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HomeMy WebLinkAbout0029 BUCKINGHAM WAY - Health (" 29,Budkingham 1Nay d 'n _. I Cot it A 021 044 j t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Kevin Cochran use the return Name of Inspector Y Aardvark Environmental Inspections �y Company Name P O Box 896 Company Address - East Dennis MA 02641 City/rown State Zip Code 508-385-7608 13356 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 Tide 5(310 CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Nee urther val tion by the Local Approving Authority 04/17/14 r S ature 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 shopid 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. y t5ira•3113 Title 5 Ofiaal won Fomc sewage Dimpmal system•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owners Name information is required for every Cotuit MA 02635 04/17/14 page. city/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 Oyes",°no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ❑- Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Uapection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. c4 rown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired-. B) System Conditionally Passes(cunt.): ❑ 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-3113 Title 5 Official heron Form:SOW13ce Sewap Disposal System.Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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. ElThe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool- ❑ ® Static liquid level in the distribution box above outlet invert due loan overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than '/z day flow tiros-3113 Title 5 Official bq)edion Form.Subsuface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or°no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 tsins•an3 Title 5 otrctal trspechon Fortrr Sub a Sewage Disposal System•Page 5 of n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. Citylrown 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? E ❑ 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•3H 3 Title 5 Or6dal trtspection Forth:Subsurfaos Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Officia Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. CAyRown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes E No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump?- ❑ Yes No Last date of occupancy: 11/13 p Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non:sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page.e. City/Town 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 0 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 El 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•3/13 role 5 Ofridal Inspection Form:Suburfaoe Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments UV 29 Buckingham Way Property Address Daniel Schwenk Owner owner's Name information is Cotuit MA 02635 04/17/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (corn.). . Approximate age of all components, date installed(if known)and source of information: 12/12/10 per BOH Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 2.9 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): 2.1 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list:age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal - Sludge depth: 311 t5ins•3/13 Title 5 Official Inspection Form Sulmsface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-W13 Tide 5 Official heron Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. cityfrown State Zip Code Date of Inspection D. System Information (corn.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface S Sewage Disposal stem Form-Not for Voluntary Assessments P Y 29 Buckingham Way Property Address Daniel Schwenk Owner Owners Name information is required for every Cotuit MA 02635 04/17/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. 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.): "If,pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�° 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page_ Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ® leaching chambers number: 18 ❑ 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.): This system has 18 infiltrators in an 9'x32'field of stone. There was no sign of ponding or failure in the stones. 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-W 3 Title 5 Mad huperbon Form:Subsiaface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. citylrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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•W13 TiBe 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5. 