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HomeMy WebLinkAbout0072 BAYBERRY LANE - Health 2 �Sayberry Bane Cotuit P A - 019 120 1i TOWN OF BARNSTABLE • SEWAGE LOGATION-76 VILLAGI�o 1� AS ESSOR' MAP&PAR EL - Z 0 INSTALLER'S NAME&PHONE NORP [AIA-A I if 1'. SEP�TICg C 'A�ITY LEACHING FACILITY: (typ�z (size) P-500 OW(Oki NO.OF BEVROQMS 3 OWNERA-11-ni ( ( PERMIT DATE: I 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 RecLr aF Hause z-2y y 2 3 3 r7� - Q�,y � 3 SHED 4 TOWN OF BARNSTABLE LOCATION ;(. _ �NtSEWAGE # VII.LAG �- ASSESSOR'S MAP & LOT S � �\� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) P I-t' (size) (a l�lD f NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE,DDATE,:�./� l 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 i O A�as � iS� �IS�e TOWN OF BARNSTABLE Ili LOCATION C SEWAGE # VILLAGE C�t47PUI Z.: ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO.&ViNfF�,,NC I.VORNC &-A& SEPTIC TANK CAPACITY 1®®�'J 9-4eCe/YS LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished bvl�kl(/"X i3 D 13 a� Oc 3d' /�- l3 I 13A o F Fie use ,y No. FEE COMMONWEALTH EALTH OF MASSA'l HUSE TS � Board of Health, MA. APPLICATION FOP, DISPOSAL SYSTL[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade0o Abandon( - ❑Complete System AIndividual Components Location L4r-0- co+0`}- Owner's Name R i c VIA(`d lze.,(1 Map/Parcel# (q _ )2,® Address f l o, Pax 'L90 Cow;}- M flv Q Zfo3S Lot# o r- (j 4210,A (3 V� l y l Telephone# _ Installer's Name Designer's Name 's t.,l e yr s�nrc -t g r Address 0,G, Go �o t'�-dlYSk a`Q 1�i� ®?.(o`jLAAddressLd Ed .,ZlC�f S, �C Telephone# 67O g_d 33--`1 FC19 Telephone# L( Type of Building f?E S Lot Size �Z 160 sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building AJ A No.of persons Showers ( ),Cafeteria( ) Other Fixtures N j A` Design Flow(min.required) '7V3 CI gpd Calculated design flow ' a Design flow provided gpd Plan: Date 'l/t �_2?i �t �" Number of sheets Revision Date Title +(C- S .a. U rbyt�f P( Description of Soil(s) TC s ( 0.-4 <-:. +C ,4 latka-4u Z tt Soil Evaluator Form No.1 R��t/1&(� pe- I-P Name of Soil Evaluator(r k, MC y -erQ Date of Evaluation 10 Zj t� DESCRIPTION OF REPAIRS OR ALTERATIONS n (a 9� 'ZT S'tt C G Q (l nit C'11on-► l3 < S ire The undersigned agrees ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not ace the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ®J � & ons I 4(2k -------------- ------------------------------ r, _ .,r'•...r .-.•�-'r��'� ...-r'rYl�•,/jr.tr="L''.�h... `i�•`�1•.•- �-it�r�.-..fir ,,.-�, `1r�r�.r . ., ... r -" 7 %. No. l FEE IY4 ,s COMMONWEALTH OF MASSAC14USETTS ` v , Board of Health, a A r+r�s� 4s _ , AM. 4 } p APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repaii( UpgradepQ Abandon( - ❑Complete System A.Individual Components ' Location "}, "CryLA � �-�t}- Owner"'s Name Map/Parcel# Q 1 g - LQ Address'e'o, (31,®x - $U Q 24-55, Lot# Lo ar- Telephone# _ Installer's Name ,jui ,qC V �4�5�� (V� Designer's Name Address` 0.(,, (�,o X Co�Ts irectz w�e M k o Ll�`t�( Address t ZUjC f2r rf T1.4 Id adt lies ko(gAe Telephone#--,, Telephone# MA-6Z(o cl q i z I Type of Building i ti f u q Lot Size 2 7, 160 sq.ft. Dwelling-No.of Bedrooms 3 k Garbage grinder ( Other-Type of Building ti/A �A No.of persons Showers ( ),Cafeteria( Other Fixtures Design Flow(min.required) gpd Calculated design flower a Design flow provided gpd -_ Plan: Date lei 2? t Number of sheets �Z Revision Date Title& mw_ Se#Q+,c,t s k�M U,-&rg� l�(qh •72 �4u�Cn(L Can �a i r 1: I- ''"""i, Description of Soil(s) d TV-Z- Sa.sd latkd Soil Evaluator Form No.(3�nSt 6-6 4 1 WM Name of Soil Evaluator(&-W MC-FA� Date of Evaluation ��� Z. t t ST(7- DESCRIPTION OF REPAIRS OR ALTERATIONS l 4 L �-Q+IXX L, .o f'C�� •�-�^-t ' �C S 1-err`E The undersigned agrees to/%J'�nstall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to`lace the system in operation until a Certificate of Compliance has been issued by the Board of Health. �� _5 f ems--• Signed / Date yP7 .4•rrsp cMrons 2_ r .