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0006 CEDAR STREET - Health
b CLdai yStroet t Cotuit k. i.t f 1 za oulylatenais.Inventory zs eet L;heCKIISt j Date Physical Street Address-Check database to ensure it exists -77:Working Phone Number Actual Amounts - ( ie. gas being used to fuel machines, thinner to. clean brushes all count as hazardous materials-no blanks) 1/ Storage Information -location of storage, how long is storage for? If none, note that. Disposal Information :where and who? If none, note that. Applicant Signature -understand what is listed and noted Staff Initial -any questions, know who to ask ____J—Vehicle Washing/Rinsing? -give a vehicle washing policy and �—explain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the.business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. t YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00.for 4.years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. a DATE: Fill in please: APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: TELEPHONE # Home Telephone Number • NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS r IS THIS A HOME OCCUPATION? x YES>, NO ADDRESS OF BUSINESS ,, MAP/PARCEL NUMBER 01 -Q!)j -Or) I Assessing)' When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the To ;n of Barnstable. This form is in to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner f,Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business M this.town. 1. BUILDING COMMISSIONER'S,OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTi, - This individu has b ormeVthe it requirements that pertain to this type of business. MUSTCbWLYWIfiFLALL Authorized Signature** HAZ4RWW MATERM REGULATIONS COMMENTS: z 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. . Authorized Signature* COMMENTS: ' _ I Date: /aSl/of TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: �, L'_�'� t? �-{- INVENTORY MAILING ADDRESS: �/'�'�' s'+- r062 i TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON. EMERGENCY CONTACT TELEPHONE NUMBER: — °E MSDS ON SITE? TYPE OF BUSINESS: iA Ccr�y�d_ ��0 INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: �y� Last shipment of hazardous,waste: (Cln Name of Hauler- Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Obser d/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils l 5"u'~ I," Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas -50-1(6k* ak Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink / Degreasers for driveways & garages Wood preservatives (creosote) v Caulk/Grout 5" blocs Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar I VC t&q N+.e�y� PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers ' Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOWN OF BARNSTABLE + =_ TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: r F01j i�1 _s4- INVENTORY V MAILING ADDRESS: ��CIGr S� CO(o , 4- I/l/+ (/{ /1'� Gy �„� TOTAL AMOUNT: `TELEPHONE NUMBER: f O (G--2�0 2 CONTACT PERSON: Mo aw41o�c 6,f EMERGENCY CONTACT TELEPHONE NUMBER: -D '(-f�G! — ! 4 if MSDS ON SITE? TYPE OF BUSINESS: CCLS Lf--c L C L1 r I/✓LdGF c(, �, INFORMATION/RECOMMENDATIONS: .J Fire District: Waste Transportation: �u/n Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: V Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils ( `" ° "_`y Pesticides / NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas JC�116�n^aX Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar may. PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED ° Y Any other pred`ucfs with 'poison" labels Paint & varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which y_ou feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers V on r✓� Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No..c = / ' s ti Fee XLI) J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes apphration for � gpo al *pgtem Congtrurtfon Vertu Application for a Permit to Construct( ) Repair K Upgrade,) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. � Owner's Name,Address and Tel.No. Assessor's Map/ParcelOYA ^Q 0 f✓ �e)r oN #1,4D`/ CIO !�'► Installer's Name,Addresjel 1whMosom Designer's Name,Address and Tel.No. W. Yarmoutp)), MA 02673 m!� 2f r Type of Building: Dwelling No.of Bedrooms L Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / /!/ Design Flow(min.required) `V 7 U gpd Design flow provided �� gpd Plan Date Number of sheets Revision Date Title /" % S l Size of Septic Tank / y Type of S.A.S. Description of Soil Pe:f' .41y Nature of Repairs or Alterations(Answer when applicable) /`.may- 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 ealt / -7 gned C Date Application Approved Date (p Application Disapproved by: Date for the following reasons Permit No.. —/� Date Issued„= �-c No. Fee THE COMMONWEALTH OF MASSACHUSETTS- Entered in computer: „ti PUBLIC HEALTH DIVISION ., TOWN OF BARNSTABLE, MASSACHUSETTS ,Yes Rpplication for Migogal *pgtem Con5truction Permit Application for a Permit to Construct( ) Repair( Upgrade Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �p�` S Owner's Name,Address, d Tel.No. re i,-7 Assessor'sMap/Parcel1�0 14l1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: / Dwelling No.of Bedrooms L/ --" Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) " Other Fixtures Design Flow(min.required) U gpd Design flow provided /��U gpd t` Plan Date 3�c� 7 Number of sheets Revision Date i" Title -&a2-ce l� 4- /.1/ic Size of Septic Tank /J D U Type of S.A.S. Description of Soil /D,-` 1)14,1 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: w 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 Vealt gned l f t Date Application Approved b�y.