HomeMy WebLinkAbout0164 CAP'N SAMADRUS ROAD - Health J-64 Capt'n S amadrus Road
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Commonwealth Of Massachusetts
` Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form -Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
C74, i1 Certification
Property Address: 164 .Samadrus Rd.Cotuit Ma. � 7
Owners Name:Paul&Diane Clark
Owners Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Date of Inspection:8/9/2006
Name of Inspector(please print)Sean M.Jones
Company Name:S.M.Jones Title V Septic Inspection
Mailing Address:74 Beldan Ln.
Centerville Ma.02632
Telephone Number:508-778-4597
-. CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is trueaccurate and complete as of the time of the inspection.The inspection was performed based on my
ti 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 evaluation by the Local Approving Authority:
Fails
Inspectors Signature Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board-df 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 o�fice 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.
Page I ,.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coN n-4m)
Property Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane Clark
Date of Inspection:8/9/2006
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:
B.System Conditionally Passes:N/A
One or more system components as described in the"Conditional Pass"seam need to ber replacedorr
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 u 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 the 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 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 Clue 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coNTwuw)
Property Address: 164 Capt. Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane Clark
Date of Inspection:8/9/2006
C.Further Evaluation is required by the Board of Health:N/A
r
Conditions exist which requirer further evaluation by the Board of Health in order to determine if the system
Is failing to protect public health,safety or the environment.
I.System will pass unless Board of health determines in accordance with 310CMR I5.303(I)(b)that the
System functioning in a manner that protects the public health,safety and the environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100€eet of
Surface water supplyor 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 less than 100€eel but 50 feet or mmt-frtbm 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 coli€orm
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:
OffICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coNTNUED)
Property Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane Clark
Date of Inspection:8/9/2006
D System Failure Criteria applicable to all systems:
You most 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 'A 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
-
X 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.
X Any portion of cesspool or privy is within Zone I of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply well.
X Any portion of 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 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A
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:
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 R of a public water supply well
If you 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
signiftcant threat under Section E or failed under section D shall upgrade the system in accordance with 310
CM15.304.The system owner should contact the appropriate regional office of the Department.
IOff][CIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner.Paid&Diane-Clark
Date of Inspection: 8/9/2006
Check if the following have been done.You mast 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 system components pumped out in the previous two weeks?
l
X _ Has the system received normal flows in the previous two week period?
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 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 tee,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 ofthe failure criteria related to Part Cis at issue approximation,of
distance
Is unacceptable)[310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART C
SYSTEM INFORMATION
Property Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner:Paul&Dime-Clark
Date of Inspection:8/9/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4_ Number of bedrooms(actual):—3_
DESIGN flow based on 310 CMR 15.203.(for example): 110 gpd x#of bedrooms):474 GPD
Number of current residents:-2—
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):_No [if yes separate report required]
Laundry system inspected(yes or no):—N/A
Seasonal use:(yes or no) No
Water meter readings,if available'(last 2 years usage(gpd):
Sump pump(yes or no): No
Last date of occupancy/use: Current
COMMERCIAL/INDUSTRIAL:N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gDd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes orno):
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:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was this 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 the system owner)
Tight tank Attach a copy o€the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information,- 1999
Were sewerage odors detected when arriving at the site(yes or no): No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner:maul&Diane Ctark
Date of Inspection: 8/9/2006
BUILDING SEWER(locate on site plan)
Depth below grade—_Z.L below TF�F
Materials of construction: cast iron_X_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition,no sign of leakaae.
SEPTIC TANK:—X_(locate on site plan)
Depth below grade-.—IS"
Material of construction:_X 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: 1500 Gallons
Sludge depth: 14
Distance from top of sludge to bottom of outlet tee or baffle: 2`
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle:T6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: opened covers and took measurementsT
Comments(on pumping recommendations,inlet and outlet tee or raffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
Inlet and outlet tees were intact and in good condition.Tank was structurally sound.,liggid levels were gad Tank
was not leaking.