29 Buckingham Way Property Address Daniel Schwenk Owner Owner's Name information is required for every Cotuit MA 02635 04/17/14 page. city/rown State Zip Code Date of Inspection D. System Information (cons) 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 fleet Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately front 30 22 40 42 54 34 t5ins•31`13 Title 5 official lnspedion Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts m UTitle 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Buckingham Way Property Address Daniel Schwenk Owner Owners Name information is required for every Cotuit MA 02635 04/17/14 page. Citylrown State Tip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe-how you established the high ground water elevation: USGS maps show anelevatio of over 20.0 feet. t . Before filing this Inspection Report, please see Report Completeness Checklist on nextpage. t5ins-3113 Tits 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 29 Buckingham Way Property Address Daniel Schwenk Owner owner's Flame information is required for every Cotuit MA 02635 04/17/14 City/Town page. State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary:A, B, C, D, or E checked Z 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-W 3 Tft 5 Oftal ftpec ion Form Subsurface Sewage Disposal Systern-Page 17 of 17 Town of Barnstable P# 3 3 Department of Regulatory Services WAFN �. : Public Health Division Date 1 0 200 Main Street,Hyannis MA 02601 Date Scheduled 44L,L Time Fee Pd.__116 � Soil Suitability Assessment for Sewage Ns osal Performed By: r'En Witnessed By: GV LOCATION& GENERAL FORMATION /Location Address �} ��L G K1'4 7 U _ • Owner's Name /1J Address Assessor's Map/Parcel: i 'O j - I / Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(35) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well t} Drainage Way ft Property Line _____-_-_ft ` Other ,ft- SKETCH:(Street name,dim nsions of lot,exact locations of test holes&perc tests,locate we ands 1n proximity to holes) l � i Parent material(geologic) Depth to Bedrock Depth to Groundwater. StandingWater in Hole: Weeping from Pit Rnee -v9 t1 Estimated Seasonal High Groundwater O >1 DETERMINATION FOR SEASONAL HIGH WATE7TABLE Method Used:Depth Observed standing in obs.hole: In. Depth to soil mottlin.tV m Depth to weeping from side of obs.hole: in. Groundwater Adjustment_ ft. Index Well# Reading Date: Index Well level, Adj,fhctor Adj.Ciroundwnter lxvel Observation PERCOLATION'PEST Date�.� Time ' Hole# 1� Time at 4" Depth of Pere Time at 6" Start Pre-soak Time @ I 0 9 Time(9 -6 ) End Pre-soak -7 Rate MinJlnch L h Site Suitability Assessment: Site Passed ,\ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1)week prior to beginning. Q:\S EPTICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil. ' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. tl on i tenry6y� Gravell ^��K tL-,oq.A 1 9 c� C- 2. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. r r si tency,% ravel l Y✓ (,�a �aQ 4 - �, tt v s.? DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color =:' -•Soil' Other Surface(in.) (USDA) (Munsellj''•- Mottling (Structure,Stones,Boulders. '• Consistency, Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consistency, 1 � I Flood Insurance Rate Man: Above 500 year flood boundary No Yes _ Within 500 year boundary No ✓' Yes Within 100 year flood boundary No-7 Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring,pervious material exist in all area's observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per ious material? Certification l� I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the require3�t ' ' ,experti a and experience described in 310 CMR 15.017. Signature Date to Q:\S.EPTI0PERCFORM.DOC _ TOWN OF BARNSTABLE LOCATION SEWAGE#,Z()/O — 1/?0 VILLAGE ASSESSOR'S MAP&PARCEL D� 0 INSTALLER'S NAME&PHONE NO.a&�Ls�� SEPTIC TANK CAPACITY LEACHING FACILITY:(typea (size) �r 6 NO.OF BEDROOMS OWNER,)1pnJJ t A �1 'tCy� f PERMIT DATE: _ Z; -Z,5 10 COMPLIANCE DATE: 2-O kO 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 O � �_ Vy � �1 � � � �.,- No. Fee �00', THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplicatiou for �ispogat 6p5tem Cou tructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components 0� �L9C.�9/ ' Location Address or Lot No. Y. Owner's Name Address;and Tel No. Assessor'sMap/Parcel��� Installer's Name,Address,and Tel.Noezalto, Designer's Name,Address and Tel.No.