HomeMy WebLinkAbout0023 BRAMBLEBUSH DRIVE - Health 23 Bramblebrush Drive
Cotuit P _v
A = 040 086
TOWN OF BARNSTABLE
LOCATION Q B(JS'J J)PSEWAGE# I fl) -05
VILLAGE Z ASSESSOR'S MAP&PARCEL OO
r INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
z LEACHING FACILITY: (size) ,
NO.OF BEDROOMS
OWNER SSA
PERMIT DATE: , -.2 N' COMPLIANCE DATE: 2
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) 1 Feet
FURNISHED BY
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No. go 10 ^��� Fee / &0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0(ppYicatiou for Migoml *paem Cow6truction Permit
Application for a Permit to Construct( ) Repair Zupgrade
p ( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.,4-7 �k Owner's Name,Address,and Tel.No,;F�
T, /7
Assessor's Map/Parcel 0 b _��� nA
Inst Iler's Na Address d Tel Nod/"oJ/` ��e De igner' Name,Address�d Tel.N '��v,e/ �
a'o��60 40/ .Z
Type of Building:
Dwelling No.of Bedrooms Lot Size d 00 sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures q
Design Flow(min.required) �Y-36 gpd Design flow provided �/` �/ gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.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 Date Q"�
Application Approved by .?( p � Q Date �- -G C)
Application Disapproved by: Date
for the following reasons
Permit No. o Date Issued
� rw_
No. O I0 65� /
_ 7 Fee
TH.E'COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
:=r .
} ZIppfi ratio n for W5poaf 6p5tem Construction Permit
Application for a Permit to Construct( ) Repair(U)` Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No (J5 Owner's Name,Address,and Tel.No
Assessor's Map/Parcel /S fi ._._Z�)10
6
Installer's Narne Address d Tel No. y Designer' Nam ,Address and Tel..zN}
j-Jo�IiT� C 5'T � /�q o�'�d/ �6 f � g8! - /U/���� �
Type of Building:
Dwelling No.of Bedrooms Lot Size d 1:00 sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures -� q
Design Flow(min.required) �� gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. pS
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 e y Date / ��
Application Approved by (,,;�E 1 -� C —� Date (— v
Application Disapproved by: Date
for the following reasons
Permit No. 7 Q t Date Issued
` -`THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CER/TIIFYY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( K Upgraded ( )
Abandoned( )by
at _ W�aU S - � ,IfVr/has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. a01 D ^ a Sd dated d t C)
Installer Designer
#bedrooms Approved design fl gpd
The issuance of this permit shall not be construed as a guarantee that the system wl functio as desi°�ed�> �(
Date (J Inspector
'r No. d �(� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'=igpo!5a[ 6p5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon )
System located at Q3 Ok� 2pj- f3Us/4 (for,)/
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this perm
a `� " r
Date 0 Approved by _ �.�
APPLICANT: 41K
ADDRESS: 2�j `�.�Nlpc,E��S(� Dom.le,Co vrr mil
DESIGN FLOW: gpd
REVIEWED BY: DATE:
N/A . OK NO
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan'[310
CMR 15.220(4)(u)]
Locus Provided 310 CMR 15.2204 t
Plan proper scale?(1"=40'for plot plans, 1"=20'or fewer for
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a)for
upgrades]- i not, a variance.is required 310 CMR 15.412(4)
Location of impervious surfaces (driveways,parking areas etc.)
[310 CMR 15.220(4)(d)] X
Location all buildings existing and proposed 310 CMR
15.220(4)(c)] �(
Location and dimensions of system components and reserve areas
[310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(f)]
daily flow
septic tank capacity (required andprovided)
soil absorption system (required andprovided) X
whether system designed for garbage grinder
North arrow [310 CMR 15.220(4)( )]
Existing and ro osed contours [310 CMR 15.220(4)( )]
Location and log of deep observation holes (existing grade el. on
each test) 310 CMR 15.220(4)(h)] x
Names of soil evaluator and BOH representative[310 CMR
15.220(4)(h) and (i)]
Location and date of percolation tests (performed at proper
elevation?) 310 CMR 15.220(4)(i)]
Percolation test results match loading rate?-[310 CMR 15.242] ,
Certification statement by Soil Evaluator 310 CMR 15.220(4) )
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Location of every water supply,public and private, [310 CMR
15.220(4)(k)] x .
Address 4D,-iT A44 Sheet l of 7
i r
within 400 feet of the proposed system location in the case
of surface water supplies and rayel packed public water supply
within 250 feet of the piioposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells k
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. 310 CMR 15.220(4)(1)] X
Water lines-and 6theF sibsufface utilities located [310 CMR
15.220(4)(m) (if water line cross see 310 CMR 15.211 1 1 )
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR 15.220(4)(6)] /1
Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.22 0(2)
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)] f .
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2)or as.approved for an upgrade under LUA at 310 CMR 15.405(1)( ] x
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103(4)]. X
Test Holes adequate to cogfum adequate groundwater separation? .
