS NAME&PHONE NO. B gr Q EJtcAVA?2onJ So$- y77 - OG S3 SEPTIC TANK CAPACITY /SOO qa//OAS LEACHING FACILITY:(type) Soo qQ I cAaMS 2) (size) )3 it ZS' x 2 NO. OF BEDROOMS OWNER 4anCr �- i cr �J PERMIT DATE: G -7 COMPLIANCE DATE: ® [ Separation Distance Between the: l 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 Al-3e'� .3, A2.aS" B3 -S-g' a a Ay.Ss' 9EcK 'e4 AS•G3�6 a y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P"r"I 12 Anchor Lane Property Address Lance & Monique Chevalier f ; Owner Owner's Name information is / required for every Cotuit Ma 02635 8-27-15 is page. City/Town State Zip Code Date of Inspection u� U1 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: `"J, # key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 aluation y the Local Approving Authority 8-27-15 Ins tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Qo VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewa D posal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is I required for every Cotuit Ma 02635 8-27-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D I A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", 'no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) _ ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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): rr I Y N ND below): ❑ distribution box is leveled o replaced ❑ ❑ ❑ (Explain be o ) ❑ 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(l)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Anchor Lane - - - Property Address Lance & Monique Chevalier Owner Owner's Name information is Cotuit Ma 02635 8-27-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system SAS and the SAS is within ❑ Y p p Y (SAS) 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 forma 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. CitylTown 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 E] ® obstructed pipe(s). Number of times pumped: ❑ E 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 ❑ FT the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone Il 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No Y ❑ ® 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: Numberof bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 31.0 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): " 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Anchor Lane Property Address Lance& Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail 2013-75,000gallons 2014-66,000gallons Sump pump? ❑ Yes ® No Last date of occupancy; 2 weeks ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑_ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 12 Anchor Lane Property Address Lance& Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 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: Was system pumped'as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons I How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool - ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a.copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 H 5 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma. 02635 8-27-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' 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): 2' 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 gallon Sludge depth: 6„ t5ins•3/13 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 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30", i Scum thickness 2" 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 15" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time. 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•3113 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 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 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): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ► Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-box is in working order with no sign of back-up or carry over. 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.): I * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Anchor Lane Property Address Lance& Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: 2-500 gallon chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology.- Comments (note condition of soil, signs of hydraulic failure, level of'ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Chambers were dry with no sign of back up. a Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit -Ma 02635 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below Q drawing attached separately .ti i A2-as' A 'Sy B3 ',5'9 Rca, A B A 4.sr� B4 AS•6316`' Q I I t5ins,•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 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: No Gw 120"feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6-08-07 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Anchor Lane Property Address Lance & Monique Chevalier Owner Owner's Name information is required for every Cotuit Ma 02635 8-27-15 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • Town of Barnstable �SFIE 1'. Regulatory Services Thomas F. Geiler,Director + DAFtNS'�'A;BbE, + a Public Health Division TFp, Thomas McKean,Director 200 lain Street,Hyannis,MA 02601 Office:.508-862-4644_ Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer: ����. �'6 �J Installer:. Y ( Address: . � Address: 1 �, On �V , � � � was issued a permit to install a (date) (installer) septic system at Z. �� C based on a design drawn by (address) . dated 6 -3- 4 7 (designer) I certify that the septic system referenced above was installed substautzall. accord' .he design, which may include minor approved-changes such as lateral i location of he. _dam. ibution box and/or septic tank. 1� I cer.WTthat the septic system referenced above was insta -d with ma ,chars es P . g greater that 24 lateral relocation of the SAS or any veat6ak relocation of sny comport t of the septisen1)but in accordance with State &Local'Regulations. flan revisioxk oT . certified as-biit by designer to follow. (Installer's S re) B. �, Na 1066 sgN►TAR�P� _ Desi er's Si . afore( gn } (Affix e igner s Stamp Hexe) PLEASE RETURN TO BAHN',WBLE PUBLIC.HEALTH DMSI®N CERTIFICATE OF CQMPLIANCE WILU NO BE ISSUED 'BOTH". FOR11 AND' Ate. BUILT CAS AlaE RECEI VEI3 BY `] B S�T.�LE PUBLI SAL D SI5 T. THANK YOU. <: Q:_Health/Septic/Designer Certification Form , , i V. Town of Barnstable P#J/ of� Department of Regulatory Services DAIDIffrABIA Public Health Division Date uCo � •yap. �e� 200 Main Street,Hyannis MA 02601� Date Scheduled Time Fee Pd. . K Soil Suitability Assessment for Sewage Disposal Performed By: "'" ��D �� '�JV® Witnessed By: LOCATION& GENERAL INFORMATION Location Address Owner's Name I o t,(-e C f) e Va l le rr j COfU17' Address Co i-u l r Assessor's Map/Parcel: d 2H— 0(. O Engineer's Name D4\11 d Ma 50 n NEW CONSTRUCTION REPAIR x Telephone# 5 D$`3 6 `7 O �l Land Use 1� � Slopes(3'0) Z /� Surface Stones Distances from: Open Water Body It Possible Wet Area It Drinking Water Well !!�ft Drainage Way T It Property Line w ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands?n proximity to holes) T2,- � d , Parent material(geologic) vU Depth to Bedrock 7L Depth to Groundwater: Standing Water in Hole: 'T � Weeping from Pit Fpce Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _ in, Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level _ ti R w Adl.factor Adj.Oroundwater Level PERCOLATION TEST bale 2 Tlnte Observation 1 Hole# Time at 9" Depth of Perc _� Time at 6" .. Start Pre-soak Time @ Time(9"•60') i 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----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC �. 1 DEEP.OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil er Surface(in.) (USDA) (Munsell) Mottling (Struct e,Stones;Boulders. Con istenev M ravel 33 S — 141 7- DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi enc % ra el 44 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. Con iste o p vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, O C -U Flood Insurance Rate Map: ful Above 500 year flood boundary No_ Yes .. [� Within 500 year boundary No I Yes Within 100 year flood boundary No Yes Ij i 1` Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us ate ial exist in all areas observed throughout the area proposed for the soil absorption system? — d If not,what is the depth of naturally occurring pervious material? "T Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by me consistent with . the required training,expertise a d experie ce described in 310 CMR 15.017. Signature Date Q:6SEPTICVERCFORM.DOC No. . aOo?