GREASE TRAP: X/A (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.):
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 164 Capt. Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane Clark
Date of Inspection: 8/9/2006
TIGHT or HOLDING TANK: N/A (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 lust pumping:
Comments(condition of alum and float switches,etc.):
DISTRIBUTION BOX_X (if present must be opened)(locate on site plan)
Depth-of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
Leakage into or out of box,etc.):
D-Box was level and in good condition, Cover is down 28 inches
PUMP CHAMBER: N/A (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:):
L
1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:164 Capt.Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane Clark
Date of Inspection:8/9/2006
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits.Nuer:
_X Leaching chambers,number:-
5-Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,diinensions:
overflow cesspool,number:
innovative/aiternitave system Typetnaine of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Soil was dry there were no signs of hyfiaulic failure Vegetation was normal At time of inspection,Leachine
chambers had 19 inches of available leaching: Cover is down 33 inches.
CESSPOOLS: N/A (cesspools 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 ofcesspool:
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: N/A (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.):
:OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property YAddress: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane Clark
Date of Inspection: 8/9/2006
SITE EXAM '
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 5+ feet
Please indicate(check)methods used to determine the high ground water elevation:
_X Obtained from system design plans on record-If checked,date of design plan reviewed: g/12/1999
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:
High groundwater elevation was determined by accessing The'Town Of Barnstable Groundwater Contour Map,also
by researching the design plan on file at the Town of Barnstable Board of Health showing no water encountered at
120 inches.
r
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 164 Capt.Samadrus Rd.Cotuit Ma.
Owner:Paul&Diane,Clark
Date of Inspection: 8/9/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
FRONT OF HOUSE
A PORCH 8
❑ F -71
1 2 3 4
TANK D-BOX S.A.S.
A-1=27'6 A-3=427' A-4=60'
B-1=66'9 8-3=497' B-4=36'
A-2=34`8°
B-2=57'6°
q,
No. /�' ,� 03 Fee Y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for �Digogar bpsstem Con6ttrruction Permit
Application for a Permit to Construct( VRepair( )Upgrade( )Abandon( ) LR"Complete System O Individual Components
Location Address or Lot No. Y C1910W 1519,01 1W dS P- Owner's Name,Address and Tel.No. 5_0 ff��—6 Y�S
CU-rue-r P�9 t/L CLAILIC
Assessor's Map/Parcel
3FS Ivto (Diry LOT,np) /'I"OL/JEA'l M,+.Installer's Name,Address,and Tel.No. 3 t y —g 4V 7 q- Designer's Name,Address and Tel.No. ?7 5_—Q 7 3 S
44Y C&ram/,v® A/FFLL,64 * 1�55ec
Type of Building:
Dwelling . No.of Bedrooms Lot Size 79 sq.ft. Garbage Grinder VJO
Other Type of Building LAW b fi AMF- No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow � � gallons.
Plan Date ' /-7 a Number f sheets Revision Date
Title Ito nvOlky_
Size of Septic Tank 5_ Type of S.A.S.
Description of Soil dA a&
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 Certifi-
cate of Compliance has been issued y this Board of Health.
Signed Date
Application Approved by Date —ram f
Application Disapproved for a foldowing reasons
Permit No. "ry 3 Date Issued
_• -r�No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF,BARNSTABLE, MASSACHUSETTS V
Rp*rtcation.for Miopooal *potent Conotructfon permit-
Application for a Permit to Construct(VRepair( )Upgrade( )Abandon( ) [Rtomplete System ❑Individual Components
Location Address or Lot No. (p Y C,9?W _5fidldDl?IDS P.P Owner's Name,Address and Tel.No. �(� - �a� —6 O 5—
Co?uiT pl414 C4.42.ic
Assessor's Map/Parcel
3� y agv core
Installer's Nam ��C ..-e,Address,and Tel.No. y 7 7[� Designer's Name,Address and Tel.No. �7 '? Q 5—
Y CATF-kI vo Tj ,v,vI5 �tss�c
Type of Building:
Dwelling No.of Bedrooms; .`' Y Lot Size oT 0. 5 V sq. ft. Garbage Grinder WO)
Other Type of Bu 1�d ng1WMy 6M WE No.of Persons Showers( Cafeteria( )
Other Fixtures 11
Design Flow 19147 S XU gallons per day. Calculated daily flow NJ gallons.