1310 CMR 15.103(3)] k
Benchmark within 50-75'of system [310 CMR 15.220(4)( )]
Materials specifications noted? [various sections of 310 CMR
15.000] X
System components not>36" deep(unless Local Upgrade
Approval or LUA.requested)f310 CMR 15.405(1 b X
Address 2-3 UAP, 15LLB46 4f DR. Sheet 2 of 7
G�
� II
Size 3OK? '[310 CMR 15.223(1)]
Inlet tee located ten inches below flow line 310 CMR 15.227(6)
Outlet tee 14" or 14"+ 5"per foot for increase ft depth [310 CMR X
15.227(6))
Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)]
Note regarding installation on stable compacted base [310 CMR
15.228(1)] )C
Separation between inlet and outlet tees (no less than liquid
de th) 310_CMR 15.227(2)] X
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5))or permitted for X
upgrades under LUA [310 CMR 15.405(1)(k)]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1)and 310 .k
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20"or greater)
middle access at least 8" (b 7/07) [310 CMR 15.228(2)] 'x
Access to within 6 "of grade -one port for systeins<l 000gpd,
two fors stems>1000 d 310 CMR 15.228(2 X
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)] X
> 10 ft from building foundation [310 CMR 15.211(1)]
.Buoyancy.13uoyancy calculation Required/Done 310 CMR 15.221(8)] X
H-20 Where appropriate? 310 CMR 15.226(3)
Setbacks from resources [310 CMR 15.2111 X .
-t
Required when other than single-family dwelling or flow>1000
d [310 CMR 15.223(1)(b)] x'
First compartment 200%daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2) and'(3)]
"U"pipe through or over baffle, outlet of each compartment with
Ilf as baffle or approved filter[310 CMR 15.224(4)]
Address Z-�J � �C = �,d Sheet of
Located at least ten feet from any water line? [310 CMR
15.222(2)] X
Disposal piping at least 18"below water line (when water and
sewer cross, see 310 CMR 15.211(1)[1 ) �(
Cleanouts required/provided ? 310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR"15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)] X
Proper pitch on all runs?(.005 within gravity-distributed trenches
and beds) 310 CMR 15.25](9)and 310 CMR 15.252(2)(c)] X
Siphonproblem/ leachfield below 2ump chamber)
Endca s or vent manifolds ecified? X
Size and orientation of discharge holes specified?(not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed) �(
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)] �(
Splash,plate or baffle tee required on inlet/provided?(when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 1.5.323(3)(a)]
Riser if deeper than 9" [310 CMR 15.232(3)(f)]
Inside minimum dimension 12" 310 CMR 15.232(2)(b)] �(
Minimum sum 6" [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)] X
Capacity(emergency storage above working=design flow)?[310
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20"MUST BE
TO GRADE [310 CMR 15.231.(5)]
Service components accessible (not too deep,with piping,
disconnects accessible)
Alarm floats-alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [31-0-CMR 15.231(6)and (8)]
Stable Compacted Base [310 CMR 15.221(2)]
Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)]
Sheet 4 of 7
Address 7_3 DZAM bt6I8USff 4OR- ,
i
Calculations correct?
4 feet of naturally occurring material demonstrated?[310 CMR
15.240(l)]
Required separation togroundwater? 310 CMR 15.212)]
Aggregate specified-as double washed [310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) 310 CMR 15.241J x
Inspection ports specified and within 3"final grade?[310'CMR
15.240(13)
Breakout requirements met?(No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
'Nam NAM
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)] .
Each structure with one inspection manhole(if>2000 gpd must
be tograde) 310 CMR 15.253(2)] X
Aggregate I'minimum 4'maximum. 310 CMR 1.5.253(1) ].
2'sidewall credit maximum [310 CMR 15.253(1)(a)J
In bed configuration,inlet every 40 s ft. [310 CMR 15.253(6A
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)]
100 feet-maximum length 310 CMR 15.251 1) a
Minimum separation 2x effective depth or width whichever
eater(3x if reserve between trenches) [310 CMR 251 1)(d ]
Situated along contours [31 a CMR 1.5.251(2)]
Breakout OK? [310 CMR 15.211(1)[4]:and Guidance Document]'
Nam
minimum 2 distribution lines 310 CMR 15.252(2)(a)]
Maximum separation between lines 6 310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)
Aggregate depth below discharge pipes 6"minimum, 12"
maximum. [310 CMR 15.252(2)( )]
Separation betweert.beds 10'.minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only 310 CMR 15.252(2)(i)]
Address Z,2j 3l f tc 6 tu Sheet 5 of 7
Pressure Dosed System ? Provided pump and piping
calculations as required,required,f 310 CMR 15:220 4 (r)] X
Pressure dosing required on all systems>2000gpd or alternative
systems undw-icrnedial approval [310 CMR 15.254(2) and I%A x
Remedial Use Approvals]
If used in gravelless system -make sure jet is directed as not to
scour soil interface [Guidance Document] X .
Inspections once per year(systems<2000 gpd)or quarterly
(>2000 d ood to note on plan 310 CMR 15.254(2)(d)].