— •ASS i �. f Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RpPlication for �BiZpo aY 6pgtem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 12 A Rcho r L fu CD TV r r Owner's Name,Address,and Tel.No. f �prlt-tt ��ctIe Ghevaller Assessor's Map/Parcel #a fCe �� �2 At n c.ho r La n� 5 0 g..y 2$ -1"1 4 1 nstaller's Name,Address,and Tel.No. J`S�g-4 1"b6S3 Designer's Name,Address and Tel.No. bte.T C-�I LFo - t-Q Excava+ion 7a\io Ma.5on R5, !)a(- invimnbesigns r +' Sa4-8 2l Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date (o I O 0 7 Number of sheets Revision Date Title } t 41-1W/Tale �d Size of Septic Tank 0 0 QU Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed b Date G i 12I U-7 Application Approved by Date Application Disapproved by: Date ' for the following reasons Permit No. 0 07 — 2- 5S Date Issued •" 6-fN-n-7 No. d �?. r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS.. Yes 2pplicatiou. for Migpogar *p5tpm Construction Permit r Application for a Permit to Construct( ) Repair(Upgrade Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. I q(1�hC�r L�"�(J Ut1' tner's Name,Address,nand Tel..No�V�I � J�C1 r1 Lei N i C t i e4� t Assessor's Map/Parcel --"'i a y _Pc)f(a } L n G{1!�r LG(1e 5 U 8 .412$ -1-7`t 1 _ nstaller's Name,Address,and Tel.No. �'��' Designer's Name,Address and Tel.No. -'bee.T G1 Lr-O 131 (3 Cutclva41c)n ►Dr-Dr ma�,Cn rz_s, �)GL t rluirp��PS«jfi5 1 err nP �c,r s ciGl� Snn N 5Uk d — zo Type of Building: � Dwelling No.of Bedrooms ,`':31 It Lot Size r sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons r Showers( ) Cafeteria( ) Other Fixtures f Design Flow(min.required) 330 gpd Design flow provided {`r gpd Plan Date �o 'g I U 7 Number of sheets Revision Date Title 5 1 -e i ~ Size of Septic Tank 1 0 G(� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) . Date last inspected: Agreement: ",The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage dispos`a]Vstem in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed D Uzq� Date G 11 21 U-7 Application Approved by w Date (9` g4-�g Application Disapproved by: Date for the following reasons d Permit No. d O G7 ` 5.1 Date Issued 6`11(`0 - --------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by B 1 E 1Cr(1\l(, 1/� at 7 A n Lh b f" L C.k ne- 64-t"` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a'C" 7 ' X'S 5 dated 6' N 0� Installer 2 bbe-2_T LF b\( Designer O\( I o ()M #bedrooms�� Approved design flow�� gpd The issuance of this permit shall not be on dues a guarantee that the system,will c'funo'n a de g ed. Date YJ /J Inspector, _.�-- -——— c — .! ——— ————————————--------------- No. �SJ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS _ Mfi5pool *p.5tem Construction Permit tPermission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at 2 A n c_hor I(,h_�1..6— f r, � U l-r-" � a "and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Date C tr7tior(r�u�t be completed within three years of the date of this permi ate C, Approved by f``� TOWN OF BARNSTABLE t� SEWAGE # 7- / LOCATE �nid ok L 6 VILLAGE �L/ ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. Q O /I0V SEPTIC TANK CAPACITY 106 0 A r` LEACHING FACILITYAtype) /,% (Size) /®00 NO. OF BEDROOMS' PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER �'CJtiS UC /�� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: -Yes No ��yl �? � ifs �� ���' �� /f - �/� �, '� 2. O No.. Fps.. ............ THE COMMONWEALTH OF MASSACHUSETTS o 2A � BOAR® OF HEALTH Allp irFafilan for flispas al Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct q—) or Repair ( ) an Individual Sewage Disposal System at: ................ __ , ....1. ,Y4 .D.. ...--1-.tV .................... _AW..-D-3----------o... ...ra..J..r.............------------ or Lot �c2. . .ly TPC�7���tY.._. �. = a/ aN?".ff. — - ..•----- Owne Address ---------------- Installer Address PQ U Type of Building Size Lot.... 1Fl�f_, Al d..Sq. feet �-, Dwelling—No. of Bedrooms--------- --------------------------Expansion Attic ( ) Garbage ,Grinder ( ) aOther—Type of Building P .1-11J.6. No. of persons..........4__------------ Showers ( ) — Cafeteria ( ) dOther fixtures - ------------ -------------------------•-•------------------------------------------------- ---------------------------------------- Design Flow...................... _---------____gallons per person idr d Total 1 fl 334.__... _...........gallotis. � Septic Tank—Liquid capac>ty� Qgallons Length••_ ___•- Width._�.../V. Diameter---------------_ Depth...S.40 . Disposal Seepage Pit Nol._ _--f______-_ Diamete Width..........::.Dept below inlet....._ _ Totalleaching leaching area area.----.�f_..