Plan Date Number of sheets Revision Date
Title ► .
Size of Septic Tank S^ Type of S.A.S.
1 Description of Soil d,4 19-:91
t
c _
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 Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date pt-3/
Application Disapproved for e f6tiowing reasons
Permit No. . .'i(n ?� DateJssued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( I/)Repaired ( )Upgraded( )
Abandoned( )by C A Z i fL/ic/D
at llo t( �'i9 P 1-4 IA, S AM CO I�U'/t- has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. -S6 dated
Installer Designer s
The issuance of this permit shall not be construed as a guarantee that the syste 4i11 function as designed,
Date Inspector L T tc tea.�1t..- r
No. 9^ �� 3 Fee J O a
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mtooal *r5tem Construction Perron
Permission is hereby granted to Construct( V)R pair( )Upgrade( Abandon( )
System located at
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 coomgpleted within three years of the date of this t.
Date: Z / Approved by ..),c
f
TOWN OF BARNSTABLE
LOCATION �� ���r: �%�- �/io;.�n 1Z-, SEWAGE #
VILLAGE Co -7 ', ASSESSOR'S MAP & LOTS
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS �-
BUILDER OR OWNER Lys ,o 6 �-
PERMITDATE: COMPLIANCE DATE:.
I Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Privdte Water Supply Well and Leaching Facility (Ifeany 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
uo�/bb(70$I
1
sn ��
Fims.......lQ. :.....
THE COMMONWEALTH OF MASSACHUSETTS
"Of 9 BOARD OF HEALTH
0
E �C .................OF....EjA.1Z R, , .
•1 c liplirFatiun for Bispoii al Works Tomitrurtiun ranfit
L P on is hereby made for a Permit to Construct ( a-)-or Repair ( ), an Individual Sewage Disposal
.....-•-•-� jX -•cJ i S .c �....._..... i.. MAP,� . .........................••--••-........_.
Loca,on-Addr ss /,�, r or o.
- j '
W - Owner A ss
__�_f ....................... ..... L. l _.Ll .a.�---
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling.—No. of Bedrooms_____________ _____________-_-___Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building ............................ No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures __________________________________
W Design Flow................. ...................gallons per person per day. Total daily flow-----___._ ._. ._..gallon s.
WSeptic Tank—Liquid capacityl�®_gallons Length___- ___ Width�:_-_��__ Diameter________________ Depth_ -7.._.
x Disposal Trench—No_ ____________________ Width Total Total Length._._..___._..._. Total leaching area....................sq. ft.
Seepage Pit No--------f_........... Diameter...1�_'_C�_.... Depth below inlet....�!�__...... Total leaching area._ 9z- _s ��
Z Other Distribution box ( Dosing tank
Percolation Test Results Performed b _. 4A. .LU.6)!15 LU ....... Date_10.A_a.14,41�9
Test Pit No. 1......�.......minutes per inch Depth of Test___` Pit..... -i------- Depth to ground waterr7M.o.Q_l��uyi
Gz, Test Pit No. 2... ___..minutes per inch Depth of Test Pit__-_12)_ ________. Depth to ground water.Mi i��
-!PW
O ---•-----7------j____ D_-- --- �-•-•- --•--•------------------------- _______ ___--••---•-•-----___________-------------•--•---------------
_Descpption of aSoil'_-IIt �.-- ..C.'• i-1 .t_.
V8 t.'�..F� �� ._ �13� .1�- C.S L ek,E� 4ct��1?�Sc Y�_d.0 ;5.g .3o-----;---
W
VNature 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 iIT 11 5 of the State Sanitary Cpjde— The'undersigned further rees not to place the system in
operation until a Certificate of Compliance has bee ssued by e bb geal.t.h.