Construction in fill Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)? X
Impervious,barrier and/or retaining wall ?[Guidance Document]
Impervious barrier installation must be supervised b
P Y
designer[3 TO CMR 15.255(2)(b)] X
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)] X
Side slope not exceed 3:1 ? 310 CMR 15.255(2)
Breakout requirements met? [310 CMR 15.252(2)and
Guidance Document] X
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) (310 CMR'15.255 (2)(e)] X
:.25 I i
Check DEP A roval�letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface X
Was DEP Approval Letter ro.v-idedand/or have you
reviewed the letter for conditions? X
Is the technology being properly"applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement fo'r
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applicant submitted a co y of a maintenance
Are the variances listed on the plan ? [310 CMR 15.220
(4)( )]
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed - [Refer to 310
CMR 15.414]
Address Z32gg�� //� Sheet 6 of 7
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR-I5.216 - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)] x
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)]
Pumping to.se tic tank? [310 CMR 15.229
Shared System 310 CMR 15.290
Address Z3 �� _ Sheet 7 of 7
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
• wrnarABL&
� "� �,� Public Health Division
Arre�a. Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 503-8624644 Fax: 503-790-6304
Installer & Designer Certification Form
f /
Date: a7 �� Sewage Permit# / --O AssessWs MaplParcel �g6
Designer: D14 YY'�I�1 i" / �ey / 1
g d installer: /.' �
Address: �� �.� Address: czS(o/��2t%/-2 C,
AW
On (date) (Installer)
utaller)�� �✓ was issued a permit to install a
�
se tic system at Z3 /3�czn,,l/e bLs4 -based on a design drawn by
(address)
(designer) dated
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. V
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
_ OF
DA
(Installers ignature) a; il. 0 y
w
6 NIT00
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNS BLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COiNIPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNST,ABLE PUBLIC HEALTH DIVISION. THANK YOU.
r
Q: Health/Septic/Designer Certification Form 346-adoc
I
Town of 1aa"i"nstable. Po
oft I .
Department of Regulatory Services
►erg
]Public Health Division Date
prnga.
i639. �e� 2G0 Main.Street,Hyannis MA 02601
�rfDtVl� '
Date Scheduled 2 'Time� ZU U `!_ Fee Pd. 00
i
I
,foil Suitability AssessM"ent fog- Sewage Disposal
-sposalI
jmla'�, f"I e i a Witnessed By: ! J/1 v C� �l�]/y /uN r
Performed By: -
LOCATION & GENERAL INFORMATION
Location Address. i Owner's Name r6b . 1V4-jg7�,)•Z /47;
_.. _ :23 13w�.&_e Bus 6 ooy3 �Y
60rV17- �a I Address Day t.t.r4.S ,-)r -21L6 s
Assessor's Map/Pdtcel: Q yd/Q g6 Engineer's Name L)4��r A4 �VI
NEW CONS1RUt'f." 2N REPAIR I Telephone*/ .5O S
Land Use �YZ� �V` Slopes(% ' ' S"I(D Surface Stones
Distances from: Open Water Body �2� ft Possible Wet Area 7 2—ft Drinking Water Well
i
Drainage Way ft Property Line ft Other
ft
SIKETCH:(Street name,dimensiods'of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
_ vVU g( _
PAVED DRIVEWAYI 1 �rn
----------------I� W
1 II 1
I
�I Gav v � I I I rn
i II to
all
Cn
�
i
WATER LINE rl__-IJ I
Ex496)79 Zeochpit — n v r ( /1
r (Note 10) 2011 a 1- - i t lJ 1
m
wo
I _ \---------4-
_4354, H-t i 2�30 1 \
j I I PAVED D-----
1 - I
-� 'Ga
\ I
1 6C ------------ 1
1 \ FTI
\ i
cN \
tiL.._..----..-..------N�---J
173.00 ft GO \
Parent material(geologic)
Depth to Bedrock
Depth to Groundwater. Standing Water in Hole:' N i Weeping from Pit Face
{
Estimated Seasonal iliigh Groundwater N
DtTERKWATION FOR SEASONAL H1GH WATER TA19LE
Method Used: � i
Depth C�b,�erved standing in Ili. Depth to Sall m9ttles: in,obs.hole: __ p ft,
Depth toiweeping from side of obs.hole: in. aroundwacr Adjustment
! ! !actor.,._._,. Adj.droundwaterievel,,,,e,
Index Well# Reading Date Index Well levy ---- Adj.
. . I
PERCOLATION TEST . Date Time .
Observation I Tints At 9" �LA
Hole#
r�q Time at6"
Depth of Pere — ...�-
Start Pre-soak Time.@ Ito Time(9"-6' ------
End Pre-soak
Rite MinAnch I I 1
Additional Testing Needed(Y/N)
Site Suitability Assessment: Site A
Passed_� Site Failed; '
Original:.Public He'�Ith Division Observation Hole Data To Be Completed on Back—
***If percola#on test is to be conducted within 1009 of wetland,,you must first notify the
Barnstable C44servation Division at least one (1) week prior to beginning.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
7'3$t<
W/^'1 LSD V "! S �►
DEEP OBSERVATION HOLE LOG Hole#_
Depth from Soil Horizon- Soil Texture Soil Color Soil Other
Surface(in.) ' (USDA) (Munsell)-- - Mottling---(Structure;Stones,Boulders.