�..sq. ft. Z Other Distribution box Dosing tank ( ) a Percolation Test PiT st NoRisult�---•--minutes p Performed bah--D p�th o4�s•�i1�P�-�-/�1-Depth grounder._---�^_�y" f1 Test Pit No. 2..... ........minutes per inch Depth of Test Pit.................... Depth to round water___ ._.Q� TC P P P g /` O Description of Soil......................... 911Q)-l--Ow........ �:- - - - - - .. � 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 L i':1-2 p5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of he th. Signed-eons: ---- -- .- . - w--// ' �21l -------- - --------------------------- X Re Approved BY---- ----- ------........ ..._......._._...--•-- �.... .l I- ate Application Disapproved for the following red •----------------------------------•-----------------...._...----------------------•-......................... ....................................•--------------•---•-- -------- ••--------•------------------------•-------•-----•--•-----• --- .---- --------...-------------------- Permit No....0r .-.J...�....................... Issued_....._._ C?.9 _!? - ---- ...................... ------ Date ........................THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' e. W..Al......oF..�.�:��i:�.� ............................ Appliration for Disposal Works T000t.rnrtion Frrutit Application is hereby made for a Permit to Construct.{ ) or Repair ( ) an Individual Sewage Disposal System at: , .. .J`I Location-Address or Lot No. ' .72:1------------------------------------ Owner ` Address ............. 2E .0---.�1fCn7—n&_A.I..r�►'j....------ ----•------•• 0- ----------------------------------- Installer Address Type of Building Size Lot... �!.,� ,� ----Sq. feet U Dwelling—No. of Bedrooms.._....j•--_--•---•--------- -----Expansion Attic ( ) Garbage Grinder ( ) a — aOther—Type of Building� 1 �L �4/_ .. No. of persons.........1................ Showers ( ) Cafeteria ( ) � Other fixtures Design Flow.................... per person per d Total Il fl w__.__.... � .. 1 ns. ; WSeptic Tank—Liquid capacity/j,.0.6.gallons Length..g...6.__.. Width./ _IV.... Diameter________________ Depth_./.Q. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--------f---------- Diameter._._.__.�j Depth below inlet..... ...... -.Total leaching area sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by.__-4_-0LP1.e_L4/.....AA/ _ �.�=�,r�..Date_._./�-"':--- _ Y. . Test Pit No. 1____•,e-------minutes per inch Depth of Test Pit.................... Depth to ground water._--yy_.�_I___._.___:._�y}- TF fZ4 Test Pit No. 2.__4........minutes per inch Depth of Test Pit.................... Depth to ground water._/.._.10�/.... --------------------------------------•-•-•---•-•---------.......-•----..........------------.------......................................................... 0 Description of Soil......................... ....... W ---•------•-----•--••-••••--•--•---•---------------------- /-At -c------- f�j --...--•------------------------...----------•--•-•-----------•------------ ---------------------------•----•--•-••••--------------------•------------•----•-••-•-....•-----------•--•-----•----•----•-•----•--•--------••-•------------••--•••-•-••......-••--••-•--••------•••••. U Nature 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 TrmLEE j of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe(-sons: _ $r ..... _- r�!:t.r- 'L ate Application Approved BY ='-1= r -I Date Application Disapproved for the following re -------•-------•....................•------------------------•-------•-----•-••--•--------• at.e----•--------- t1 . -••---••-••-•-----•-•---•----•••...•-------•-•---------------•---- 2rr,,,, 11��J�------------------------••--------....-------:--------------- - / Date 7 Permit No.. r! ,•1-------------------------- Issue(L �a�! �I--•-------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFr�}} HEALTH _ ..... :. /............OF.... .1�../!o. ..� ,G- ..................... Trrfifirtttr of Tontpliattrr THIS IS TO C�RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } by------------ . :..'��.1_ ... � 1 �?��'!c ' ` ------------------------------------------ Instaler at----4Q---?7- �........I--A+AID•. --•-• -----------•- '-2.--.6 /--.l.......................................... has,been instailed in accordance with the provisions of Ti T E j of T I e State Sanitary Coe s d s �i' in the application for Disposal Works Construction Permit No..� . ............. dated__...____. .a /._......_._... t '( THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. ! , ,,-/jam DATE...