Signe -------------- ----
�.�,arx Date
Application Approved By-----6i► u --
Date
Application Disapproved for the following reasons---------------------•-----------------------------------------•---------------.................................
-•------------------------------------------•----------•-------...----•--•-------•-._.....--•-------.......--------------------------------------------•--------------------------------•----------------
qr s Date
Permit No. f.�...--.-d�---�-..---•-•................. Issued.......................................................
Date
7
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH F' G13
o �ROB " ''`.�-' `--,`
p" 5 Appliration for 11isposal Works Tontitrurtion ranfit
G �G►STE@� �,k+
s470 LE cation is hereby made for a Permit to Construct ( a. }--or Repair ( ) an Individual Sewage Disposal
at
................2. ..... f•./ s AFs. ,.�f 9�•'S .........................................
i y Locatyion Address .{��p p�,a _ or Lot �Io
),,%11--
.
(� rr
a 4=I� _. _.r .i�ST. J�x '7t� ............. .�..�1P �V.A.J Gt�J ?..€.� .t_.., �Owner Z02
�J- 4 c
M Installer Address '/
VTyype of Building Size Lot............................Sq. feet
Dwelling..—No. of Bedrooms.._-",.... _-------------_-.-•--_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ........---•------------------•---•---••--------....--'----•-•---•----•-------•-•----•-- ••-••-------. •-------------------•------------
W Design Flow................,.?...................gallons per person ye day. Total daily flow____.....
gallons.
WSeptic Tank—Liquidcapacity�t��'.gallons Length._'_ ._ram_.. Width....t',1�a__ Diameter................ Depth_`�=__ ....
x Disposal Trench—No..................... Width.#_.....If._._.... Total Length...._............... Total leaching area---------------------sq. ft.
Seepage Pit No........ !A=-"'' ,� e;' �-�.
� ._.... Diameter.... _ _. Depth below inlet.__.:__"_._...._.. Total leaching area..x_=._1.l_s4= D
Other Distribution box ( �"' Dosing tank ( )
a Percolation Test Results Performed byfli 24- ..Ew., '4C=I. :__-•-
} �
a Test Pit No. 1...._�s_......minutes per inch Depth of Test Pit @ `" .�.___.__ Depth to ground waterl Llei. ' 'fl �v, , 4-1111Z�l
1� Test Pit No. 2.......�,-._....minutes per inch Depth of Test Pit..... . ......... Depth to ground water-k'h:"A??a kkk
O
,D c;iption of tSoil, �i� �' �� s-C�;'5ev i `>r x: F, - :3` l., �' � � ��; '!�'�. ,i�I n ��..
Wc ._.t�,M .__` =?.__._._(4� v€� •- 1 Via=_ .... .. _- ._ 1 cJ r�PC '•' a 1�"°°�
•--------------------•----•-•------------•------------...----••-------•••••..------•••-------•---------•---....---------•-----------------------------------•---....--•........_------•--•----------•---
V 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 iITLE, 5 of the State SanitarL_ssued
e ndersigned urtl:er reel not to place the system in
operation u l til a Certificate of Compliance has l e b d o ealth.
Signe .-----------•---
)-a-
Date
Application Approved By----•- _ ..................................... ....... .....a-ram...
Date
Application..Disapproved for the following reasons------------------- •--------•------------------------------------------------------ ............................
..................................................-......................................................................................................................................................
(�' Date
Permit No. <._. . ._d�...�5�-------------------•--- Date
Permit
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'< Cam...........OF........... (?.(....................................
Cprrtifiratr of Tamptiattrr
THIS IS TQ CERTIFY, T t the Individual Sewage Disposal System constructed�) or Repaired ( )
by............... ,� ,...... .-- ....._..........------•--------•-•------------.........------------•---------.--...--------.....----.....-------•----------.....---
Install
at. L"�� ,......... .......J..: err- ..-----C .............. �,[,� ---- ------- -----
has been installed in accordance with the provisions of TI" "r' j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......... d-ated-............. ................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON ED AS A GU NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ ....-1k`-- Inspector.....