Consistent %Gravel)
3s '- 12s G 7/f
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil r Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
i '
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, Gravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Ycs
Within 500 year boundary No k Yes
Within 100 year flood boundary No k Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system? P_
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Envir mental Protection and that the above analysis was performed by me consistent with
the require ining,expertise and experience described in 310 CMR 15.017.
Signature �" - Date 23
0 '
Q:\.SEPTIC�PERCFORM.DOC
TOWN 9F BARN(STTA/BLE
LOCATION ' (.1�� Y K Il / l� I V► SEWAGE #
VILLAGE l AbAM ASSESSOR'S MAP & LO 2
_ o
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �®
LEACHING FACILITY: ( pe) (size) 1,000qj Wxwf
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 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 �����
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t`Y
., Barnstable
o�Wr Town of Barnstable
Regulatory Services Department A�U1tCrICBCIiy�
anxrvscaat.>w.
g, MAS& Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
t
CERTIFIED MAIL# 70081830000205008857
6/01/2009
Adilson Santos
23 Bramblebush Road
Cotuit, MA 02635
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at Bramblebush Road, Cotuit MA was last inspected on
May 13, 2009 by Robert Paolini, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR.15.00)due to the following:
• Backup of.sewage into-facility or system component due to an overloaded or
clogged SAS.
• Static liquid level in the distribution box above outlet invert due to an 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.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date'you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF TH BOARD OF HEALTH
omas McKean, R.S., CHO
Agent of the Board of Health
� 1
r
s - Commonwealth of Massachusetts
Title 5 Official Inspection Form
^a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
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 A. General Information
forms on the J
computer, use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
Q�nmmi�
P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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
5/13/2009
Inspectors 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.
�o 6
/oq
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal stem•Page 1 of 17
r
r.�
T.
Commonwealth of Massachusetts
W' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every 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
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in hydraulic failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 23 Bramblebush Rd.
..... ..... ..... ..
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
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 i functioning sin a manner that protects the public health,
y p p
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 4 of 17
O. k
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
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 6 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 16,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
I
ar. r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is Cotuit Ma. 02635 5/13/2009
required for
every 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
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the'SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
o"
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,distribution box and leaching pit.
Number of current residents: 4
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d unavailable
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/13/2009
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:
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
r
. ......................
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1980
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ® 40 PVC ❑other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents
Septic Tank(locate on site plan):
Depth below grade: 18"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
11
Sludge depth: 6
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
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
26"
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
0"
Distance from bottom of scum to bottom of outlet tee or baffle
6"
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.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Water
level in tank was over inverts at time of inspection.Tank appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
I
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
M. 5 .
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. Cityrrown 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.):
I
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
V`y L
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. Citylrown 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 Yes
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.):
Box is Ievel.Box has one outlet lateral.Evidence of solids carryover.Evidence of leakage out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site.plan, excavation not required):
If SAS not located, explain why:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 112 of 17
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
':. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. City/Town 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.):
Damp soil.Leaching pit is full and in hydrauilc failure.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every page. CityTrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
- . . Commonwealth of Massachusetts
,,..,, Title 5 Official Inspection Form
Su
bsurface
urtace Sewa a Dis osal System Form -g p y Not for VoluntaryAssessments s
,'.. 23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is Cotuit
required for Ma. 02635 5/13/2009
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
Q►� ow
n/
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S70 E T
t5ins•09/08 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
y�
✓� �'� ' X. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G .
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is Cotuit Ma. 02635 5/13/2009
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: Bottom of LP 35,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:
As-Built Card
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
C � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Bramblebush Rd.
Property Address
Adilson Santos
Owner Owner's Name
information is required for Cotuit Ma. 02635 5/13/2009
every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
C;)A
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TOWN OF BARNSTABLE •
BOARD OF HEALTH
ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner Tenant
Address 3 8�"1'619k iS!Ar, Cc Address
Complionce Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
1`�'i"t�e..� h' 9,R' �.•t G�r'r"P1f� ei C���A ,
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation ani Maintenance of Facilities
10. Curtailment obervice e
11. Space and Usl
12. Exit§
.. a
13. Installation a]Maintenance of Structural
Elements
1
14. Insects and Rents
L^a+ i3jQ� {�'(i
15. Garbage andjbbish Storage and Disposal e p
16. Sewage Disp I
i
17. Temporary Hsing
I
PART 11 U C-CGfj 9.�I r/.�.�� ��v°�• 1��'" f
37. Placardingof�demnedDwelling; A1(° cceA 0L-14fC �+ Cv�+1�`/'
Removal of Octants; Demolition 1 ,
Person(s)Interviewed. Inspector v
If Public Building suchwtore or Hotel/Motel specify here
190( so n
YOU WISH TO OPEN A BUSINESS? F1,,-sf h-12�
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1s' FL.,.367 Main
Street, Hyannis, MA 02601 (Town Hall)
DATE: 2- 16 �0 . 04 S G�eB sgNT S .