`__ Date Al(D - Application Disapproved by: Date for the following reasons Permit No. —/�� Date Issued. >_ oh-�o -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS � Y . BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage DisposallSystem Constructed ( ) Repaired ( __Upgraded ( ) Abandoned( )b C U at has been constructed in accordance / with the provisions of Tittle 5 and the for Disposal System Construction Permit No. ©G 7 —10 dated-73 Installer /-",(1 C) Designer #bedrooms Approved design flow A /1/t gpd r f The issuance of this permit shall not be-construed as a guarantee that the system wil'b�function as designed ,r Date l lr� t/ Inspector f l fl�� /�Y �/XJj ✓`, i f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS 1=i5po5ar *pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at �r��f z e�:2 Ze , ; 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: Cons(truucction ust be co pleted within three years of the date of p't. Date �J 6� Approvl by ,t t Town of Barnstable Regulatory Services Thomas F. Geiler, Director URMABLZ ATM Public Health Division Thomas McKean, Director - - _ 200 Main Street,Hyannis,NIA 02601 Office: 5087862-4644 Fax: 508-790-6304 Installer & Designer Certification Form i Date:Yk Iq 17 Sewage Permit# <)00)- 6 Assessor's MaplParcel 0/8 Desi ner: K, �' --- �'�-t/ g Installer: Address: �� Address: A & B CANCO vl W W. Yarmouth, MA 02673 On —3 07 was issued a permit to install a (date) / (Installer) 1 septic system at Sf . C•��v� based on a design drawn by l /,, /� �► ,, (address) f r/V✓►�`?/�G�'i� kq-dated .3 - (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component . of the septic system) but in accordance with State & Local Regulati ns. Plan revision or certified as-built by designer to follow. of M4ss90 D EN tiG staller's Si nature) yy_ N . 1140 ��� s°gNITARIPN (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTA CPUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3=2670, doc 6U41 lr TOWN OF BARNSTABLE �p� L'OCATION L�rD�l2 0IYLce'll- SEWAGE# ?00 — D 9 -VILLAGE COTU'T ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 4'r`19 COIUC'-6 -7 SEPTIC TANK CAPACITY LEACHING FACILITY.(type) t f•/V Kr�l'L��Y'-3�'� (size) 3q'X(Z,3 3")( 2-' NO.OF BEDROOMS OWNER S-e CZ 0, n PERMIT DATE:_ 3 a2 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility —I)el V 1417 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 A - A � - i f tX�-K O ` i J ob 5c- 3-7 arnstable. Town of B r# Department of Regulatory Services • Public Health Division Date p ". : Atitly S •�fo tYUt�,6$ 200 Main Street,Hyannis MA 02601 T ' Time c c Fee Pd.� Date Scheduled I • Foil Suitability Assessment for Sewage Dis sal r 2- r-111WI-0! . Performed By: Witnessed By LOCATION & GENERAL INFORMATION Lmation A€+dress.6 Ce!q p(i� TP� 7- '; C`wner's Name `f HUM1 S S . Address G .C e r)A-�—, ,5 r, d•7V17 Assessor's Map/Parcel: Q( /®SS-/ C]O Engineer's i NEW CONSTRUtON REPAIR _� j Telephone# S68 3(o2- Lam" Slopes(�a) � Surface Stones Land Use Distances from: Open Water Body.,>�6 k Possible Wee Area } 6 ft Drinking Water Well> � ft �`�� I. ' ft Drainage Way ft. Property Line >1'0 ft Other SKETCH:(street name,dimeusiWs'of lot,exact locations of test holes&perc tests,locate wetlands m proxitnity to holes) i Parent material(geologic) -G'•^ v " ' K fi, Depth to Bedrock Pit Face /v Depth to Groundwalar. Standing Water in Hole:' ' Weeping from s Estimated Seasonal high Groundwater NIA ta- D 'I'ERMIN�`TION FOR SEASONAL HIGH WATER TAULE ,_�� � -'• Methm,Used ! to call tnottles< <i In. �, Depth dbaerved standingtn obs.hole: ° it;. Dep�"' j"—ft Depth toiweeping from side of obs.hole: ? in, tiioundwater Ad ustment,�.v.�, Aar,ClroundwiiCexLiVi Index Well# Reading Date: Index Well level ----- AdI�Actor,,,,,..4. _ Cl' PERCOLATION TEST Date < Cn r Observation � ( Tunis at 9" u .r' m Hole# --7"'---, Time at 6" Depth of Perc Start Pre-soak Time.@ C<O� _ I Time(9",tin) ---- End Pre-soak 11 2--I, Z Rate MinJlnch Site Suitability Assessment: Site Passed X Site Failed Additional Testing Needed(YIN) Original•.Public Heklth Division Observatiori Hole Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,:you must first notify the Barnstable C44servation Division at least one(1)week prior to beginning- DEEP OBSERVATION HOLE-LOG Hole# Depth from Soil Horizon Soil Texture Soil''Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stotture,.Stones,Boulders. onsist6nc . %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface Gina (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Nil DEEP OBSERVATION HOLE-LOG -- Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsistenc o 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. r' ,t Flood Insurance Rate May: Above 500 year flood boundary No— Yes Within 500 year boundary No X Yes , Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring per i us material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring peArious material? Certification y I certify that on ® c( . (date)I have passed the soil evaluator examination approved by the Department ro mental Protection and that the above analysis was performed by me consistent with 9 p l? ; the re uire trainin ex ertise a ex en ce described in 3,10 C]VIlt 15.017. . J , Signature Date a Q:\.SEPTICVERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS u il ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A 350 MAIN STREET WEST YARMOUTH,NIA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS M SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 CEDAR STREET COTUTT,MA 02635 s— OvvZier's Name: SEGUIN,MARY JO C/ ONi ner''s Address: 6 CEDAR STREET _ COTUIT,MA 02635 Date of Inspection NO'1v'EMBER 28.2006 Name of Inspector:(please print) -JAM ES D.SEARS Company Name: A&B Canco Nlailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: .' 