THE COMMONWEALTH OF MASSACHUSETTS
1 '
BOARD OF HEALTH
,} -�. `Z..........(f(., ..........OF.. ..... .:........ ..............
No...9t) FEE.....
Rapusa1 WorhD
Permission is hereby granted..........41 4a��....
to Construct (X or Repair ( ) an Individual Sewage Disposal "System " � (�
.__ __ _ ....... ---y---------___ . ...............
Street �
as shown on the application for Disposal Works Construction Permit o.lU- 01---- Dated..........................................
DATE_ Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
nn TOWN OF BARNSTABLE
LOCATION ��� `ArT Jia,��on�n JZ� SEWAGE #
VILLAGE ���"r ASSESSOR'S MAP & LOT Q��"�Qi�
INSTALLER'S NAME&PHONE NO. (JjCC"i�n,-G-
R
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) 4 �'�4�.S 1
®••yam�:..��
NO.OF BEDROOMS
BUILDER OR OWNERys ,�`'
PERMITDATE: COMPLIANCE DATE:
_Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet,
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
� n
uo)/b�QO�I
1
sn 19#
jq3 TOWN OF BARN STABLE
LOCATION SEWAGE # Q,--)-o2 gs l
VILLAGE ASSESSOR'S MAP & LOTO'3,r-US2
INSTALLER'S NAME & PHONE NO. 1"" d
.r QQ�- � /�
SEPTIC TANK CAPACITY ,d®a �1(�.('
LEACHING FACILITY:(type) �.!/�� ° (size) /aw hie
NO. OF BEDROOMS PRIVATE WELL OR4 PUBLIC WATER 6
BUILDER OR OWNER e4f#fflrde�t
DATE PERMIT ISSUED: (/
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes CNoo
��
� k
� 4
yam'
a � � ' .F
�r
.��. r�.
" ��
�� _
� '�
� ; '
. � � ,.
� :
'`:J �
4�
f n,
.� I.
Town of Barnstable r a
Departtttent of Ifeaflh,Safety,avid Environntyental Services
°f119 Pubilic Health Division Date 919
367 Main Street,I Iyannis MA 02601
HAMSTARM
tEornK+" Dale Scheduled z9� 2 5F 2Time o d•o• Fee jdje,�o
o
a
Soil Suitability Assessment for ,Sewage Disposal
f Performed By: v Witnessed By: ��4�'— FM�,
IrcATloly& N1t11� INOIZMA'1ION
Location Address Owner's Name
c'a�e�f -7— Address
Assessor's Map/Parcel: &4 Engineer's Name '
NEW CONSTRUCTION REPAIR Telephone H
Land Use ,µ ,C9 Slopes(%) d "1 Surface Stones
Distances frorn: Open Water Body t V Il Possible Wet Area IV q 'R Drinking Water Well _ft
F }e
Drainage Way R Property Line ao n Other R
SKETCH:(Street name,dimensions of lot,exact locations of lest holes&pert rests,locate wetlands in proximity to holes)
® ®- -LA500
Parent material(geologic) Depth to Bedrock Ilk
Depth to Groundwater: Standing Water In Hole: yldw0 Weeping from Pit face Y1 M^Qr
Estimated Seasonal High Groundwater.' 11► _
: : :« :.....,..:..:................................................................... ..... . ........
° TImA D : tRA
0-
-method Used: . ..........:
Depth Observed standing In obs.hole: in. Depth to soil mottles:
Depth to weeping front side of obs.hole: In. Groundwater Adjustment (1.
4ndex Well N -Reading Dale:_ Index Well level. ___ Adl.factor Adj.Groundwater Level
_ :.:
:»::.::::::;:::::. :;. ::.::,::>:::<:;:::::I'ER [0 TI
Observation
Hole!! Time at 9"
d
Depth of Perc -ol Time at 6"
S4ar3 Pre-soak Time® J f Time(9"-6")
End Pre-soak -
Rate Min./inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) �, y
Original: Public Health Division Observation Ifole Data To Be Completed on Back
r'nnv• Annllrnnr
4 - 1
I
Gl' Bit '.
