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HomeMy WebLinkAbout0026 CHERRY TREE ROAD - Health VCotuit 6-Ciierry i ree Ro�e�P A = 019 104 i I S�- ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A' W DEPARTMENT OF ENVIRONMENTAL PROTECTION AP 104 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 26 Cherry Tree Road Cotuit MA 02635 r Owner's Name: Michael Griff { �=' Owner's Address: Same # Date of Inspection: October 18,2004 } Name of Inspector: PATRICK M.O'CONNELL _ ? '= Company Name: SEPTIC INSPECTION SERVICES CO. :r` Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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 59111111 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ���. �N OF _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails t L co-; Inspectors Signature: - Date: 10/18/04 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: System in good condition.Observed no evidence of backup or saturation. ""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 1 f Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T41a G TnQTar}lnn Rnr 4/1 ci)nnn 2 Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 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 I 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: Titlo S inennntinn Rnrm All 19i10nn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 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. X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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 I1 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. TWA C inenantinn Rnrm 411 v)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? 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? 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. 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)] T41a 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOL UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 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 4 of bedrooms):330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—94,000 gal.2004—59,000 gal.=209 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Owner 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: 6 years old Were sewage odors detected when arriving at the site(yes or no): No Titlo C Tn arfi P7n 411.VIMA 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 25' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' P 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: 10.5' long x 5.8'wide—1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet pipe Tank not in need of pumping at this time. Recommend pumping every three to five years depending on use. GREASE TRAP: No (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.): Titla 4 Tncn—tin" Vn Oil';i)nnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 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.): Liquid level even at all three outlets.No high stains or solids present. PUMP CHAMBER: No (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.): Tit1a G incnortinn Fnrm Ail;Onnn 8 i Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: _X—leaching fields,number,dimensions: One 20' x 25' +/-field. overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): No excessive vegetation,probed area of leaching field and found no evidence of saturation. CESSPOOLS: No (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: No (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 T41.G incnantinn 17-411 si)nnn Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 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. Cherry Tree Road qq ui 1500 gal tank 5 outlet d-box 20 x 25 field TirIP G incnarfin+Fnrm/.ii cnnnn 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 Cherry Tree Road,Cotuit Owner: Michael Griff Date of Inspection: October 18,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) X Accessed USGS database-explain: USGS topo amp and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.5 and topo map shows property above el.40. Titles f �ncnantinn Fnrm 411 VIAnn 11 . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F i m RECEIVED a •` SEP 2 2��2 3 ` TITLE 5 TOWN BARNSTA�4E TH DEPT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 5Jr Property Address: 26 CHERRY TREE RD COTUIT, MA 02635 0i Cj10q Owner's Name: MARILYN O'BRIEN Owner's Address: PO BOX 725 COTUIT MA 02635 Date of inspection: 8/26/02 Name of Inspector: (please print) , '. JOHN GRACI icopv Company Name: SEPTIC INSPECTIONS 1rb Mailing Address: `` �P.O.'BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-68111TAX 508-564-7270 CERTIFICATION STATEMENT 1 certify that 1 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 Tale 5(310 CMR 15.000). The system: X Passes _ Conditionally Pas s _ Needs Further aluation by.the Local Approving Authority Fails Inspector's Signature:, i I Date: 8/26/02 The system inspector shall submit a c py 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 off ice of the DEP.The original should be sent to the system owner and copies sent to:the buyer, if applicable, and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that lime.'Phis inspection does not address how the system.will perform in the future under the same or different conditions of use. Page 2 of 1 1 OFFICIAL INSPECTION TORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 CHERRY;TREE RD COTUIT,MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 Inspection Summary: Check.A,B,C,D or E/ALWAYS complete all of SectiGn D A. System Passes: X l have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section reed to be replaced or repaired. The system, upon completion of the replacement or.rep-,ir,=,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N NQ) inthe for the following statement. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20'years old is avaiiabte. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled`or_uneven.distribution box. System will pass inspection if(with approval of Board of Health): ' _broken pipe(s)are replaced _'obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping inore'than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board o .l Health): _broken pipes)are replaced _obstruction`is removed ND explain: n/a Page 3 of I I F s OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 26 CHERRY TREE RD'`COTUIT, MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 5:;?1'`' 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 mannO,—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 A. 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-tarik and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to d"surfai e`water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 aseptic taxi an'd S.AS`and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the Well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds ihdicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a t s� � Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 26 CHERRY TREE RD COTUIT, MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 D. System Failure Criteria applicable twall systems: You must indicate"yes"orT"no"to each of the following for all-inspections: Yes No X Backup of sewage into faci,l.ity 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 '/2 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 NO PIIMPIN(' INFORMATION. X Any portion of the SAS,ces"spool or privy is below high ground water elevation. X Any portion of cesspoot br privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool.or privy,is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma. (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The''system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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`systemsin addition to the criteria above) yes no 'r0. .t.. t :r X the system is within 46,0 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply; :yell 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 U shall upgrade the systeiu in accordance with 310 CMk 1 5.304. 'I'lie syslan myna should contact the appropriate regional office of the Department. ;rt, n Page 5 of I I . t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 26 CHERRY TREE RD COTUIT,MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 Check if the following have beeii done;.You m;ust indicate "yes"or"no"as to each of the following: Yes No X _ Pumping information was,provided by the owner,occupant,or Board of Health X Were any of the system co mponents.pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period 9 X Have large volumes of water:-been,introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelI'ing inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tan0ignholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance " of subsurface sewage disposal system`s'? ` ' '." •t : The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no " X _ Existing information. For`example,a plan at the Board of Health. X _ Determined in the field(if any'of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] H11 ' s, Page 6 of I l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 26 CHERRY TREE RD COTUIT,MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/62 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):t3, `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: n/a Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO " Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):mla- ��— `�p�jjOCO Sump pump(yes or no): NO (DO . U 1000 Last date of occupancy: 8/18/02 y 4 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMRk15,:203):.n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO , Industrial waste holding tank present s c,(yes or no): NO Non-sanitary waste discharged to the Titie system(yes or no): NO Water meter readings, if available: n/a; Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NO PUMPING INFORMATION Was system pumped as part of the inspection,(yes or no): NO If yes,volume pumped: o/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box;soil absorption system _Single cesspool _Overflow cesspool _Privy , { _Shared system(yes or no)(if;ygs,attach previous inspection records, if any) _Innovative/Alternative technologyf'Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the.DEP approval Other(describe): n/a date installed(if known)and source of information: Approximate age of all components 3 YRS BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO �", 3 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cont'i,ued) Property Address: 26 CHERRY TREE RD COTUIT,MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction: cast'iron:X40 PVC_other(explain): n/a Distance from private water supply well.or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes :,r no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H•,15' 6",W 5';8" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum°to bottornbl outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE., GREASE TRAP: _(locate on site plan) a+ Depth below grade: n/a Material of construction:_concrete' ;metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom cf outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related . to outlet invert,evidence of leakage,etc;jt .g,1 n/a i. ; 7 • Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 CHERRY TREE RD COTUIT,MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 TIGHT or HOLDING TANK: (tank must`be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal,_fiberglass_polyethylene_other(expiain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day, Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and floa-,switches,etc.): n/a DISTRIBUTION BOX: XS(if present must be opened)(locate on site plan) Depth of liquid level above outlet inve : LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOSUNQ. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a .y R Page 9 of I I t . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 CHERRY TREE RD COTUIT, MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 SOIL ABSORPTION SYSTEM (SAS): XC (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 0 leaching trenches, number, length: 0 3 leaching fields, number: LEACH FIELD CONSISTING OF 3 n/a overflow cesspool, number: TREN n/a innovative/alternative system 0 R Type/name of technology: n/a Comments(note condition'of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): TRENCHES ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 5 FT. eA . CESSPOOLS: (cesspool nidst,be pumped-as part of inspection)(locate on site plan) Number and configuration: n/i Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil;,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) � f Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a r r n 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: 26 CHERRY TREE RD COTUIT, MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 'In FP,i 6 rf_ic AC 3 3 J✓ lJ 4 in • Page I 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 CHERRY TREE RD COTUIT, MA 02635 Owner: MARILYN O'BRIEN Date of Inspection: 8/26/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12'+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavafor:s,'instal lers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. t � ' No.w -A FEE THE COMMONWEALTH OF MASSACHUSETTS �� ^,Br��N.fTABLE MASSACHUSETTS � ltctttt� for 1 ,4gstrm Construction jhrntit 1 Application is hereby Ide for a Permit to Construct(A�o) or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. .31 s/-,e2YTipFE,�p CO7U/r 1&wsx G07't1/T A `4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ife/STOIDi &7z E. ��4G�t/IauT� S 8•�S/Z 5r Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder( ) Other Type of Building No. per Persons Z Showers( ) Cafeteria( ) Other Fixtures Design Flow SS— gallons per day. Calculated daily flow 33o gallons. Plan Date �Z, 9-S Number of sheets Revision Date Title /�i2oPos� iWO-461AM -40" S"YS72iU G0C-47'/o.