Fill in please:
APPLICANT'S YOUR NAME:; ,EJ�
BUSINESS YOUR HOME ADDRESS: �3 13�'A�3�� ��S/� D•Q
age soea69O!V- a? Co'(vi � 4-714 o2G 35
BMW TELEPHONE # Home Telephone Number fob yao o�3 4
NAME OF NEW BUSINESS -AdZAQ9 i R TYPE OF.BUSINESS C
IS THIS A HOME OCCUPATION>?_ _YES N.O:
Have you been given approval from the building division? YES NO 140 10
ADDRESS OF BUSINESS J3 P K BI A/is& 0 R e�tyr T MAP/PARCEL NUMBER (J
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable.
This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St.-(corner of Yarmouth Rd. & Main
Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFF E
This individual has b inform of any permit requirements that pertain to this type of business. -
Autho ized, ignature**
COMMENTS: C) (o e
2. .BOARD.OF HEALTH
This individual has informed of the it requ 1. nts that pertain to this type of business.
A thoriz Signatur **
COMMENTS: �:. �Z
77
oc / -
3. CONSU ER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
COMMONWEALTH OF MASSACHUSETTS
in. W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner's Name: Joanne Sheehan
Owner's Address: #23 Bramblebush Drive
Cotuit,MA
Date of Inspection: 07/01/05
Name of Inspector: (please print) Mr. Carmen E. Shay
Company Name: CAPEWIDE ENTERPRISES,LLC
Mailing Address: P.O.Box 763
Centerville,MA 0632
Telephone Number: (508)-428-4028
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:
XX Passes
Conditionally Passes OFM4S
Needs Further Evaluation by the Local Approving Authori P sgcy
Fails o� CARMEN N
o E. .
Inspector's Signature: v�2 Date: 7/01/05 0 o SHAY o
F T%
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of _
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,
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
3' Liquid observed in Leach Pit.
4 ****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will-pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
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
"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:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
XX Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
XX Any portion of the SAS,cesspool or privy is below high ground water elevation.
XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
XX Any portion of a cesspool or privy is within a Zone 1 of a public well.
XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
T . :. .,..,. 4
Page 5 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
XX Pumping information was provided by the owner,occupant,or Board of Health
XX Were any of the system components pumped out in the previous two weeks?
XX _ Has the system received normal flows in the previous two week period 9
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up'?
XX _ Was the site inspected for signs of break out
XX _ Were all system components,excluding the SAS, located on site'?
XX _ 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?
XX _ 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
XX _ Existing information. For example,a plan at the Board of Health.
XX _ 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)]
M
Page 6 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
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):
Seasonal use: (yes or no): Yes
Water meter readings,if available(last 2 years usage(gpd)): 109,000 gallons—2003/107,000 gallons 2004
Sump pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank,present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unk.
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy ;
Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology.-Attach a'copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1982-ori2inal,- per Owner&BOH Records
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction: cast iron _40 PVC XX other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 12"to Top of Tank
Material of construction: XX concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 5' deep x 5'wide by 8' long (1,000 gallons)
Sludge depth: 4.0'
Distance from top of sludge to bottom of outlet tee or baffle: 2'
Scum thickness: '/4 inch scum laver noted
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
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.):
Structural intecirity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. 4" PVC Tee present at
inlet end. Outlet baffle present and in good condition. Liquid level equal with outlet invert.
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
.,. ,. 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): D-Box Present—onw outlet,no evidence of significant carryover.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
XX 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.): No evidence of hydraulic failure of septic tank or of leach either leach pit. 3' Liquid observed in
leach pit. Cover located and removed as part of inspection. No Riser present. Top of leach pit is 24" below
ground.
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 or no):
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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #23 Bramblebush Drive
P Y
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
Swing Ties:
BRAMBLEBUSH DRIVE
A- Tank In—42'
B- Tank In—23'
A—D-Box—49`
B—D-Box—35'
A—Leach Pit —64'
Watey Line B—Leach Pit —3 V
Exist House
A B
Deck
Septic Tank
(1000 Gal.)
D-Box
Leach Pit
10'
i
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #23 Bramblebush Drive
Cotuit,MA
Owner: Joanne Sheehan
Date of Inspection: 07/01/05
SITE EXAM ,
Slope
Surface water -'/Z mile+/-
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 20' feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Ouadrangle of USGS Map.