'.�1I Y±DN Ii����I✓�,G IYuI� t# l:
Depth from Soil Horizon Soil Texture 4 . Soil Color Soil Other
Surfnce(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
L lsistencv.%Cravel) e
0—
\e Vs 11 AM
DEEPATIZ]N II4LE LQG Hole # _
Depth frorn I Soil horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
%
A
d
3 Ae
D �lf tJI3S1tA7`1bN 1dC Ld.Colty
Depth 60,11C Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
%
•f
D . :OVO �IOOIRPVAT �
Depth from Soil Horizon So if Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
%
d nsurance Rate Map1
Above 500 year flood boundary No_ Yes
�.h Within 500 year boundary No— Yes
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervlous Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout llte
area proposed for the soil absorption systein7
if not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (dale)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 required training,expertise and experience described in 310 CMR 15.017.
Signature Date a a 9 9
A
TEST HOLE LOG
DATE:AUGUST 12, 19" P-9490
SOIL EVALUATOR: M.O'LOUGHLIN,CSE
WITNESS: D. MIORANDI
PERC RATE: Q MIN./IN.
(ov I "
( 0" F
ORGANIC 62.0 0 ORGANIC 3" 61.8 3" 61.
' — ( LOAMY SAND A a LOAMY SAND
10YR6/2 10YR6/2
5" 61.6 S" 61.
Bw,LOAMY SAND Bw=LOAMY SAND
I 1 10YRS/6 10YRSM
32" 59.5 32" 59.
C=MEDIUM SAND C-MEDIUM SAND
1
1� 2.SY7/4 2SM/4 V
I I � � 1 120" i $2.0 120" $1
I I' 1 fn
' NO WATER ENCOUNTERED
\ 0 XXX
0 1 1
DESIGN DATA
LA
l 1 DAILY FLOW: (4)BDRMS.z 110 GPD=440 GPD
\ Q 10, : 111 1 SEPTIC TANK. 440 GPD z 200%�80 GPD
1'
USE: 1500 GALLON PRECAST SEPTIC TANK
l� I LEACHING FACILITY:
\ I USE: (5)500 GAL.DRYWELLS LINED w/2'
I i OF WASHED STONE
l.o 2Cs 'j CAPACTTY:
2D,57B mf SIDEWALL: 111 a 2 z 0.74= 164.3
/� _ W ___ ; _ O BOTTOM: 9 a 46.5 a 0.74= 309.7
\ I� TOTAL: 474.0 GPD
-Tw= E L. (oo'Z 1 'a
y
pop
A
NOTES: A
1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. (J
2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION o
BOX.
3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN
6"OF FINISH GRADE.
4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A
GARBAGE DISPOSAL.
5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED
ON A 6"LAYER OF STONE. 2•LAYER OF 3M"PEASTONE OVER
R A OUN
6. INSTALL GAS BAFFLE IN OUTLET TEE. .t D WASHED STONE ALL
ARD
TOP OF FOUND.
-ram , sq.7
EL. ro3..00 10• 14-
• .
SEPTIC SYSTEM PROFILE
GENERAL NOTES
1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION
OF ALL UTH.ITIES,ABOVE AND UNDERGROUND,PRIOR
SITE ^• SEWAGE PLAN TO ANY EXCAVATION OR CONSTRUCTION. .
FOR 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH
310 CMR I&00i TITLE V. '
164 CAPTAIN SAMADRUS RD., COTUIT, MA. 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE
LOT 26-LCP#24623 B DETERMINATION.
4. ALL DISTURBED AREAS TO LOAMED AND SEEDED.
PREPARED FOR
` PAUL CLARK 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY
REQUIRED INSPECTIONS.
10 OF Af, 0 0f
DATE: AUGUST 17,1999 SCALE: 1"=30' 0�4• DANIEI 1.