() Description of Soil 7 ZWO 151 SS49SD<C, l� y /5/�i/" Z' Off 1V Gy�Gt Nature of Repairs or Alterations(Answer when applicable) DESIGNING ENe%,INIccQ M! STSLIp-VISE INSTALLATION AND CERTIFY IN ING THE SYSTEM WAS INSTALLED IN STRICT ACCOFIDANa To PLAN, Date last inspected: Agreement:. The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date I A. Application Disapproved for the following reasons Permit No. — 8 'A Date Issued THE COMMONWEALTH OFMASSACH M NPING ENGINEER MUST SUPERVISE MASSWCUH438SWO CERTIFY IN WRITING THE SYSTEM WAS INSTALLED IN STRICT Cfertifirate D Q-10tu lialTMORDANCE TO PLAN. 1p THIS IS TO CERTIFY hat the On-site Sewage Disposal System installed( ) or repaired/replaced( ) on °�M by for at � S- 7Jias been construe ed in accordance with the pro ' ions of Title 5 and the for Disposal System Construction Permit No. /dated Use of this system is conditioned on compliance with the provisions set forth below: s The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on DATE Inspector i TOWN OF BARNSTABLE L` LOCATION C� I�QZv,y,. `�,�: SEWAGE # Jr-I VILLAGE ASSESSOR'S MAP & LOT I Q 15 INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY: (type) —_ �^�.1` (size) NO. OF BEDROOMS BUILDER OR OWNER An C7g� PERMITDATE: ! —I Z- - 75 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facili ty (If any.wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist witlun:300 feet of leaching facility) Feet Furnished by i r . U'>G No. " � 11 'y� I FEE THE COMMONWEALTH OF"MASSACHUSETTS MASSACHUSETTS plicatia , for P, ispusal Sgstent C anstrurtt`on jJerntit .� Application is hereby -ade for a Permit to Construct (,0 or Repair( )an On-site Sewage Disposal System at: �. 4 Location Address or Lot N,o/. Owner's Name,Address and Tel:No. Z-67 27 C�1E.e,e y TeF .�0�� Mx" �L �N L/J.e/EitJ rr . 3/-s/-iF,eiL-'Y Installer:s'Name,Address,and Tel.No. Designer's Name,Address and Tel.No. k_ Type of Building:,-� Dwelling No. of Bedrooms 3 Garbage Grinder( ) Other Type of Building No. per'Persons z- Showers ( ) Cafeteria( ) Other Fixtures Design Flow' SS gallons per day. Calculated daily flow -�3o gallons. Plan Date 12SS Number of sheets Revision Date Title 820Pese_4 &44/ C Al JC / _5eV��- .V-Vf 2(.il L0C-97/0,o Descripti,of Soil �i sw`rf/.1)� N_atu a of Repairs or Alterations(Answer when applicable)f ^ )�1 } - 1 Date last inspected: Agreement: 4 �� \ The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal' system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operatioh;until a Certificate of Compliance has been issued by this Board of Health. ry�" V PJ F Signed _ 4 t' Date Application Approved by ` Date Application Disapproved for the following reasons Permit No. / zl - ' A Date Issued �t^ THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS Cgertifirate of OlUmplianre w' THIS IS TO CERTIFY that the On-site Sewage Disposal System installed(i ) or repaired/replaced ( ) on by 'M A 4 u for at —/'l e.� 4 / has been constructed in accordance with the pro t�ilsions of Title 5 and the for Disposal System Construction Permit No. e RX46dated V Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires onl r DATE Inspector ` t LTHE COMMONWEALTH OF MASSACHUSETTS No. b� l -u ���Es � , MASSACHUSETTS FEE too ptspusal *Votent CZunstrurtion jJermit Permission is hereby granted to h _ •� to construct ��y) or repair( ) an On-site Sewage�System located at L 07 02 7 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. All construction must be completed within three years of the date below. DATE l Approved FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA , TOWN OF BARNSTABLE LOCATION l A l`�Q2C446, `��d SEWAGE # S a I VILLAGE C6", (1 ASSESSOR'S MAP& LOT-A Ll I INSTALLER'S NAME&PHONE NO. IYl p� SEPTIC TANK CAPACITY f rgo '51: LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER pn_ 0 `f'a AA4,t