Per USGS MAP PLATE 2:
Elev.of Ground=64 Feet
Elev.Of Groundwater=30 Feet
Elev.Of Bottom of Leach Pit 56 Feet
Therefore: 56—30=26 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well SDW-253(C): 4.0 feet
Adjusted Groundwater Separation=26' -4=22 feet between bottom of pit and adi.groundwater
Grade=Elev.64 feet
Pit#1
Septic Tank
Bottom of Pit=Elev. 56 feet
Adj. Groundwater=Elev. 34
c
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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TITLE 5 0T
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner's Name: JOANNE SHEEHAN
Owner's Address: 3 PAUL REVEAR ROAD ACTON MA 01720
Date of Inspection: 4/29/04
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS [HEALTH
Y I" O ZOO4
Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536
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Telephone Number: 508-564-6813 FAX 508-564-7 70 DEPT.
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 Further Eval n by the Local Approving Authority
Fails
Inspector's Signature: Date: 4/29/04
The system inspector shall submit a copy of fUreport
inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection.If theem is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit 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.
TItlP 5 ImnPntinn Pnrm h/1 5/')000 1
Page 2 of I 1
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
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 1'l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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 4 of r 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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 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 nLa.
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.l
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large 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
Y g ) Pp
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.
I�. d
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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)]
1 5
Page 6 of•11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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: 0
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): YES
Water meter readings, if available(last 2 years usage(gpd)): rya 6� [ VOU
Sump pump(yes or no):NO
Last date of occupancy: 4/25/04 OZ
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,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: n/a
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:
20 YEARS PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
BUILDING SEWER(locate on site plan)
Depth below grade: 20"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 14"
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: L 8' 6" H 5' 7" W 4' 10
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0"
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: 18"
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 ARE 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: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX IS STRUCTURALLY SOUND.
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: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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 WAS EMPTY AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD
MORE THAN 2" OF LIQUID IN IT. BOTTOM IS AT 8 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
III Q
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
ao
o
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I
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Page 11 bf I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 BRAMBLE BUSH DRIVE COTUIT,MA 02635
Owner: JOANNE SHEEHAN
Date of Inspection: 4/29/04
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)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12 FT:
it
10 C T ION °2/ SEWAGE PERMIT NO.
`VILLAGE
I N S T A LLER'S NAME ADDRESS
e i o ��jP® AaklG/'I S
S. IgkwocY4
0 U I L D E R OR OWNER
DATE PERMIT ISSUED
e4
�l
DATE COMPLIANCE ISSUED
W I'I
Mb -�
C14IZQ
LIN
O"
Ymi;.J ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L/. ....................OF.... . .............................
Appliration for Dispasal Works (foustrurtintit JIrrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
. ... ... ....V. ..................................................................................................
Location-Addressr Lot
L..^0........................ .. . ..............aLe=..........
0 ner Address
..........4,.............
Installer Address
Type of Building Size .....Sq. feet
Dwelling—No. of Bedrooms............3.............................Expansion Attic Garbage Grinder
Other—Type of Building 12,e5.-__..12Aw4No. of persons......(�.................. Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow........a5.............................gallons per person per day. Total daily flow.........!13.0........................gallons.
Septic Tank—Liquid capacity_. PPCgallons Lengthho..'.�....... Width...s......... Diameter- Deptl0(=.'..3....
Disposal Trench—No..................... Width.................... Total Length..................._ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..........._.__..... Depth below inlet_..............._._. Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
0-4 Percolation Test Results Performed by....A10-f�.Al.- . ............ DateA4
$4 Test Pit No. I................minutes per inch Depth of Test Pit_._.............._.. Depth to ground water.._..................__.
Test Pit No. 2................minutes per inch Depth of Test Pit.__.............._.. Depth to ground water........................
.............................................................................................................................................................
0 Description of Soil..... .................................................................................................................................................................
W
U ....................... .................................................................................................................................................................................
.................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
..............................................................I............................................................................I...........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL 1',1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance.has been i sued by e oard�olheallh. /
Sign ... ...
.... ...............
l
7
ApplicationApproved By..... ............................................................................... ow
Date
Application Disapproved f r e following reasons:...............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
=MEOW
No._ ...1..... FEs..is 1.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....-...............................
Apli iration for Disposal Works Tonotrur#'ion jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.......... ...... ......... .. ...... --------
......... --------------------
_ Location-Address ff or Lot No. _
.._.. �'........... ..... /7....C_:........�i........................ ........`� !.... ...........................................rG /L '../(/, •�••__.....___
/l Owner / Address
Installer Address
Type of Building - Size Lot....:.:.:....::..^_...._..Sq. feet
Dwelling—No. of Bedrooms...........__=............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _(.._c_:____._.!!._._...'No. of persons______6___________________ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------•-•••---•-•--•••---•-----------•----•--••-••------•.....-•--...••--•-•-••.....--•-••-•-•----_•-
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..__f!fn':Z., ? r r' = ��r� Date_.:: * �..............
'......_._._
4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
(T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ------------------------------------------------------------------------•-••••--••---•----..._....-•.........................................................
ODescription of Soil..........................................................•------...-----------•-----------------•--•-•---------•----•---------------------......•--•---•----........__.
U .--------------------------------------•-•-----------------------------------------••------...._...----•-•----------------...---------------------------................................................