UAMCIVIL AN +
c� $ vim
V No.3269ec y
7F
WELLER & ASSOCIATES ss/oNa� bd
1 445 FA z
LMOUTH ROAD-SUITE 4C CENTERVILLE,MA. 02632
TEL: (508)775-0735 FAX: (508)775-0754
APPROVED BY:
TEST PIT * l -I':S7 P!T *2 GENERAL NOTES
50x0 r- _-- 8'-6'.
TOPSOIL TOPSOIL
ri r__.__ r :- i- Al_L ELEVATIONS SHOWN ARE BASED UPON AN
SUBSVIC SJBSOIL I ice.__
i
:..__ -z --- ASSUMED DATUM
3' 3' _o 2. PITCH ALL LINES A MINIMUM OF 1/8`� /FT LIN'._ESS
OTHERWISE SPECIFIED.
2a '9o0 c of
3. ALL PIPES TO AND IN THE SYSTEM SHALL BE CAST
- -- 0 0C 0 s t, r IRON OR SCHEDULE 40 PVC.
"o 4. ALL SEPTIC TANKS, DISTRIBUTION BOXES, AND
CLEAN CLEAN I 000 `� ') 0 �' ' r n0 LEACHING PITS SHALL BE DESIGNED FOR H
O -20 WHEEL
MEDIUM MEDIUM — -� 000 -) �"? a 0 OO q' C,: E �� ';'
SAND SAND __ __ _ } 000 .� r r �;n LOADINGS WHEN UNDER PAVING.
t � � � C t; 1 i
I --10��-- -- ��„ 00 . a ;� 0 oQ p �� !`(�C 5 REMOVE ALL UNSUITABLE MATER',�+L BENEATH THE
-L- 3 _ nC 7 INVERT ELEVATIONS OF THE LEACHING PIT FOR
DISTRIPUTIUN BOX OOC� C + ,� O OEMOG 0 + A DISTANCE OF 10FT AND BACKFILL WITH CLAY -
i FREE SAND 81 GRAVEL HAVING A PERCOLATION RATE
NOT TO SCALr � _ _6' n __.� Oc- 2 MINUTES PER INCH OR !_ESS.
I3' - NO WATER ENCOUNTER`-__ t A } TI I
-- - - - ---- NOTE DISTRIBUTION BOX AND r T t TOWN OF BARNSTABLE &r�ARD OF HEALTH MUST
ENCOUNTERED GAL. REINFORCED SEPTIC TANK BY BE NOTIFIED WHEN THE SYSTEM IS NEAR COMPLETION
OBSERVATION PIT TYPI�,AL 1000 GAL. SEPTIC TANK ACME PRECAST OR .IAL TYPICAL LEACHING PIT AND PRIOR TO BACKFILLING.
7 UNLESS OTHERWISE NOTED, ALL. SYSTEM COMPONENTS
PERCOLATION RATE:: 2 min/inch .,T TO SCALE V07 TO SG'a SHALL_ BE INSTALLED IN ACCORDANCE 'WITH TITLE -2:
OBSERVATIONS BY- PAUL ANDREWS NOTE- TANKS REINFORCED THROUGHOUT WITH OF THE STATE SANITARY CODE AND ANY LOCAL
TOWN OF BARNSTABLE BOARC Of= HEALTH ELECTRIC WELDED WIRE WITH 24-1/2" RULES WHICH MAY APPLY
ENGINEER ARROW ENGINEERING INC. EMBEDDED STEEL RODS IN TOP 8i BOT- LIRE 61E.Ifi.LN6 DISrAAVE 8 CONTRACTOR IS TO NOTIFY ENGINEER, PRIOR TO THE
rr ! N 3IB'II'Io"w 29.00 INSTALLATION OF SEPTIC SYSTEM
DATE JUNE 14, 1990 TOM CONCRETE IS 4,OOG PS.I. TEST. , OF ANY DISCREP-
P-7613
ANC,IES BETWEEN TEST PIT RESULTS AND FIELD
CONDITIONS
9 ACCESS MANHOLES TO SEPTIC TANKS AND LEACHING
PITS TO BE BUILT UP TO 12 INCHES BELOW FINISH
GRADE.