PERMTTDATE:- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i r 63 o r i No. �� �1 FEE / d COMMONWEALTH Of MASSAC14USETTS Board of Health, 30- 11) " MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to ConstructWK"P�air( ) Upgrade( ) Abandon( ) - Aomplete System Cl Individual Components Location —Z& CLe---j Tne d, Owner's Name Map/Parcel# (` 0 Address Lot# Telephone# Installer's Name Designer's Name C c Address Address Telephone# Q z Telephone# Type of Building &' QR_ Lot Size 2 sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furth r�eestto lace th t 'o e ation until a Certificate of Com hance has been issued b the Board of Health: Signed Yi p Date ��fl P ` y ,,,.. . .... ti No. �� FEE /dr M�' Board of Health, &1 117) "/P , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct air( Upgrade( ) Abandon( - X'Complete System ❑Individual Components Location C Lp_-i Tree (Z O 4t,,+ Owner's Name /V( Ct v e � O r Map/Parcel# % G Address Lot# Telephone# Installer's Name ( Designer's Name C r Address Address Telephone# 0 Z Telephone# Type of Building ,.Cg Lot Size y 97 sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria O Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 4 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ees to of to place th Sys operation until a Certificate of Compliance has been issued by the Board of Health. .. Signec�<.l�.0 � 10 Date `/ No. / .S���C�(3/v FEE COMMONWEALTH EALTH Of MASSA'1,HUSETTS Board of Health, `+scl f P? MA. y CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) Kcomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: nn / at has been installed in accordance with-the}�ro 'sio s of 310 GMR 15.00 (Title 5) and t e a proved design plans/as-built plans relating_to application No./.� date ( 19 App�"oved Design Flow 3 � (gpd) Installer ^~-�. ; ",✓ Designer: Inspector: Date: The issuance of this permit shall not be co�t trued.-a guarantee that the system will function as designed. FEE COMMONWEALTH OF-MASSACIIUSETTS Board of Health; (30-1'07 I /e— , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at 2 � 7 ��1.e rp� i dui r as described in the application for " Disposal System Construction Permit No. /S dated Provided: Construction shall be completed within three years of the date of this permit. All l0 1 conditions musts be met. y S Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date � O Board of Health C.e- i 1 6+ �40 t TOWN OF BARNSTABLE q LOCATION =� �� (�j a • SEWAGE # A VILLAGE ASSESSOR'S MAP & LOT-ILL? INSTALLER'S NAME&PHONE NO. .- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C�ID (size) NO. OF BEDROOMS BUILDER OR OWNER C) . PERMTTDATE: i -.),-—1-)- ' �S� COMPLIANCE DATE: �� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Date: Q ©3 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: C9 C u.Ek o \,( 1Ct_>_E K MAILINGADDRESS: 0 N U 1, f-t- Mail To: Board of Health TELEPHONE NUMBER: g 14 Q-0 4661 Town of Barnstable CONTACT PERSON: Vk( L k t P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: -V�I\k Hyannis, MA 02601 TYPEOFBUSINESS: kC-Q �� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES X _ NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: _ ADDRESS: C1\EQk,\4 C0 �'�(mot- 1t TELEPHONE: C WR J �C2 Q W_*� LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers ���•l`�hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) maybe toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS i N Date: - 0 TOXIC AND HAZARDOUS MATERIALS REGISTRATION~FORM NMEOFBUSINESS: BUS, NESS LOCATION: MA L 6 Eta 1p `-( Mail To: MAILINGADDRESS: 0 �- L) ( 171 Board of Health TELEPHONE NUMBER: CIO Q 6,!�'f Town of Barnstable CONTACT PERSON, ..(Ist, ( 1L R.O. .BOx 534 EMERGENCY CONTACT TELEPHONE NUMBER: 4) k Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES _ NO This form must be returned to the Board of Health regardless of a yes or no answer.,.Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: IQL& CKED `rl� IrIE L)I %r 6 TELEPHONE: If 1OIq LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity r Antifreeze(forgasoline orcoolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes% Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer)4 lubricants, gear oil NEW USED Degreasers for engines and"metal` -Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes , Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers -. x Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, " Floor& furniture strippers Metal polishes ,a>��hydrochloric acid, other acids) Laundry soil & stain removers OK Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids -����-�� �o � a (dry cleaners) Other cleaning solvents , Bug and tar removers r t `s !y,'• WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS SEWAGE SYSTEM PROFILE & DETAILS TOP NOT TO SCALE FOUNDATION 47.0 F:F.