�/�l�/,� / ��✓� Type of Building: Dwelling No. of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i x. Design Flow(min.required),330 gpd Design flow provided 3 j �— gpd Plan Date /�/y��Q�(� Number of sheets Revision Date Title r Size of.Septic Tank A&V Type of S.A.S.ti5 A&I'v" aMS �S'd Description of Soil �✓I�yf✓6� SQ✓dq, �L') Nature of Repairs or Alterations(Answer when applicable) � xos 5 gee_ 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 o the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this oar of Health. Signed A AM cs ate l/ 10 Application Approved by I Date Application Disapproved by: Date for the following reasons Permit No. Date Issued No.; A /0_4� ;V Fee o6) y THE COMMONWEALTH�OF MASSACHUSETTS Entered in computer: PUBL C HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi.5pogal 4,5tem Construction Permit Application for a Permit to Construct( ) Repair(-) Upgrade'(-) Abandon( ) ❑.Complete System ❑Individual Components F Location Address or Lot No�&pZ Owner's Name Address,and Tel.No Assessor's Map/Parcel�G ��1 �v✓ � - Installer's Name,Address,and Tel.No.e440/b4!� ��/frJ��. Designer' Ns ame'Address and Tel.No.9xV/,j L' P6��� dog- �o-/Z� � s1r,S�t� >c /'��• v8-f'3 3-W177 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3Za gpd Design flow provided j L gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank fjaj:y7 Type of S.A.S.r� � � ,yC Tr ..Description of Soil _ W_,(J11^ ',la##fg7 r/e Nature of Repairs or Alterations(Answer when applicable) 14AUS OA7 Z X4S e4,tA_-Z5 At46 A).,U) L /U /S7 1l'U7rid/l l dl� 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. n f, Signed .I 44� {/�► /! v ate 111;idle/ 1;l Application Approved by ��//� ��(/ / l�f � � ate X 4,1A`? y /7 -� r Application Disapproved by: / Date for the following reasons Permit No. v t/ (/ �� Date Issued / �V r f. THE COMMONWEALTH OF MASSACHUSETTS ------`---- BARNSTABLE, MASSACHUSETTS Certificate of (Compliance. THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgtaded ( ) Abandoned( )by at has been constructed�in/accordance with the provision_s of Title 5 and the for Disposal System Construction Permit No. // / 6� a�! !dated Installer Designer 4 bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will functiiojn/as designed.1 f Date / ��/� Inspector �(�/ 1 No. ------------------- Fee �` `------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpo$al *p!gtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at ,At &d," and as described in the.above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be mpplsetted within three years of the date of this permit. Date ,� � 9 �( � Approved by_ /P A t /PA", Town of Barnstable U . Regulatory Services Nam. ` - 'O,� • -' Thomas F.Geiler,Director HARNS`1'hBEE, � pQ a Public Health Division Qp t639., `0� rFQ p a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office::508-862-4644. Tax: 508-790-6304 Installer &Designer Certification Form Date: Designer: , Installer: �� , Address: . - !f ��� Address: _N--- On 1I r&1 1Z) M{ c71 was issued a permit to install a (date) (installer) septic system at G W based on a design drawn ley (ad ss.) • � ated (designer) „_certify that the septic system referenced above was installed substan-daily`:, accordin 'to g 'the design, which may include minor approved changes such as latcras.relocation of the d1stdbution box and/or septic tank, I certify,that the septic system:referenced above was instal d vInth'.plafor,changes ( ;p, greater fli "10' lateral relocafi6h of the SAS or-any vertical reloca ran of any component- of the.seph�systeem)but in accordance with State&Local Regulations. Plan revisi.n or ce fied as-btlty cfesi'gner to'follow. �H Qf Mqs 2� 1 AVID taller' ignature) WASt)N_ rn . ,a�.a.. 9 Iday 1fl6s �. ,;• SgAll TARP (Wsiff s Signature) (Affix er's Stamp Here) PLEASE RETURN TO IBAf U4 I"A)ii>;E PUBLIC-HEALTH DIVISION:° C1�RTIF�C TE OF�: CQMTL- IANCE WILL N��' Z-E`= SSUED', BOTH :TI3l[5°FOI�VI " BUiI.T14CARD ARE RECEM- D BY.TBE:BAR STABLE PUBLIC,MMA13U DM,1910N. THANK YOU. Q:I�ealtPi/Septc,Designer Certification Forrs , ti � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 10T . TITLE 5 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 1 . PART A , =: CERTIFICATION Property Address: Ici Owner's Name: _�O.Y1�pYlQ, ' Iu) Owner's Address: -- Date of Inspection: ZT r.1 M Name of Inspector: lease print) S� Company Name: Mailing Address: $ Telephone Number: zGo 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'15 060). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: fq p The system inspector.shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. } Notes and Comments ****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 l l ° OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 3.10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ' I., s a cv 4� �M E 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 rago I of i i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: w\S 42— Date of Inspection: ti p�- 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 failin o protect public health,safety or the environment. 1. System 'II pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)t t the system is n functioning in a manner which will protect public health,safety and the environ ent: _ Cesspool or p. ' is within 50 feet of a surface water _ Cesspool or pri within 50 feet of a bordering vegetated wetland or a salt marsh . II Z. System will fail unless the Board of Healt and Public Water Supplier,if y)determines that the system is functioning in a manner that protects t ublic health,safety and nvironment: _ The system has a septic tank and soil absorption s tem(SAS)an e 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 wit ' Zone I of a public water supply. The system has a septic tank and SAS and the SAS i ithin 50 fee f a private water supply well. _ The system has a septic tank and SAS and the S is less than 100 feet b 50 feet or more from a private water supply well**.Method used to det ine distance "This system passes if the well water anal is,performed at a DEP certified laboratory, or coliform bacteria and volatile organic compounds ' dicates that the well is free from pollution from t facility and the presence of ammonia nitrogen and itrate nitrogen is equal to or less than 5 ppm,provide at no other failure criteria are triggered.A cop f the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(con'tinued) Property Address: I cicic 1ti1 — Owner: C. Date of Inspection: 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''/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (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. Large Systems: To considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must in ' ate either"yes"or"no"to each of the following- (The following c ' ria apply to large systems in addition to the criteria above) yes no the system is within feet of a surface drinking water supply the system is within 200 feet o 'butary to a surface drinking wa supply the system is located in a nitrogen sensitive a(Irate ' ellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in S 'on E the system is sidered a significant threat,or answered "yes"in Section D above the large system ailed.The owner or operato any large system considered a significant threat under Section E or f ' d under Section D shall upgrade the syst 'n accordance with 310 CMR 15.304.The system owner shoul ontact the appropriate regional office of the Departm 4 i Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ?A Owner: RN On-Z Date of Inspection: 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 _ If Were any of the system components pumped out in the previous two weeks? j _ Has the system received normal flows in the previous two week period? J Have large volumes of water been introduced to the system recently or as part of this inspection? f _ 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 tthe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? J _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no •/ _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: , v\S O rye Date of Inspection: a FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CNQt 15.203(for example: 110 gpd x#of bedrooms): C� Number of current residents: ��LL Does residence have a garbage grinder(yes or no):`�t' Is laundry on a separate sewage system(yet or no): 0[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):►`� Water meter readings, if available(last 2 years usage(gpd)): M/�k Sump pump(yes or no):r`%t, Last date of occupancy: e °� OMMERCIALANDUSTRIAL T f establishment: Design based on 310 CMR 15.203): gpd Basis of design eats/persons/sgft,etc.): Grease trap present(yes or Industrial waste holding tank present Non-sanitary waste dischar a Title 5 system o Water meter readings ' vailable: Last date of oc cy/use: OTH (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):tn..& 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/Altemative 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): a Approximate age of all components,date installed(if known)and source of information: t_T Were sewage odors detected when arriving at the site(yes or no):_)2�0 6 • , 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: 7,k �c ern lam` a Owner: cw\S one , Date of Inspection: a BUILDING SEWER(locate-on site plan) i� Nr Depth below grade: Materials of construction:east iron-,..,/40 PVC_other(explain): Distance from private water supply well or suction line: 4o cnr►.