�✓, 1 l�o t V v OOC3000pOJ000OUC 0Gp.)OOC',OOOOG 00000000000000 O O O o 0 a 0000 C, O O O O p 0000000 GC C O 00 O 0 00`OC•GOOD 0000000�000G000000000 Op 000000 Cr00p(Va00000000 No. _3 FEE COMMON LT14 Of MASSACHUSETTS / Board of Health, I!F4ni S(-c- K , MA. CERTIFICATE OF COMPLIANCE 3 Description of Work: kIndividual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgradedf(,),Abandoned ( ) by: at b°eh"Y P has been installed in accordance with the pr?visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.jd I S r 377 , dated 1 U l�F11 r > , ApprCS DTg n Flow�31(gpd) Installer 1 1 1 Designer: Inspector: VV h Ay VMS Date: r The issuance of this permit shall not be construed as a guarant2 that the system will function as designed. ,.S _ w�3o�Vtre"5w'y'Jso� eorlocsttyzrbt>'bi so�m�3Jz Pa.o ec ao+i firaa�o o.trflo6pa•o�Yb j '�a aeoao"ovoT i' ��a'Fao�"a�oo o .o o�cc o e0a�njao/oc}w:ostnc7al No. /�O/ — / j } FEE COMMONWEALT14 OF MASSACHUSETTS Board of Health, (e- , Aft DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade(e<) Abandon( ) an individual sewage disposal system at 7 Z 30, kj my Cr-, C o ''-� as described in the application for Disposal System Construction Permit No J /, ted Provided: Construction shall be completed within hree years of the date of this per n5-17" 1 I al o ditions must be met. Form 1255 Rev.5/96 A.M.SUlkin Co.Chadestown,MA Date � Board of Health ✓, � :° / Town of Barnstable s Regulatory Services ` Richard V. Scali,Interim Director MA"' Public Health Division N�.1 t6g9. ti Thomas McKean, Director 3' 200 Main Street,Hyannis,MA 02601 91 i, ra Office: 508-862-4644- ; Fax: 508-790-6304 ILn Installer & Designer Certification Form, Date: t` 146 ( IS' Sewage Permit# ;06-22/7 Assessor's Map\Pareel.. 61 R —),Z. it t r �a D signer,—, Y a n � �=g � "��� ..� �� �E+k, Installer: �e�a t eic_e V ek 60'1S�ve% •�"�. Address: 12, J�-k\a 4Z� Address: t. 7 of was issued a permit to install a (date) (mstaller�) septic sysienl at, t t` t -1___..__ based wi a'clesign drawn by. (address) dated (designer) (designer) - _ . I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the . distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory, { �3 i I certify that the septic system referenced`above was installed with major changes (i.e, f> greater than 10' lateral relocation of the SAS or any vertical relocation of any component It of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory, I certif, the' e sy tt n�;referencedl above was constructed in cori liance; wit the terms ,of the 1\A rovabletters (il`,applicable) PETER T. r ( er5 S1 ature Mc EE ': ) CIVIL Na: a51C9Psi esigner's Signature) (Affix Des j T fct-,) PLEASE.RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CER111I'ICATE Aili COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FQ M -AND AS BUT_ CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIN SIGN. THANK YOU: Q 1;septic\Designer Certification Form Rev 8-14-13'.doc Town of Barnstable ' P#� U / oFTHE Tpk i Department of Regulatory Services * BARNSTABLE, " ` Public Health Division r Date '- y MASS. �p 1639. 200 Main Street,Hyan MA 02601 �`� / •� TfD MAt ' ! �0 ✓ O Date Scheduled r iine ( Fee Pd. 'Soil Suitability Assessment for Sew pie A o v 7` O /�,, � rl_ f. z Performed By: 1 �f P'l C64�� P_ � 5e A !�4? Witnessed By: LOCATION & GENERAL INFORMATION Location Address -7 Z L� Owner's Name (z e�e�r� /��, ` ` l Address l� f3�y� z.E-C) 7..�,.. , Assessor's Map/Parcel: Engineer's Name f Q I,ZCJ � NEW CONSTRUCTION REPAIR !�' Telephone# S4:? 4 Land Use Slooes(%) ^Z Y Surface Stones Distances from: Open Water Body AJ 1A ft Possible Wet Area ft Drinking\Vater Well .ft Drainage Way yy-/J h0r ft Property Line © 1—� ft Other _ ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ZPIT Parent material(geologic) Depth to Bedrock 1j � Depth to Groundwater: Standing Water in Holc f j f H Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: - Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment fl. Index Well# Reading Date: Index Well level Adj.factor__ Adj.Groundwater Level PERCOLATION TEST Date_ _. Time Observation ��� Hole# ?—( ,-Time at 9" i Depth of Pere w �" Z q', -Time at 6" Start Prc-soak Time t✓n 1 S{k• h Time(9"-6") End Pre-soak ' .y V 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 p Barnstable Conservation Division at least one (1)week prior,to beginning.; QASEPTIC\PERCFORM.DOC a � b� VS DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil tither S irface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ,o i teticv.