W
x •---••-•••---•-----••-••-- ---------•--•-•••-••-•-•••-••--•--•--•••-•••-•-•••-...-•------•••-••-••••----••---------•-••--•••----•••••...-•---•-•----•-------------•---•-•-....•••--•••-••--•-•--•-_--_•-
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 I TI�'
p 5 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.
ApplicationApproved By....... ----- . ..'------..------------------------------------------------------------------ s° .................
Date
Application Disapproved f r e following reasons:................................................................................................................
----------------•---------..-•--...._._....------------•-.--...------------------------•---•---------------•-•••-•-••----•-•----•------•-•--•---•••----•--••-••--••-•--•--------••••-------•--•---...-•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF....... - ✓f'Xv r f.s!r (-7.........................
..................... ..........
Trrtifiratr of TompliFanrr
THIS IS TO CERTIFY,, That�the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
--•----•-----------•--------------------------•--•••-•....-•-•---••----•--=----•----••-•......._..---•-•-------•---....._--•--•-----••--
has been installed in accordance with the provisions of TITLE 5/of The State Sanitary Code a desAibed in the
application for Disposal Works Construction Permit No....�r...l.'_.4�_1_1.____._.____ dated-------/_U,_, V1,k_�1,k-Z................
THE ISS ANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
SYSTEtd 1N L F . TION SATISFACTORY.
DATE.. .2Z.- 1,•------------------------------------------------------ Inspector....:..-- -•---------_____--------------•----•-•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFj HEALTH
....................OF...... ................ .—
No.__��..-__42.1_ FEE........................
Disposal orko;Tonotr ion- anti#
Permission is hereby granted.__._.�....f........ •-�'�
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No... = •=......... ....`........^` ' ..7 rr ...' �
$treet
as shown on the application for Disposal Works Construction Permit No... __ d__f ____.°'-_. ��...............
�-.__._.�_.fGd'.--- -
Bo d of Health
DATE.............-------------------------•---------............--------•--•-••-•-_.
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
W
1`"
r:.
5
LEGEND
PROPOSED CONTOUR
PROPOSED SPOT GRADE ���5 PONp m
EXISTING CONTOUR
1-66 I W p
+ 96.52 EXISTING SPOT GRADE SITE
/j III W— EXISTING WATER SERVICE c '-
I , m
, , - ' TEST PIT pRNE .
L O T 18
i AREA = 20600 sf
I
LOCUS MAP N.T.S.
mI I GENERAL NOTES:
T 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
( -- BOARD OF HEALTH AND THE DESIGN ENGINEER.
64-` I, ?� II 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
i OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS.
W
C I II 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
m ( n TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
- i I ! Z- �.J / DESIGN ENGINEER.
i i I T 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
I ` 0o r ! I Z I FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
I Existing Leachpit 20 4t �� z ` I ` 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
,� (Note 10) _ _ "4,z __--!-- THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
i �� pD 0 - ' HEALTH FOR.PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
DRI
P -!I � TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
�j I AVE -- __ I 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
i H-1 / \ T 64 ! CONSTRUCTION.
i� 43 54, 32 Op' `� ____ I / 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE V.
I \ 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY .
13. NO PRIVATE WELLS WITHIN .100 FT. OF PROPOSED LEACHING
14. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. OTHERWISE)
15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW
FOR THE USE OF A GARBAGE GRINDER
v--- 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING
` —----
1 _ --- - 62
6
- --
- - --- BENCH MARK
OF PAINT SPOT ON
DRIVEWAY CORNER �E
t I$�9&EN er ELEVATION.,= 62. 59 PROPOSED SEPTIC SYSTEM UPGRADE PLAN
MEYER
BARNSTABLE crs ;DATUM 23 BRAMBLEBUSH DRIVE, COTUIT, _MA
No. 1140
c� MAP.•040 Prepared for: Mike Dedecko
LOT.• 086 Engineering by: Surveying by: SCALE DRAWN
SURVEY REFERENCE: S01TAR\ DEED BOOK.•24175 DARRENM.MEYER,R.S. Boo-Yeah environmental 1"=20' DMM
PLAN OF LAND BY ROBERT RAYMOND, PLS �2361C� DEEDPAGE.• 190 Po Box981 (508) 364-0894 DATE: CHECKED SHEET NO.
EAST SANDWICH,MA 02537
DATED: SEPTEMBER 21, 1973 sos-W2-2922 02/23/10 DMM 1 . of 2
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:59.39
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.
T.O.F. EL.=64.48 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT' OVER. OF MgsS
OUTLET AND SET TO 6 OF FINISH GRADE SET TO 6 OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G.
"., F.G. EL.=64.0± F.G. EL.=62.25t F.G. EL: 61.0t F.G. EL: 61..0-62.0(MAX.) o' DAR
.-M YER
CJ1No. 1140 "'
L = 10'"t P
9" MIN COVER/ L 35' L = 10'( ) INSTALL TWO INSPECTION PORTS (MIN.)