\ Comments(on conditio of joints,ventin evid ce of leakage,etc.): GAO �gg� SEPTIC TANK:_(locate on site plan) Depth below grade: 2d - Material of construction: concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , Dimensions: x Sludge depth: C4 Distance from top of sludge to bottom of outlet tee or baffle:- j Cr „ Scum thickness: r Distance from top of scum to top of outlet tee or baffle: —Co Distance from bottom of scum to bottom of outlet tee o baffl How were dimensions determined: DI-0 Comments(on pumping recommendations,inl t and outlet tee or baffle condition,structural integrity,liquid levels as related to out t invert evide a of le ge,etc ✓' /i a G EASE TRAP:_(locate on site plan) Depth b w grade:_.__ Material of c ction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o t tee or baffle: Distance from bottom of scum to bottom o or affle: Date of last pumping: Comments(on pumping rec endations,inlet and outlet baffle condition,structural integrity, liquid levels as related to outlet inv ,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: 2 �• v� 1� • , i Owner: oYSSL Date of Inspection: Q GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below Material of constructio . concrete metal fiberglass_polyethylene other(e lain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order r no): _ Date of last pumping: Comments(condition of al oat switches,etc.): DISTRIBUTION BOX: (if present must be opened)(lgcate 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 of of box,etc.): RUMP CHAMBER: (locate,on site plan) Pumps in wor i r(yes or no): Alarms in working order y Comments(note condition of pump c a ondition of pumps and appurtenances 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I Property Address: 7 ckg u % V� Owner. Date of Inspection: 10 ItO SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,.excavation not required) If SAS not located explain why: Type �/ leaching pits,number: leaching chambers,number: V leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):elk o© so 11 ci— \je_4g A.Lb n t) &A v r'f CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) er and configuration: Depth— of liquid to inlet invert: Depth of soli ayer: Depth of scum lay Dimensions of cesspoo. Materials of construction: Indication of groundwater inflow or no): Comments(note condition of soil,sign hydraulic failure, level of ponding, ition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condit' of soil,signs of hydraulic failure,level of ponding,condition of vege ,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1 Property Address: I- �1 Owner:�Ci^aiL."aC oY�2 0 Date of Inspection: 5. o / 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. 13 © \4 b ! 0 �Z- 3 0 t 10 r Page 11 of 11 •e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ck, L Owner: r, ,�Cooe Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 151'/-feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ` e Accessed USGS database-explain: 3 You must de cribe how you established he high ground water elevation: r; r` Q 0 Q Q ry kc t ' 11 TOWN OF BARNSTABLE LOCATION SEWAGE # �^ VILLAGE ��y. C ✓ ASSESSOR'S MAP & LOT Y INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)�l (size) 0,e I NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER s BUILDER OR OWNER_St ® - - at DATE PERMIT ISSUED: 3 DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No F ` - � n �� _� Q Fz$..., ,. .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ......."............. ...................OF...7 hld ----.----.-.-...---•- ---- ApplirFa#iun for lliiivuiiFal Works Counts iun "anti# Application is hereby made for a Permit to Construct (V'�'or Repair ( ) an Individual Sewage Disposal System at: ..... u i Wit.... `l ............................. - ...--.....-......------------......------....................-•----------. cation-Ad s� or Lot Owner ^� Address a _ �� L------------------------------------- �J , e--.../ 1r. .............................. Installer Address U Type of Building Size Lot._Z .�J®_._g ......Sq. feet Dwelling—No. of Bedrooms.._...... .............................Expansion Attic (k/6 Garbage Grinder (Vo Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................ Design �5..................•..gallons per persong Total qil flow_.__.._... gallon W Desi Flow----•---•-•-- -. � c�.y. yr, ��1.�--------------- � � WSeptic Tank—Liquid capacity.1 .gallons Length. ...-�d_..•.. Width../12----- Diameter.__.......... Depth..-� '.?.... x Disposal Trench—No..................... Width_._............