% r v l't� DEEP OBSERVATION HOLE LOG Hole E7_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones,Boulders. —917 4( _ y _ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ( they Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistemev.95 Oravel) _ -- — DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Sirface(in.) (USDA)• (Munsell) Mottling _(Structure,Stones,Boulders. onsistencv.9b Oravel),,�,,. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Witlun 500 year boundary No Yes Within 100 year flood boundary No Yes , Depth of Naturally Occurring Pervious Material Does at least four feat of naturally occurring pervI s material exist in all areas observed throughout the area proposed for the soil absotption system? 'e� If not, what is the depth of naturally occurring pervious material? �.. I Certification I ertify that on �OLC�d� (date)I have passed the soil evaluator examination approved by the Department of Enviro motection and that the above analysis was performed by me consistent:with . tf e required traini expertise and experience described in 310 CMR 15.017. Date C��.?l I t� S gnature . . Qs\,S BPTICIPERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROT , TI N u w - T y 7 W q TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR ' k;C-1VED PART A CERTIFICATION JAN 0 8 2003 Property Address: 72 BAYBERRY_lW COTUIT 02635 0\ TOWN OF BARNSTABLE Owner's Name: JAN SCULLIN HEALTH DE Owner's Address: 160 COMMONWEALTH AV.405 BOSTON MA.02116 ST � bo � Date of Inspection: 12/9/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS }x1( Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs FurWr Evaluation by the Local Approving Authority Fails �1 s Inspector's Signature: i Date: 12/9/02 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. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. TitiP 5 fncnartinn Firm (%/i v?nnn 1 I Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped AUGUST INFO FROM OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. • a Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page-6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): tO U t(�a t OU0 Sump pump(yes or no): NO Last date of occupancy: n/a o c w Vw COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: AUGUST INFO FROM OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1970'S BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page-7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" 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: n/a 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.): SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page-8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD Y OF LIQUID IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN Y OF LIQUID IN IT.BOTTOM IS AT 9 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a A I Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. I nrntP nil a/Pllc u/ithin 1 M fPPt 1 nrntP whPrP nnhlir.wnte.r glin lv enter-the..hlnldlnP. 0 Pc ~I 0 n�+ as • III. Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 BAYBERRY DR COTUIT 02635 Owner: JAN SCULLIN Date of Inspection: 12/9/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. tt ti LEGEND N —— 98 ——EXISTING CONTOUR X 100.98 EXISTING SPOT GRADE 102 PROPOSED CONTOUR �b yy EXISTING WATER SERVICE EXISTING PITS Mash ee Neck G EXISTING GAS SERVICE Rd �� crockers TO BE PUMPED & U UNDERGROUND WIRES FILLED W/ SAND poponessett TEST PIT BENCHMARK BENCHMARK OUTSIDE CORNER OF 3 LOCUS BOTTOM STEP a EL: 25.34 (Assumed goyberN Ln EXISTING SEPTIC TANK `o TOP OF TANK EL.=23.53 LOCUS MAP INV(OUT) EL.=22.201- NOT TO SCALE \ / + 25.88 \ / \ (-- N 69'34'00" W i \\ 1 177.00' 1 LOT 11 i ,^ PARCEL ID: 019-120 1 � 1 27,100 .S.F.t LO � S t 1 i - I I 1 SHRUBS 1 - I 1 x 23.58 �:2S PREP. S.A.$ ,I + 24.97 25 c✓J C14 P�1 + i— CN / 25.11 23.21 -- J 52 I 23.38 _ 1 << I I SHRUBS 24 6 1 25.3 ' N 24 4 A_ ,24.85 �G��01i x j/3.96 z DECK WAL O DECK to ao 1 f - 0 LA / 21.95 22.64 n N RET. WALL d I / /EXISTING is.o ` ; i 8 o : N i HOUSE (#72) T.D.F.=25.5t1 x 23.6623.94 -' 1 4.52 cS? � I _—�4--- 20.,36 i lk J 23.54 / 19.7 ::17 5.5.:.;,: 18.36 .�, 9.06 23.13 .p.- l-� / a D .M.- •." '16.42xyC�' f 22.14 x 17.06 ' \ 19,70 � L::1:4-:71; :;•� I x /L=135.92' / R=591 .51' _ 15.92� 14,75 � 1 80 . 