508-775-2800 ------ - — ' c CERTIFICATION STATEMENT I certify that I have personal]).inspected the sewage disposal system at this address and that the informatil reported! ' belo.v is tnie,accurate and complete as of the time of the inspection. The inspection was performed bas1ed`on my -- training and experience in the proper function and maintenance of on site sewage disposal systems. I aE�DEP r� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system; Passesco Conditionally Passes C-► r- Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Q Date: 11-•29-06 The system inspector shall subunit a copy of this inspection report to the Approving Authority(Board of Health or DEP)vithin 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 tot he 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 hose the system.will perform in the future under the same or.different conditions of use. Title 5 Inspection Fonn 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 CEDAR STREET _ COTUIT,MA 02638 Owner: SEGUIN,MARY JO .Date of Inspection: NOVEMBER 28,2006 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 1.5.304 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"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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally soumd,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 back-up 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 Healthy' broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 6 CEDAR STREET COTUIT,MA 02638 _ Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 2006 C. Further Evaluation is Required by the Board of health:N/A 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 enviromment. 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Fonn 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 6 CEDAR STREET _ COTUIT,MA 02638 Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 2006 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than'/z day flow �— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Nunmber of tunes pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes' or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 CEDAR STREET COTUIT,MA 02638 Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including 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 infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been deternuned based on: Yes No ✓ Existing infonnation. 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(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 CEDAR STREET COTUIT,MA 02638 Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 2006 FLOW CONDITIONS RESIDENTIAL./ NOTE: HOUSE (3)BDRM. &(1)BDRM.APT.ABOVE GARAGE. 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: 33 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2005-92,000 GAL/2006—60,000 GAL. Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? _ Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: AROUND 1977 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 CEDAR STREET COTUIT,MA 02638 _ Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 2006 BUILDING SEWER(locate on site plan): 2' Depth below grade: Materials of construction: Cast iron ✓ 40 PVC e other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): GOOD SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 3' 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: 1000-GALLON PRE CAST. Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: ASBUILT,TAPE&SLUDGE JUDGE. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL. TANK AT Y BELOW GRADE,INLET COVER AT 10". TWO(2)INLET TEE'S,(1)FROM HOUSE—(1)FROM GARAGE APARTMENT. OUTLET BAFFLE,NO SIGN OF LEAKAGE OR OVER.LOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): � o 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 reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 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: 6 CEDAR STREET COTUIT,MA 02638 Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 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 last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX UNDER TWO-CAR GARAGE,INSPECTED WITH VIDEO CAMERA. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. BOX LOOKS SOLID—ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Fonn 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 CEDAR STREET _ COTUIT,MA 02638 Owner: SEGUIN,MARY JO Date of Inspection: NOVEMBER 28, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields, number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE(1)1000-GALLON PRE CAST PIT. PIT AT 4'WITH COVER AT 3'—6",3'WATER—STAIN LINE AT 6"ABOVE WATER. NO SIGN OF OVER LOADIING OR SOLID CARRY OVER. CESSPOOLS: (cesspool must be ptunped as part of inspection X locate on site plan) Number and configuration: Depth—top of liquid to iirlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page]0 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 CEDAR STREET _COTUIT, MA 02638 Owner: SEGUIN.MARY JO Date of Inspection: NOVEMBER 28. 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benclunarks. Locate all wells Nvithin 100 feet. Locate where public water supply enters the building. 