- fi�� ` ----------------- ................................ Inspector..... '� ,W f/.•.._� ........................ r'. THE COMMONWEALTH OF MASSACHUSETTS f' BOARD OF HEALTH ........-0--�.�r..........OF.... f��. �'.. ..� , ............... NOg....� FEE..... ........... Disposal Workii Tono#r ion rruti# Permission is hereby granted.... ......................... to Construct* ) or Repair ( ) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit N -(/ _ Dated.......................................... � --------•--• - ---................................_ Board of Health DATE.. 7_19819.1--•-------•---•-••---------.-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ` ASSESSORS MAP.. 2 TEST HOLE 0 E LE LOGS -pal# 11 OTES: i PARCEL: , 1 is V t o SO i L EVALUATOR FLOOD ZONE: WI TNESS. tZ 1 The installation e shall coin 1 with Title V and Town of Barnstable�D t 2. � -. :. ) comply able Board of 13�E- S REFERENCE. .; _w._..._�- ._f��. �*. �, GATE. �k Health Regulations. _ gu P� ERCOLATIO T 1N f G j4L./ N A E -� Z !� � 2 The n ���.. � r ) e installer shall verifythe location of utilities sewer inverts and septic prior components r m o to stallation and setting base elevations. 1I� � 71,1VP S s 3 All gravity i a t septic c piping to be 4 inch Sch 40 PVC at 1/8 per foot. Th,TH- i _ ) g Y, p P P g p o e first TH 2 , twofeet eet out of the d-box h 1 to the leaching shall be level. � lbfr4 lA+� w 4 This lands not to be utilized for roe line determination tti J4 ) _P P propertynor any other u ose other than h'� SM1ti.1 t the proposed` osed system installation. 0 � purpose P P Y 1 � . All septic components must meet Title V specifications. 0 ) p p p . 6 k , Parking shall not be constructed over H10 septic components. r � r ) g P h LOCATION MAP , , The property is bounded ) P P Y d by :corners and property lines. , 5 _ 8 The r n' e property owner shall review design considerations to approve) P P rtY g pP,ove of total design n -. � flow and number of bedrooms to be considered for lest n. Receipt f g pt o a ment for the plan _p y e a and installation based on the plan shall be deemed ?� P to b _l approval of the design flow b the owner. PP g Y The existing leaching st eac or cesspools shall be pumped and filled with material g g P P P I , rTil V 't e t e abandonment rocedures. Those within the r Z � PP proposed SAS shall be removed In with �.. e o ed along t contaminated soil and replaced with clean washed sand - = � g P a y 1r�1a� ... - � r Title 1 e V`specs. 10 Systemcomponents y to be 10 feet from water line. Sewer lines crossing.the S water line hall be sleeved with 4.inch SCH 40 PVC with ends grouted i g o ted f SEPT C S ST M Y E DES 1 GN applicable.= 11 If grinder responsibility a garbage de exists it is to be removed and is the res onsibilrt of the g g �' P Y FLOW EST I MATE owner to ensure such. 12 The installer e nsta er is to take caution in excavation around the gas line if applicable, : PP. 13 The proposed septic tank and leaching components are rated for H1 i J_BEDROOMS AT /LO GAL/DAY/BEDROOM ,J-0 GAL/DAY ) P Po P g p o 0, f rt is r installed as such, vehicular traffic is prohibited over the tank. d` SEPTIC TANK fib x 2 DAYS - GAL 0 USE ` GALLON w�Tl G LL N SEPTIC C TANK C. � P. ( �N S�l�. ABSORPTION S S OF Mq � ON Cl) O C -r t t -1 q � o tD No.to - t 2 413 y ZXCO- sT� -- S 1 DE AREA. 'f '� 7 p BOTTOM AREA: i b 7 = / X 2r�Di �. SEPTIC SYSTEM SECTION -. C � -- V M11j, YAW 1v1 PL I� / Z 3 STaW 6& W _ $ - 1�,9 0 13, 4 C JGYX� GAL „ {I , 6 lra Y• SEPTIC ,, TAN s. e �a _ G SITE AND SEWAGE PLAN -. -~- Gt..1� LOCATION : IZ. � �C'�- �-- 0 ?Z ` D rl 1. .:..PREPARED FOR : , 2 � �xc�4V�7?!�I SCALE. � - a s _. o - LU ©AV 1 D 6 . MASON �� DATE: (v DBC ENV.I RONMEN� AL DESIGNS _ Z SANDWICH . W EAST AND ICH . MA DA TE HEALTH AGENT _. (,508) 833 2177 7 o s}rtWwa<if.AUAWs'f�'�'•�yi++r' r."-*rd<rv..xM.aa.+:.:1v:riMKa.=xmror.Mt±tw.!.Naffs'xM,k•+e'.�.vw..+xRr.Y�.unP•,Mdia�.^ iY[YW v/,�++'a.�M1it«a' ta.:s..wtm'a,an.•+rwY.w-..Lrxaaenn•,wu'vmvrrm..e>W>.•r>.y'ht,n:x,uwv+,>: we,,ncrvm-.^.:ur...weW.•.+*•.r+:ra:¢s rtaar•ei�=4d.'x.�..xw• ,•.....,:�,o asssn:.e.M°wPbx'++_•'s+rtA-.'ea'.M'it4:iw.'aioraeWyfODR'�,.vw..�avx..aa...:,a.� E�a�..n:arv..:.,.a•�.yaMYSYmaill:®s.m,amyf<p�ubaR+AYa"b,J e'e.MY'>�"a•nn.nc vNiT+P1M.,'4Y,w'+ei.:M�...<.�nb.NWx..ik.•a ,�-acA!SYN!b+FfA4E.YY:'(uNA•n+.M1vR*.w�ea._ •-'R�M",M'. �^, •n+�'Wi"'sJRMN_ta.wS Ali}�+�. 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