10.00 23.00 TOP OF
N 309 I'40 M [! FOUNDATION
ELEV = 51425 -FINISH GRADE I I S I I . r
7—FINISH GRADE ��JISH .,BADE OVER LEACHING
FIN�-FINISH GRADE OVER TANy`; OVER "D" BOX AREA L=L-EV = 50,•0 /
ELEV.= 50.25 ELEV. = 49+5 EXIST GROUND 'ELEV = 49+5 /
PAR E L 52
_
13 4"P 90! _- - �iR------ - VCR
2��x "x `
23 68 Sf �INV.= 47+38 I WASHED STONE
_
_ T
i NV_=_46+83 46+66 -- c• - T
48.2
INV.= 47+15 1000 i INV = 46+90 L- INV,= - ��a�►, :: ; ; w
. GAL_ I _ DIST BOX o
RF.INFCRCED i (TO BE 'EVEL_ ° " :':': : : : : :. ... '°$ ° 24''x ,3/4"X
47.3C'1r��;RE I c ��'° WASHED STONE
SABLE) ° �� q
•, F.PTI' TANK
ass ..:.. : : : ' ..• .. o
g.o� ••• • •- •-• BOTTOM OF PIT
I
h. Nr f L i AHD.
f 1 --46+60 •• ° ELEV.::
TYPICAL SEWAGE SYSTEM PROFILE PRECAST LEACHING PIT
F k. OS
49J ., (TO BE LEVEL 8k S(ABLE)
N"T TO SCALE-
49 ti�O �O 2 �._E G E N D
\ MAP y�ECT10N - PARCEL LOT ADDRESS
000 GAL F X i' ? %;ON LOUR - - g -=- ---- ------ — — -- -
ae.e }°moo ! - - -- __- _ - 2
SEPTIC TANKS v 32
PROPOSED CONTOUR -___-----
--
s Rom ' ` EX►S1 SPOT ELEVAT iCN 8 X 0
[� 49.4
PROPOSED SPOT EL FVATION 8 + 0
'r 'F LEACHING PIT,�b�- // ; PERCOLATION TEST — ZONING DISTRICT FLOOD-HAZARC) ONE
JC P#I
e f �' l )RSERVAT!ON PIT
Fi _--------_RF__-_._�— -
50- !
� � t
49 / / TP#2
CIVIL
DESIGN -CRITERIA 4� . PROPOSED LOCATION OF DWELLING
a9 C,q�p 7 8, SEWAGE DISPOSAL SYSTEM
2 � o�+ `` .
N NIJMBE R BEDC>t.R CMS = -
S — — [-!o!.t� `UN PER Bl DaOC�M 2 . , iiAYMO ��>
44A -- -49� �iALLON'3, PER PERSON PER �)l1Y 55 .��`''�`37`� PARCEL 52 CAP'N SAMADRUS ROAD
DR U s I_ EaCH+NG RE: UIREo gpd a�aq� I ,rt,; f"..' . , COTUIT BARNSTABLE I MA.
LEACHING PROVIDED 549.79Pd
GISF�O SAi- NO
APPLICANT : ENGINEER
LEON JODICE ARR ;VU ENGINEERING INC;.
SEV , R DESIGN 76 HOPE LANE 1Ci CAFE ; R;`vrEL_IITE
SiC)EWAt_L.. - 2n x 6 x 5 x 2.5 - 471.2 gpd DENNIS, MA. 02638 NIASHPEE, MA C2 649
BOTTOM n x 52 x I.0 = 78.5 gpd �. ��.2� SC;AL_E 'F c -,
3Iv !a o so asv so TO rAl. 549.7 gpd �y � A5 �I !: ,,,�ry DUNE 15, 1990 1 1
pr
PLAN SCCL E_ sr.�[E rw FEEr SJR/HP GILT A-666