1 rr _� i I i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 CEDAR STREET COTU[T,MA 02638 Owner: SEGUIN.MARY JO Date of Inspection: NOVEMBER 28, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 30+ 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: Observation 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: BARN MAPS&WATER CONTOURS MAPS 30'+TO GROUNDWATER. Title 5 Inspection Form 6/15,."2000 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION - ASSESSORS MAP NO: L C PARCEL NO: d 5�� (� j <I `' < N � s`> TITLE 5 C., OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASS SSM1*TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM o `n PART A CERTIFICATION Property Address: 6 Cedar Street Cotuit, MA 02635 Owner's Name: Estate of Walter Michonski Owner's Address: Date of Inspection: June 3, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: June 8, 2004 The system inspector shall sub t 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 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with.a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced f ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- I WPA)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. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in approximately 1977-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 3' 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any sikns of leakage. Recommend pumping. The inlet cover was 10"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal - fiberglass _polyethylene _other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 TIGHT or HOLDING TANK: None (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: Qallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (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 D-box was level. No solids were present. The D-box was under a 2-car garage under a cement slab. !was unable to open the D-box and used a video camera for the inspection. PUMP CHAMBER: None (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.): 8 Page 9 of i l OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'0000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had 3'of water on the bottom. The scum line was approximately 4'up from the bottom. There did not appear to be any signs oLfailure. The bottom to grade was 11'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Cedar Street Cotuit, MA Owner: Estate of Walter Michonski Date of Inspection: June 3, 2004 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. oUt t_ GA��t 1 ,33 ay a 38 3 06 3 o a GA 00101 L 3 '7 10 Page 11 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Cedar Street Cotuit, AM Owner: Estate of Walter Michonski Date of Inspection: June 3. 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 30'+1-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. I 11 � 9 TCj TI G)F BARNSTABLE LOCATION Ce SEWAGE # vILLAGE C dTv ASSESSOR'S MAP & LOT 0/8 05 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /M LEACHING FACILITY: (type) Al' Gx 6" (size) wb NO.OF BEDROOMS -3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachingLfacility) ) Feet Furnished by 1�lS�e1Td,1 T• �D�G O O •. J 1 M IDO � J ICE rs Q• M oo T M M �9 T j JA essor:s map'and lot number ..................................�-- ewage Permit number ............................................O.I`. �C 'Ea°�`3JIC ,ai�lL. Py�FTHET0�♦ ° .. , . , -.. Z B9HHSTADLE, i House number �;��`r " Mnsa � 9 0� TOWN OF BARNS TTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....... ... TYPE OF CONSTRUCTION ........ J ............. ... ........:�I •.......... ...........................................:... ..........191.f TO THE INSPECTOR OF'BUILDINGS: The undersigned hereby applies for a permit accorAing to the follo ng information: Location :.....:.. ...... ::..:........ ........... :......................... ProposedUse ..&..... .. ............................................................................ ZoningDistrict .........1-7.... .................................................Fire District ................... ...Q.................................................. Name of Owner .QY.j-S..M1A.Q/4S..4'.LAddress ... ...CA. A.Y.......t5 ...... .... Nameof Builder ..... .... ... ................. ....................Address .................................................................................... Name of Architect ................................... ..... ..................Address ........................... ..............................:.................. .... .... ... .. Number of Rooms ........................................I.........................Foundation Exterior .................c..................................................................Roofing � � Floors -......................................interior ...........� .-VV ....................................:........................ Heating ..................................................................................Plumbing ................. _ ......................................:........:...... Fireplace ................. ---�..................::..................................Approximate Cost ......,f� �•t•••rl?..v..v.�. ...11............... Definitive Plan Approved by Planning Board ---19 Area `-:'/.. `... f Diagram of Lot and Building with Dimensions Fee .................. .............. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .a 1 .. .. ..... . ... ........e Construction Supervisor's' License .. .. McKean, Thomas From: McKean, Thomas Sent: Thursday, October 26, 2006 5:42 PM To: Taylor, Madeline Subject: Recent Amnesty Applications/Septic Questionnaires 78 Pontiac Street APPROVED-This application is approved for three (3) bedrooms maximum (reference- Disposal Construction Permit# 2005- 6 Cedar Street, Cotuit PENDING -The septic system distribution box and piping is located beneath the garage/apartment. How will the applicant address this? There are no variances on record allowing the system components to be located the foundation and living space. A minimum setback is required per Title 5. -The septic system has capacity for only three bedrooms. However, the submitted floor plans show four bedrooms, including the"office"with only a forty-one inch opening at the doorway. Please have the applicant submit revised plans showing three bedrooms maximum by openiog the doorway to five feet wide (without any doors). 1025 Service Road West Barnstable PENDING The system consists of two old block cesspools per an inspection report which was conducted four years ago (out-of- date). Please have the owner hire a DEP certified inspector to conduct an inspection of the system and to complete a 16 page inspection report. We need to know whether the system is functioning properly and whether the block cesspools are in good condition. The revised floor plan is easier to read. However, it only shows part of the home. What about the remainder of the home? Are there in fact three bedrooms total plus one office which has a five feet opening without a door? 63 SecuritV Street DENIED-This property is located within a WP district on 0.26 of an acre. Only the two pre-existing bedrooms are allowed on such small lot. No additional bedrooms are allowed. The proposal to add a third bedroom is denied. 1 n TOWN OF BARNSTABLE LOCATION ` DA 5 7 SEWAGE# VILLAG Co T ASSESSOR'S MAP&LOT 'NHS'S NMe'AME&PHONE NO. SEPTIC TANK CAPACITY s C— LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER /77/ppv PERMIT DATE: COTVPL- ib 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 14ovs� C,ARA�£ A G t t 3-3 APT Aaav� 3 t y �00 Town of Barnstable N °'n BARNSTABLE, : Board of Health 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Paul Canniff,D.M.D.. FAX: 508-790-6304 Wayne Miller,M.D. January 4, 2006 Ms. Mary Jo Seguin 6 Cedar Street Cotuit, MA 02635 RE: Variance Request Denial/ 6 Cedar Street Cotuit Dear Ms. Seguin, Your request for a variance from 310 CMR 15.211, to maintain a distribution box and part of an existing leaching pit, beneath a foundation at 6 Cedar Street Cotuit, was not granted. The following variance was requested: 310 CMR 15.211: To maintain a distribution box and part of a leaching pit beneath (or zero feet away from) a foundation, in lieu of the twenty feet minimum setback required. A public hearing was held on December 5, 2006. The Board voted to deny the variance request. Variances may only be granted when, in the opinion of the Board of Health, the applicant has demonstrated that (a) enforcement of the particular provision would be manifestly unjust and (b) the same degree of protection could be achieved without strictly adherence to a particular provision or regulation. You did not demonstrate manifest injustice. A second floor apartment is either existing or is proposed to be located over the garage where this slab foundation is located. Your proposal is to keep the distribution box and leaching pit components where they are currently located, beneath the slab foundation of the garage. You did not demonstrate that, without the approval of this particular variance, it would cause or create manifest injustice. You also did not demonstrate that the same degree of protection could be achieved without strict adherence to a particular provision or regulation. No information was provided in regards to how you would prevent the infiltration of sewage wastewater into the garage building in the future. VarianceDenial 1 your request for a variance was not ranted. Therefore yo q _ g Sinc ely yours, 'yne iller, M.D. Paul Canniff, 9. f I VarianceDenial y 2 OFTME lti DATE: f� J �3' T » �BAMSMBLE, FEE y MASS. _ � i639' ��� REC. BY AlF°M�A Town of Barnstable SCHED. DATE: 1.2 ,5" 6 Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne A.Miller,M.D. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Paul Canniff,D.M.D. VARIANCE REQUEST FORM LOCATION /� P, Property Address: tp &614,r— cS � . 02 6 Assessor's Map and Parcel Number: Size of Lot:_ Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name: APPLICANT'S ANT S NAME: Phone Did the owner of the property authorize you to represent him or her? Yes No ! ^� C) PROPERTY OWNER'S NAME CONTACT PERSON CD -c S 'Name: r Name: < Address: r Address: - p Phone: b `C 13� l �" ' Phone: so �O N VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more sp a needed) 12 r AA- o CMA- 1�. 1 si !it Z �P _el�s _�fIIIA6 QLuf-kCrems' NATURE OF WORK: House Addition ❑❑❑❑❑❑ House Renovation ❑ Repair of Failed Septic System 11 Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. — Four(4)copies of the completed variance request form — Four(4)copies of engineered plan submitted(e.g.septic system plans) — Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) — Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) — Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne Miller,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Paul Canniff,D.M.D. Q:\Application Forms\VARIREQ.DOC Town of Barnstable Health Inspector OF THE Office Hours NPR ti� Regulatory Services 8:30—9:30 y Thomas F. Geiler,Director 1:00—2:00 w BnxxsrABLE, 1639. ,m� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02 1 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: Address: �j MapO Parcel 0:5-5 -00 Name: M ovy-4 10 Phone#: 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes, how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? v 2d. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or 0 If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or �TSID a Zone ofZ7;IYE supplells 5. Is the dwelling connected to an ONSITE WELL or to PWA -- w 6. Is a disposal works construction permit on file? or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms?, YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------ _------ --------------------------------------------------------------------------------------------- v(� Mth , 2�QJ�SFOR OFFICE USE ONLY . U0 f b wThe Public Division objection to bedrooms at this property. Special Conditions: sG,cal[ l f Nl r�k Signed: 2 fie Date.I Z4©Cn � � ,k 61 "e/ Q;/health/wpfiles/amnestyapp f t a r i !S i f I t 1 t i r b � VV � o �r 6 7 6 V S f I No......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LTH 7 ..........OF.......... 401 Appliration for Roposal Worko Tonstrurtion rnmit 110/ Application is herebV_mad for a ernnt to Construct (AI or Repair an Individual Sewage Disposal System at: ..17-E....I-.S. -..C�t j............................................................ ------------------------ ..........Location-Address ........ or Lot No. .... Address ................. ---- ----- Installer ................................. .................................................................................................. Address Type of Building Size Lot............................Sq. feet U >-,-, Dwelling-L'No. of Bedrooms......2...............................Expansion Attic Garbage Grinder #0) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ....................................................................................9-------- -----------------------------*----------*---------- Design Flow...........:r--!5---------------------------gallons per person per day. Total daily flow....A-2-6.........................gullons. 9 Septic Tank/--Liquid capacity-/OffO.gallons Length................ Width..--............ Diameter--.----......... Depth................ Disposal Trench—No..................... Width.................... Total Length............_....... Total leaching area....................sq. ft. Seepage Pit No........./---------- Diameter.../A0.0.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (1� Dosing tank 0-4 Percolation Test Results Performed by. ..........D��"V........Ca/-'a- Date......./.............7_7 ... ............ �4 i - 14 Test Pit No. I................minutes per inch 6epth of Test Pit...........--....... Depth to ground water.......--.....--.....--. Test Pit No. 2................minutes per inch Depth of Test Pit................__.. Depth to ground water........................ /j - I t I ............7-------------------**............ ................................... x Description of S ............ ......t7l.- ----------------------/............................................• 0 .......................................................................................................................... --------------------------- -------------------------------------------............................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ................................................................................................................................................................................ ...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Ti IT�M 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. V-1�----- ................................ Signed../ - -- --------- Date A. ...................... ---.7-7--------- Application Approved By------ ----- ........ ..Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... D Permit No.................................. ... Issued. A.. s-- .................... ... ae...... Date No........J 4179..::. 4 . Flit .-.-,:- THE COMMONWEALTH OF MASSACHUSETTS BOARD F• VEL ----------------OF......-.. ....... -t................. Applirtttion. fear Disposal Works Tonstrurti on ramit Application ishereby made for a Permit to Construct (Y) or Repair ( ) an Individual Sewage ;Disposal System at (�a�,� yye}w► _ = - ... Location_Address.� •�I�+ ��yPr�L ` ..� .�.V__�4••••!� ]�,..�...o �t w W ---------•--- 4 = ...................................... -•-- - •--..._.. .. .. Installer� Address ,' Type of Building�,r Size Lot_______________________....Sq. feet Dwelling�No. of Bedrooms____..2, ..__.__.__. _____Expansion Attic ( ) Garbage Grinder) Other—Type T e of Building No. of ersons________________________ Showers � YP g --------------------•-----•• P ---- ( ) — Cafeteria ( Q Other fixtures .. --------------------- ----•-----. ----- ---- • W Design Flow______.r_ __________________________gallons per person per day. Total daily flow.._,2�}..........................gallons. WSeptic Tank—Liquid"capacity/00.0__gallons Length................ Width................ Diameter................ Depth................ x p Disosal Trench—No_ ............_....... Width.................... Total Length.........._......... Total leaching area....................sq. ft: Seepage Pit No........I........: 0 Diameter.- e.0_._._ Depth below ' et_ .___ ....... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ) e � /- .A.. 1 ►� ►� Percolation Test Results Performed by.._ ...... �" ''1140' r... Date..... l_.