34 \ \\ • 14.40 14.56 19.53 BA YBERRY LANE OF 4f4 ssq�y PETER T. �� PROPOSED SEPTIC SYSTEM UPGRADE PLAN M CIVILEE N 72 BAYBERRY LANE, COTUIT, MA No. 35109 Prepared for: Bevilaqua Construction, P.O. Box 628, Forestdale, MA 02644 R£GiSAER�� `�� OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. REILLY, RICHARD J & CAI C 1"=20' P.T.M. 245-15 P.O. BOX 280 Engineering Works, Inc. CO MA 02635 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. �d� (508) 477-5313 10/23/15 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:21.5 FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S. INSTALL RISERS & COVERS OVER INLET & OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER PROPOSED S.A.S. SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND T.O.F.=25.5t SET TO 3' OF F.G. TO SERVE AS INSPECTION PORTS F.G. EL.=24.9t F.G. EL.=24.8t F.G. EL.=24.5t F.G. EL.=24.0t hx ley . . , 3'(max.) . L = 37' _ (MIN.) p S=1%1(MIN.) 4"SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/S" TO 1/2 6'J DOUBLE WASHED STONE 10"I s "Ziml (OR APPROVED FILTER FABRIC) ; 74" -3/4" TO 1-1/2" DOUBLE EXISTING 48" LIQUID WASHED STONE LEv� AD�o1 . PROPOSED 4' 4.8' 4' INVFFLE .=21.30 INV.=21.13 GAS D-BOX EFFECTIVE WIDTH = 12.8' INV.=22.2t INSTALL INLET TEE EXISTING H-20 INV.=21.00 EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-10 RATED NOTES: TOP CONC. ELEV.=21.8t Al BREAKOUT ELEV.=21.5 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=21.00 aes INVERTS, PRIOR TO INSTALLATION. aaaBaatE03 aBaa 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=19.00 GRADE ON A MECHANICALLY COMPACTED SIX 4' 2 X 8.5'=17.0' 4' INCH CRUSHED STONE BASE, AS SPECIFIED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' IN 310 CMR 15.221(2). PERVIOUS MATERIAL 5' (MIN. G.W. 3) INSTALL INLET & OUTLET TEES AS REQUIRED. ) ABOVE G LEACHING SYSTEM SECTION 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL.=12.5 AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. (NO GROUNDWATER) SEPTIC SYSTEM PROFILE SOIL LOG GENERAL NOTES: DATE: OCTOBER 22, 2015 (REF. P#14879) SOIL EVALUATOR: PETER McENTEE SE#1542 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL WITNESS: DONNA MIORANDI R.S. HEALTH AGENT BOARD OF HEALTH AND THE DESIGN ENGINEER. ELEv. TP-1 DEPTH ELEv. TP-1 DEPTH 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 24.5 O 24.0 0 LOCAL RULES AND REGULATIONS. A A 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR LOAMY SAND LOAMY SAND TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 24.0 10YR 4/2 23 5 10YR 4/2 DESIGN ENGINEER. B 6" B 6" T 4ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING LOAMY SAND - LOAMY SAND FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 10YR 5/8 10YR 5/8 ENGINEER BEFORE CONSTRUCTION CONTINUES. 22.0 30" 21.3 32" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. C PERC C 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 40'/58" THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. F-M SAND F-M SAND 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 2.5Y 6/6 2.5Y 6/6 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 13.0 138" 12.5 138" DIRECTED BY THE APPROVING AUTHORITIES. NO GROUNDWATER OBSERVED 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PERC RATE <2 MIN/IN. ("C" HORIZON) THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE --25'--�{ INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. 11. 13. THIS PLAN LS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 00' PROP. S.A.S. NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 9 Q 14. THE CONTRACTOR SHALL BE RESPONSIBLE FOR OBTAINING A TRENCH PERMIT FROM THE LOCAL MUNICIPALITY IN WHICH THE WORK IS BEING 1 49 PERFORMED. ------ 8 69.5' 45.0, DESIGN CRITERIA NUMBER OF BEDROOMS: 3 BEDROOMS DECK SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) DECK DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 GPD DESIGN FLOW: 330 GPD / BACK GARBAGE GRINDER: NO-not allowed with design / OF HOUSE LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF .74 GPD/SF S.A.S. LAYOUT EXISTING SEPTIC TANK: 1000 GALLON CAPACITY PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 72 BAYBERRY LANE, COTUIT, MA SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Beviloquo Construction, P.O. Box 628, Forestdale, MA 02644 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 245-15 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 10/23/15 P.T.M. 2 Of 2