�• ®"S=1% (MIN.) 36" MAX COVER ® S=146 (MIN.) ® S®1:8 (MAXMIN.) ��STE
4 SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC NITAR�a�
2;: } )
21D
11.3" TO
INV.= 59.98 4e"ucINV.=59.?73 & INVERT -
LEVEL
• POSED INV.=59.21
-BOX3 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE = 32.0'/ROWINV.=59.33 H-10) INV.= 59.00 SOIL ABSORPTION SYSTEM (PROFILE) .
' EXISTING 1.000 GALLON SEPTIC TANK
RESTORE VEGETATIVE COVER
EXISTING SEWER OUTLET • BACKFILL WITH CLEAN PERC SAND 75"
TO TOP OF CHAMBERS
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING t. :. ;: • .
PIPE INVERTS PRIOR TO CONSTRUCTION
39=59.
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV. "�' •' ,
GRADE ON A MECHANICALLY COMPACTED SIX INV. ELEV.=. 59.00
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 58.06 EXISTING SUITABLE
310 CMR 15.221(2) 1 2,83 MATERIAL
3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 5' MIN. ABOVE BOTTOM OF EFFECTIVE WIDTH 3 x 2.83' = 8.49' �'� 76•, -
WITH 1500 GALLON SEPTIC TANK IF FAILED T.P. 'EXCAVATION OR G.W.
DAMAGED, OR LESS THAN 1,Oo0G IN CAPACITY: (6.06' PROVIDED) USE 3 ROWS OF 5-HIGH CAPACITY PROFILE
.4) INSTALL INLET & OUTLET TEES AS REQUIRED BOTTOM OF TESTHOLE EL.=52.0 = ADS BIODIFFUSER UNITS-NO STONE
W/ CONTOURED WEDGE
SEPT[C SYSTEM PROFILE TYPICAL SECTION 16
N.T.S.. N.TA 11.2"
DESIGN CRITERIA SOIL LOG P#: -}-
NUMBER- OF BEDROOMS: 3 BR EXIST. CPkoP. IS !n/ Zon1Ejl� DATE: FEBRUARY 23, 2010 --3419
SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: DARREN_ M. MEYER, R.S., CSE. #1614 SECTION END CAP
WITNESS: DAVE STANTON, BARNS. BOH
DESIGN PERCOLATION RATE: <2 MIN/IN
DAILY FLOW: 110 G.P.D/BR. Elev. TP-1 Death Elev. TP-2 Depth' 16 HIGH CAPACITY 160OBD (H-20) BIODIFFUSER UNIT
62.50 A 0" 62 "
.50 A 0
DESIGN FLOW: 330 G.P.D.
GARBAGE GRINDER: NO NOT DESIGNED FOR GARBAGE GRINDER LOAMY SAND LOAMY SAND MODEL . 16" HICAP
1OYR 3/2 10YR 3/2 LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
PROPOSED SEPTIC TANK: USE EXISTING 1,000 GALLON CAPACITY 61.75 g 61.75 9" EFFECTIVE LENGTH' 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
LOAMY SAND LOAMY SAND „ DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
LEACHING AREA REQUIRED: (330) = 445.94 S.F. 10YR 6/8 10YR 6/8 SIDE WALL HEIGHT 11.2
•74 OVERALL HEIGHT 16"
DISTRIBUTION BOX: 3 OUTLETS (MINIMUM) 59.34 a 38" 59.34 C1 38" OVERALL WIDTH 34" 4640 7RUE14AN BLVD
PRIMARY S.A.S. MED. SAND MED. SAND CAPACITY 13.6 CF
2.5Y 7/4 EPERC®'58.05 2.5Y 7/4 HILLIARD, OHIO 43026
USE 3 ROWS OF 5 - 16" ADS 16008D BIODIFFUSER Hlffcs-
-20 UNIT -NO STONE (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC.
AND EXTENDED 0.75' Wf CONTOURED WEDGES PROPOSED SEPTIC SYSTEM SITE PLAN
BOTTOM AREA: (GENERAL USE APPROVAL'
PPROVAL FOR 4.70 SF/LF OF BIODUFUSER) ,
(BIODIFFUSERS) 15 UNITS x 6.25 LFx 4.70 SF/LF = 440.63 SF 23 BRAMBLEBUSH DRIVE, COTUIT, MA
(CONTOURED WEDGE) 3 ROWS x 0.75' x 4.70 SF/LF = 10.58 SIF 52.0 126 52.0 126
TOTAL AREA = 451.21 SF PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Mike Dedecko
DESIGN FLOW PROVIDED: 0.74GPD/SF(451.21 SF) = 333.89 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN
`. DARRENM.MEYER,R.S. Boo-Teak 1s^nvironmentai NTS D.M.M.
• 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR'15.017 F&BOX981 (508)' 364-0894 DATE:
to conduct moil evaluations and that the above analysis has been performed by me consistent with the EASTSANDW/CH,MA02537 CHECKED SHEET NO.
requirements of 310'CMR 15,017. 1 further certify that I have passed the Soil.Eval. Exam in October, 1999. 23 10 5os-Fez-2922 02/ / D.M.M. 2 of 2