___...... Test Pit No. I................minutes per inch epth of Test Pit ___________.______ Depth to ground water_ __.._.._ ___.. Test Pit Nd, 2................minutes per inch Depth of Test Pit.................... Depth to ground water i r ti'' r1 Description of S �•iEs .................r" ` - � ��7 U ----------------••------•------•------------------------------- -----•----•-•--•---------------- ------------------•------•-•------------------------- UNature of Repairs or Alterations—Answer when applicable_.__.___ ____________________________________________________________________ .... . .. .. .................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-been issued b the board of health. Sig d -•-- Date Application Approved By----7�;.-~" .._....... / +_j "" --------- Date Application Disapproved for the following reasons---------------------------------------------------------------•---------------------•--•----•-•-----------•••••- --------------•-----------•-••---•-•---------------•-----•--•--------------•-----•-•--------•-------...--•----------------•---------••------•-•••------•--•-----------•...----------------•-••---------- Date PermitNo......................................................... issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS >' BOARD 9, HEALTH t-110 -..........OF..... ... 45 t. t............................................. - CIrdifirat a of TOutplfit irr THI �T %' Y, That the Individual Sewage Disposal System constructed-( or Repaired ( ) by....... .4?G... ---- ---•---------- ----•----------------- ----- ..................... ,, nstau ? ct1 t+� a s-zt.i. has been installed in accordance with the provisions of TI r of he State Sanitary Code as desc • d in the application for Disposal Works Construction Permit No.. _:____ _ ` '"______________ dated__-._ /t'. _"__�__�___.__.._._.__._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEA+I "WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector---•---...._••--•-•-------------------�.......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD. O HEALTH / . n-1'7.............OF........... ................. No........L!. FEE..../.. ............. Disposal rko. T#a trudioaa andt Permission is hereby granted.'':-- 'f ' � `�, �-----------•••. -..___....--••--•---••---•--• ------ _.... -••-- to Construct or Repair ( ),,an Individual. ra .pispQ Al yst at No. -- - "�L �'�yQ �' r ___t AYf'e.... ° --••----•-- Street as shown on the application for Disposal Works Construction Permit o.._-_______ Dated A-/ ' 7 7__._.._ Q G L Board of Health ¢ DATE, --•-----•------a FORM 1255 HOBBS &:WARREN, INC., PUBLISHERS,';' ,, TOFN OF BARNSTABLE 77 —� LQCATION �j q� S SEWAGE # VILLAGE ( �f ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 4 SEPTIC TANK CAPACITY z/&9CJ � . LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER) BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes .N r t HO 05� t LOCATION ZT GE PERMIT NO. VIL L A G E ' U/g-o,SSwa/ 71 INS A LLE 'S �,AME i ADDRESS F BUILDER OR OWNER &2dd, 9 DATE ER IT ISSUED _ DATE COMPLIANCE ISSUED r 7 ___...._........... ,. rn 40*00 4 L-� t r � c f t '•., a 7c.--- C L y F .� `'J _ .... C'^'x�H^-�:..'.� a<'.�. .� �T'a'... � � J •. :xb'^ aA':db N .. Y, a Co~ 21 d c Dot n V O 4 `TQ LOCATION 5EW C,E PERMIT UO. 3 VILLAGE , -� - - - - - - - -� ti IWSTNL ER 5 WE ADDRESS -IC - - -BUILDER 'S IJ &MF- ADDRESS DATE PERMIT ISSUED DATE COMPLI &&ICE ISSUED : r`,. -ti �----` �: f' Q �� ':z. � � , � I � l —1 — -- t ------------t-, - j cr ... .. ram .._. ... . _ _ , . --Pll T2 - 44- L M 0IFF --�- t `III. e♦ ,. t LEGEND g s E J AY SHELL a 4 l PROPOSED CONTOUR i = "� _ `.- �- ? F9 8-1 PROPOSED SPOT GRADE I � ��G y 3 SI HULL CEDAR STREET - — 98 —— EXISTING CONTOUR ' \�G� �„ RO y co O o KEELA + 96.52 EXISTING SPOT GRADE SI • W— EXISTING WATER SERVICE I \ %9 OAK ¢ ST CIOS' EDGE OF PAVEMENT TEST PIT N1C SON i — — — — --- �� TO SAll o Q r —1--j — y- - - - -- - -- - - - - 140.00 ft � � IR ? C O I I I j� / -- - - - - - - --- -- ---- - - -- - - - - --- - - - - - - - - - �� m =PIN E CFA. RD i 0 I 1 \\ —�-- I /�� ���`� II ! I LOCUS MAP N.T.S. on 0\ I o \ I \ O GENERAL NOTES: y I �` \\ I \\ I 1 I �/ N �J j 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL O I I \ ; y 1 \ / i -h BOARD OF HEALTH AND THE DESIGN ENGINEER. O I \ C \I ______ ! D AL SHALL 1 \ \ I \ I ___ / 2 ALL WORK AN NVIRO S CONFORM TO THE REQUIREMENTS --"--"--�-'----- -------�---------------------:- _"_--_ _�_.. I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE O LOCAL RULES AND REGULATIONS: 3 THE SEWAGE INSPECTION DISPOSAL SHALL C KFILLED PRIOR AND APPROVAL BY THE BOARD OF AND TO HE E X I S T I N G GAS LINE DESIGN ENGINEER. C I 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Vq DWELLING ; N FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Y W ENGINEER BEFORE CONSTRUCTION CONTINUES. TOP _OF FNDN 10 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. \\ C EL = 2 5.5 4 i O C 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 4 \ _ _+, THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. of _ 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. \\ I \ I ! \ I 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED \\ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. ------------ ---------- ---------------------------------------- ------ \ 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING \ I CONSTRUCTION. 