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......._I............ Diameter........ ....... Depth below inlet..... _.......... Total leaching area`Z .....sq. ft. Z Other Distribution box ( Dosing tank ) r . Percolation Test Results Performed by..._ . l.-•--- .�<_1CL4. . .Date....•.. _`3..-��-y......... a Test Pit No. L... ......minutes per inch Depth of Test Pit..... Depth to ground water.._t� �`� (14 Test Pit No. 2................minutes per inch Depth of Test Pit................•.•. Depth to ground water........................ --------- •--••••-•...............•.• ---•-•••...........•--•---•-••--•---------....-•------•---•.....-----.....-•-••----•-•........__....•. Description of Soil.......0.- 1-•------- ............ I ' ....---- ---------------------------------•---......------------••-•-•......-•--••- ------------ I ......... -.''-.----...... "`�----------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable..........................................:..................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage osal System in accordance with the provisions of 1.TITLE 5 of the State Sanitary Code— The undersigned f -er grees not to place 4ys., n operation until a Certificate of Compliance has been is e y e board o h. `Signed -�•�-- ---------- - ---------- •-- . --- --•• Application Approved By••-•• - -.�.....----- ---------------------------------------- Date Application Disapproved for the following reasons:............................................................................................................... .......•---------------------•---------•--------------------•-----------------•---.......----............._......----........----....--------•-----•----------------------------•-•-•-•---•-•••......._.. Date Permit No........8.1— �`1 ._____. Issued....................--• �---------• Date•-------•----•--.. ._ � �• t Ficic THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ., ApplirFation for Disposal Works Tonstrnrtion rtrutit Application is hereby made for a Permit to Construct (Aor Repair ( ) an Individual Sewage Disposal System at: cation-Add ss # or Lot `[ ram- - �:: �� .... 2ZZ. ' ... .. -- Owner Address - .:.... Installer Address Type of Building 6' Size Lot_Z2,2.2G1.....Sq. feet U — .....Expansion Attic (,�(� Garbage Grinder (n�(� DwellingNo. of Bedrooms.............�................__.... — Other—Type of BuildingNo. of persons............................ Showers Cafeteria dOther fixtures� ------------•----------••..........................•--.-------------------------------------------•---•--•--.�...................--•--..........---• W Design Flow...........:.. .....................gallons per person per d,4y. Total daily flow.......... _ . ..................gallons, WSeptic Tank—Liquid* 6 capacity.� gallons Length._ (?..... Width.y..'..... Diameter................ Depth.25.....7.... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........ Diameter........0....... Depth below inlet.....(ter_.......... Total leaching area.fZ.-��?....sq. ft. Z Other Distribution box (--f Dosing tank ( ) �. Percolation Test Results Performed by..�'?.,4,A J._1C: 'fit!...........:....................."'bate--------___ .._ `__..._.._..._.... aTest Pit No. l.._.Z'_._.__minutes per inch Depth of Test Pit.....rL_r.C?. Depth to ground water---1V4%'!4--._. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................ a+ ..........--••--•--•-a-------------•--•................ ------------ ........ ••-•---------------- -------- •---------- •---------------------------------- ••- O Description of Soil---•.!�.`f-----------'c` '� t 4'. r' IC. ---•----------------•-----------.....................---•----------- W .................................................... U---...'�-� �r:....em f UNature of Repairs or Alterations—Answer when applicable............................................................................................... •----------•-----------------------••------------------------------•-------------------....------•-----------------------------------••-----••----------------------•-•------•••---••..........._...••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage D' osal System in accordance with the provisions of TITLi� 5 of the State Sanitary Code—The undersigned f ier grees not to place the ystem in operation until a Certificate of Compliance has been is e y e board o h. r.. Signed-_. ........... .. ....._... ........... •. Date ApplicationApproved BY-------0"11_ .. ............................................ r ....................------.............. Date Application Disapproved for the following reasons--------------------------------------•...