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND FILLED 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION N ` 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 80.00 ft I rn AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY • \\i \ o "0 0 o W I I I 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING y \ 14. NO WETLANDS WITHIN 150 FT. OF PROPOSED LEACHING BENCH MARK O I\\ I 15. 48 .HOUR NOTICE FOR ENGINEER CERTIFICATION OI \\ \� i 16. EXISTING 1,000 GALLON TANK TO BE REPLACED WITH 1,500 GALLON I \ V� H-20 LOADED SEPTIC TANK \ TOP OF CONC BOUND TH-2 "\VENT ELEVATION = 16.18 L----- - — — —---------------- - - ___ BARNSTABLE CIS DATUM 1 00.00 ft \'N N O ( T of a PROPOSED SEPTIC SYSTEM UPGRADE PLAN o - M. ,r 6 CEDAR STREET COTUIT, MA \ -MEYER No. 1140 Prepared for: Mary Jo Seguin MAP: 018 SURVEY REFERENCE: LOT.•0551001 Engineering by: Surveying by: SCALE DRAWN JOB. NO. � E�c�O DARRENM.MEYER,R.S. Eco-Tech Environmental 1"-20' DMM r PLAN OF HOUSE LOTS BY N.L. CROCKER, CE. DEED BK:19601N �p� Po BOX set DATE CHECKED SHEET N0.(508) 364-0894 I TAR ()� ! DATED: AUGUST 1912 DEED PG:108 EAST SANDWICH,MA 02537 Q�j 508-382-2922 03/02/07 DMM 1 Of 2 x ELEV. TOP FOUNDATION p (Existing) r� = 25.54 F.G.EL: 23.5 F.G.EL: 21.0 F.G. EL: 21.0 FINISH GRADE=23.0-21.0 v \� 1l\ VENT REQ'D IF > 3 FT. a MAINTAIN 2% MIN SLOPE OVER LEACHING AREA BELOW SURFACE GRADE COVERS TO WITHIN 6 OF GRADE 6" INSPECTION PORT L - 6J I: W/IN 6" OF FINISH GRADE A 6 _.3.1 4" SCH 40 PVC � L = 7' (MIN.)0 10„I 14„ ® S= 1% (MIN ) a 0 0 0 0 0 0 0 0 0 0 0 0 TEE'S ARE TO BE ® S= 1% MIN. M. 4" SCH 40 PVC ._..A'... INV.16.83 INV. 0 0 0 0 0 0 0 0 0 ; 0 0 INV. 16.06 f 1 EXISTING OUTLETS BAF LE '.PROPOSED DB-3 HO HUO H. A. 0 0 0 0 H. no fl-, a" : . ••. •. '• ' H-.10 DISTRIBUTION BOX INV. 17.0 PROPOSED 1500 GALLON SEPTIC TANK NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING „ GAS BAFFLE TO BE INSTALLED ON PIPE INVERTS PRIOR TO CONSTRUCTION CULTEC Na 410 soul 9 MIN. 2) D-BOX SHALL BE SET LEVEL AND TRUE TO OUTLET TEE AS MANUFACTURED BY fXMWF AID PER TITLE 5 TUF-TITE, ZABEL, OR EQUAL GRADE ON A MECHANICALL COMPACTED SIX l INCH CRUSHED STONE BASE, AS SPECIFIED IN -`` BREAKOUT EL. = 17.0 310 CMR 15.221(2) INV. E 3) PROPOSED 1,500 GALLON SEPTIC TANK TO BE Z4" 30 5" H-20 LOADING FOR VEHICULAR TRAFFIC nouaLE If!esNm sTDNE SEPTIC SYSTEM PROFILE 4) INSTALL INLET & OUTLET TEES AS REQUIRED IN 1 BOTTOM EL,= 14.0 -� (_____48„ t CULTEC RECHARGER 330 SEPARATION 6.0 FT. I- 148" - VI SOIL ABSORPTION SYSTEM (SECTION) BOTTOM OF 111-2 EL: 8.0 USE H-20 LOADED COMPONENTS MODEL 330 R STAND ALONE MODEL 330 1 INTERMEDIATE TTn- SMALL RIB LARGE RIB SMALL RIB LARGE.RIB DESIGN CRITERIA ° SOIL LOGS NUMBER OF BEDROOMS: 4 BEDROOM c OF Mq 9, 5 " SOIL TEXTURAL CLASS: CLASS I �o REN M. ys MODEL 330 S STARTER MODEL 330 E END DATE: FEBRUARY 8, 2007 DESIGN PERCOLATION RATE: <2 MIN/IN 1 MEYER '. SMALL RIB LARGE RIB SMALL RIB LARGE RIB e " No. 1140 SOIL EVALUATOR: DARREN MEYER, R.S., CSE DAILY FLOW: 110 G.P.D. WITNESS: DONALD DESMARAIS, BARNS B.O.H. DESIGN FLOW: 440 G.P.D. GARBAGE GRINDER: NO (not designed for garbage grinder) RfCI$TE�` r 6" DIA. INSPECTION POR LEACHING AREA REQUIRED: (440) = 594.6 S.F. SANITARY n; TRIM TO ACCEPT .74 HVLV F24x4 + USE THREE (4) CULTEC RECHARGER 330 UNITS Elev. TH-1 Depth Elev. TH-2 Depth WITH 4 FT. STONE ON SIDES & 2 FT. STONE ON ENDS: FEEjCONN 7. 5 AVAILABLE 20.8 A LOAMY SAND 0" 20.0 A 0" e NDARD DUTY 25' a 10YR 4/1 SANDY LOAM (34'L x 12.33'W x 2'D) 19.63 a4" 18.83 10YR 4/2 '4"LOAMY SAND BOTTOM AREA: 34 x 12.33 = 419.2 SF tOYR 6/8SANDY LOAM 3 .5" 18.13 32" 10YR 5/aSIDE AREA: (34 + 12.33) X 2 X 2 = 185.3 SF C1 17.33 �� 32" TOTAL SQUARE FEET PROVIDED = 604.5 vs 594.6 REQ'D " . 3" 52 . .9y MEDIUM P MEDIUM ., SMALLoRIB • • LARGE RlB• 420. 3 SAND /5.80 SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN a 2.5Y7/4 25Y7/3 6 CEDAR STREET COTUIT MA CULTEC RECHARGER JJO CHAMBER STORAGE= 7.459 CFIrT > > ALL RECHARGER JJOHD HEAVY DUTY UNITS ARE MARKED W1 TH A COLOR STRIPE FORMED INTO THE PART ALONG THE LENGTH OF THE CHAMBER. Prepared for: Mary Jo Seguin CUL TEC, Inc. PH. (203) 775-4416 TM CUL TEC ContactorO and Rechargel0 P.O. BOX280 PH. (800) 4-CULTEC Plastic Se tic and 8'8 1aa" 8.0 144" Engineering by: Surveying by: SCALE DRAWN JOB. NO. FX.• (203) 775-1462 P DARREN M.MEYER,R.S. Eco-Tech Environmental N.T.S. D M M 878 Federal Road WWW.CUIfeC.COm DATE SCALE File Name " PO BOX981 (508) 364-0894 PERC RATE <2 MIN/IN. (-Cl- HORIZON) EASTSANDW/CH,MA02537 DATE CHECKED SHEET NO. Broome/d CT06804 USA CULTEC XXXXX N/S LUIS NO GROUNDWATER OBSERVED 508362-2922 03/02/07 DMM 2 Of 2 t Y _._......_-.__.- c . S � �I i a s s 0 C) allf S� o boll • � .� sae- �3. J ! p - MUM �9 v /8 — - — GXiStin9 c�rovr-lC� Pr'ofi /G f-�O E'/Z. SCALE : /"' /O� 4�: T/ O A-/ V 6- �e7 SGAC -o --o—o—o— ©,-oposGoi grour-7cf Prof;/e_ 0�\ SCNE®. -a0 PV. C. OBE �/2 - Al Lu GL S/^ d ,5>zo r3 -TA nJ K Y e � O f �j3 fox�i ,, A, - r / t._ '92- 00 0 a � 0 v �` G Ale//e, �fl.H. O a lle.,�?. —--- - ---- mow., Ga.j�e-er,9;r.eerir�9 7"�- � 2 77 TE 5 T . - ----�----:-- c� o4TL'�-1 r'I S L S BGtrns fa b/G Nea %fh Oe/o� zo. 5 2 x / 7-6- s -r ,ti o e_67 At Z E2 s Z 0 5 0 0 o0 �i6 E- _��a`?v GAL. -r.4/v.4::' e1 = /8 4 _ �{/ d = i8. a ' ;7i" :ti. ars .,rz a' 20 o S o C 24 — / EFF" L� oa E�TN I 3G ` C lG a r7 foe med 1 i / \ 5E l __ LEs9Gti Fair Sana/ y\\ e/= 7.4 /g•7 "J i - /•7n water- Pr,cour-�te•-� ' — 0 00c - -7 y r-r e_ e r- n /\ t G..aa/s Svc -� S P/r7e �id'�e .,/}�d, G t , / '/Gt5 lAq S S. Jfr' Lt/F+ GT CNO/tJ` / / cxJAMES H. YES T•E /L-'7 __- / " = 30' __ - .__ . -.. -_ , X S f �r� � G o r� -�•.o L /'-S B,:.� .�i',E�?j 6- 4-7 I G'' 1- M Aw-..q G.. T fd --- ----_O - G ...__.O _..._ F7.-a t� S d G C�/'7 �-C u r•aS' /7 I�r./t.�'s T r7 , ♦-I s s. _ # 7,;,- r ��