--------------•---....-•------------•-•-------------•-•-•........------ ---------- --------------- - .............. •--------------- ----------------------------- -•............. ••----------------------------------------•------------•----•--Dau--•----------- PermitNo........3..2-... ` *�: —------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... rg ,.Z. h_.........OF......... ..................................... Trrtifiratr of Tompliaurt THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (>0 or Repaired ( ) by............ ze......... ... ?-'....................................................................................................................... —F Installer at...............4--�-�••... •--••- = - -.--l�-1 ',� ------•-------- a. ................................. has been installed in accordance with the proovisiions of TITIE f The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... .... a.�l.......... dated_.............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................................•----•-----..._.....-•---• Inspector........................ ......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0F............ .................................. No...zS.2.... FEE....2 S.... Disposal Mork (Ionotritrtion rrmit Permission is hereby granted.------- r.-•-••• —_c::3r ¢: Xystem _eC:-------------------•---........._.......------.........--•-•-••--- to Construct (V or Repair ( ) an Individual Sewage Dispos�al .......'JcuiY__. .��6:V�+.--.....Aew .------- '!'.jl.,.t..r.,C,.L.....-••............................................ Street as shown on the application for Disposal Works Construction ermit .7_..�a.�Dated.......................................... ........................ ----��------------ .......................... Board of Health DATE-----------•-•--•g °'' J FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ) 3 9 0 <...� a .o aEa=rta 2Jo 79�-537-402,� P- 352z JC�.IN/ ./4Cc�3/- 8.0 fib._ / �•S �.� i. e) &,- YV 1AV.. 9(o 2 x 96 y ��✓ 96 9b.C,> E. �� /�z/4�4EG� �, ibSFJ� � ��>✓ • STzY✓C 90.0 ,�N<o�� MOR H l0-7— /g3 4 �P #2 17 Z7/ . Ale-) TONAL - � ASSESSORS MAP : �Z I G -- -- ---- TEST HOLE LOGS NOTES: PARCEL FLOOD ZONE: _ h� �} '�GIG��G�i _ SOIL EVALUATOR: WITNESS : I I '(gWrb" 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: C� / � �' f G k.� DATE: 1 Health Regulations. - -- - - ------/Z- —--- �� ___^ _ � gs—Z PERCOLATION RATE: . -� Z IMI i 2) The installer shall verify the location of utilities, sewer inverts and septic � components prior to installation and setting base elevations. TH'� 1 TH!2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first two feet out of the d-box to the leaching shall be level. Z10 4) This plan is not to be utilized for property line determination nor any other 04 �y �b il purpose other than the proposed system installation. 6*4 5) All septic components must meet Title V specifications. 10 33 6) Parking shall not be constructed over H10 septic components. L 0 C A T I ON MAP ( � 7) The property is bounded by property corners and property lines. M � � 8) The property owner shall review design considerations to approve of total G 1 1 n Zy design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material ,1 L"W per Title V abandonment procedures. Those within the proposed SAS shall �r � �t1J ,,q, ------`- - -- - � `�1, G� n� - - be removed along with contaminated soil and replaced with clean sand per '�,{ 1?j1?j1 Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPT I C SYSTEM DES I G N applicable. f I �Io tAld / I \ FLOW ESTIMATE 11) IIf a garbage grinder exists it is to be removed and is the responsibility of the I l owner to ensure such. I 12)The installer is to take caution in excavation around the gas line if such BEDROOMS AT I GAL/DAY/BEDROOM - GAL/DAY exists. 13)The installer shall verify the location, quantity and elevation of the sewer k SEPTIC TANK g _ lines exiting the dwelling prior to the installation. ao GAL/DAY x 2 DAYS - UX GAL Q,r�1 I USE !000 GALLON SEPT I C TANK ►�.IYJ�L_ 01 L ABSORP ION SYSTEM 6 -, v110 _IS uW ti�X 5!-� x �b5 ur &A_,bi I cov�l 2 _.� gao5X I_ x `f 18 = i 4-1b ---------- S-E-� T `I C SYSTEM SECTION 12 � E-DAI�\Im D � w��4 Iitir l� _ 11 10 I W •.� �flF�iF-T (-i�' 3b Mix _ c15AWN _ 9 0 ° p e 1 U �,i`�/ a o n o a D GAL S, _ l% 1 ° SEPT I C T NK '�- I,LYiI c�I _ Z — � _ �/O �r o ti� >��0 G 6 �y � --- SITE AND SEWAGE PLAN LOCAT I ON : A \)( PREPARED FOR : CKD AL, 607 J P ti M O SCALE: Uj DAV I D B . MASON Rz/7 DATE: III 5 DBC ENVIRONMENTAL DESIGNS W EAST SANDWICH . MA W DATE HEALTH AGENT ( 5O8 ) 833- 2 177 Z