=48.0 FINISH GRADE 45.0 LOT 22 FINISH GRADE= 46.5 FINISH GRADE FINISH GRADE OVER TANK 44.0 OVER 0 .Box= 4`.5 CAPS ® ENDS OF EACH DlSTRIBU11ON LINE 48.01 a�O � N LOT 23 - • 49.71 --- �` M M - - _ • 35.81 - ___________ __._____._._ RISERS & CONCRETE COVERS TO • 16 00' -- - __ WITHIN 12. OF FINISH GRADE-- __ __ _ -3' PEASTONE • 1 O'TEE -INV. 140TEE 42.75 ,. * 42.5 4' PERFORATED PIPE 43.0 3 �E 42.34 DISTRIBUTION\42.17 SLOPE o 0.005/Fr. 3/4' TO 1-1/2' CRUSHED, 35.21 BOX 42.0 WASHED STONE 38.81 LOT ,�j 1500 GALLON SEPTIC TANK SET LEVEL 11 21,499 S.f. SET LEVEL • BOTTOM= 40.0 46 • 37.21 3/25' LONG X 2' WIDE X 2' DEEP DECK LEACHING TRENCHES LOT 28 s 6' PRO OSE .51 �o N N DWE LIN 3 .71 N LOT 26 • r F.FL. 48. \ DESIGN CRITERIA 108' NUMBER OF BEDROOMS 3 �s PERSONS PER BEDROOM `2 . 46.2 -fs 39.51 DAILY FLOW PER PERSON 55 b 36 _. LEACHING REQUIRED 445.9 sa. FT. . 49.61 LEACHING PROVIDED 450 SQ. FT. 0 44 c,6,_ U 10.5' ' CALCULATIONS W OILS LOGS S Cn 42 - , _ 450 sQ:=FT: a. _ 6 X 25 `X 3 :, _ . - ;41.0 - , PIT_: ... I �. .., � IT, . - 2 - - -- - - - TOP- & 1 �€- 40 �B SUBSOIL L I 18" �6 �N CLEAN 66.10' .�6, 3 41 WELL GRADED • 4 .91 MEDIUM 1n SAND i 48:71 31.51 j u GENERAL NOTES C E R T E ROAD ' 1. ALL ELEVATIONS SHOWN ARE - 144" 29.0 N0 WATER ' ASSUMED. - 2. ALL PIPES IN THE SYSTEM TO BE PERCOLATION RATE = 2 MIN./INCH �61 CAST IRON OR SCHEDULE 40 P.Y.C. OBSERVATIONS BY: ED BERRY N/A 3. REMOVE ALL UNSUITABLE MATERIAL a _ BENEATH THE INVERT ELEVATION DATE TESTED: 7/11/91 o w FOR A RADIUS OF AND BACKFILL 43.01 WITH MATERIAL WHICH MEETS THE TITLE V SECTION 15.255 REQUIREMENT. 4. ALL BACKFILL SHALL BE CLEAN , COARSE GRANULAR MATERIAL FREE APPLICANT: MARILYN 0 BRIEN FROM DEBRIS & LARGE STONES. 5. CHRISTOPHER COSTA & Assoc, PROPOSED DWELLING LOCATION MUST BE NOTIFIED WHEN THE PROPOSED SEWAGE SYSTEM LOCATION SYSTEM 1S INSTALLED PRIOR TO BACKFILLING FOR INSPECTION. 6. UNLESS OTHERWISE NOTED ALL L 0 T 2 l CHERR Y TREE ROAD SYSTEM COMPONENTS SHALL BE - INSTALLED IN ACCORDANCE WITH - MASSACHUSETTS_ TITLE V SANITARY SEWER CODE AND LOCAL RULES --- \�`j Mqs �,�P��� of Mqs` WHICH MAY BE APPLICABLE IN A BARNSTABLE - (COTUIT)--MASSAC.HUSETTS -PLAN VIEW o�`' 9cy a� 9cy� WORKMAN-LIKE MANNER. , SCALE: 1"=20' �� T BI ` � SCALE: 1 =30 DATE: 12/6/95 OBRI-L27 LEGEND CO _ o 7. THIS LOT IS NOT IN THE FLOOD PLAIN. PROP. SPOT ELEV. 46X5 go. 305 �, 14 8. A GARBAGE GRINDER WILL NOT BE DRAWN BY: J.A.B. CHECKED: JJ/CC JOB NO.: o y ,=9 �o INSTALLED ON THE SYSTEM. EXIST. SPOT ELEV. 36.41 qN /STER���� �� ,�-T�F„\t is SURv�- �,�ia� S 9. NO CHANGES SHALL BE MADE TO THIS PLAN CHRISTOPHER COSTA �X, assoc. PROP. CONTOUR = 42 '�>a•.r•r WITHOUT PRIOR APPROVAL FROM CHRISTOPHER EXIST. CONTOUR 42 COSTA & Assoc. P.O. Box 128 / 465 Main st., East. Falmouth, Ma. I a SEWAGE SYSTEM PROFILE & DETAILS .•' TOP NOT: TO SCALE FOUNDATION 47.0 FINISH GRADE Y, F,F=48.0 45.0 _ FINISH GRADE= 46.5 FINISH GRADE FINISH GRADE {Ij OVER TANK= 44.0 OVER "D"BOX= 44.5 CAPS ® ENDS OF LOT 22 EACH DISTRIBUTION LINE 48.01 a`° cIV LOT '!3 • 49.71 I' d` ^' tof . • 35.81 i RISERS do CONCRETE COVERS TO { WITHIN 12" OF FINISH GRADE { 1 - - 14 - _._ - { _ 0 TEE PEASTONE - - 42.75 42.5 _ 4• PERFORATED PIPE _ 43.6 4 0 3 UQUIll DISTRIBUTION 42.17 SLOPE m 0.005/FT. � 3/4• TO 1-1/2• CRUSHED, o 35.21 ;, LEVEL 42-34 BOX 42.0 }. LOT WASHED STONE s r�' SET LEVEL 38.81 1500 GALLON "t,TIC TANK SET LC EL I 11 21,499 s eorroM= 40 O 37�21 ; 3/25' LONG X 2' WIDE X 2' DEEP I I 46 I LOT 28 DtCK I `! LEACHING TRENCHES i +s , PROPOSES 51 , .` - o ce c° LO.,, 26 ►� D VIE LI N N N N F.FL.�48. DESIGN CRITERIA f7, 3 A NUMBER OF BEDROOMS _ PERSONS PER BEDROOM 2 j 46.21 \+s 39.51 DAILY FLOW PER PERSON 55 I o 36 F; LEACHING REQUIRED 445.9 SQ. FT. p; - SQ. L 49.61 / I �, LEACHING PROVIDED 450 FT -- Wit. • n g t 01 CALCULATIONS 10.5 _z : 1 r ► _ _ c _ _ r ; , .,0 _ __._ _ .._._;�� .i,.�..:..[_. ; _�_...� ... � � _... _,,... _ - (Df-,PTH-i-DEPTH+WIDTHj(LtNGTHI -- - LOGS ILS 42 3 - [ TOP (' -40 sUB`_>� FE CLEAP, 6 6.10 �G 3 41 ; WELL GR,nET) I MEDIU i 4 .91 sr SAND LO 31.51 • 48.71 - I GENERAL NOTES T EE ROAD i 1. ASSUMED.TIONS SHOWN ARE a 29.0 NO WAD:. _ . 144 - - - 2. ALL PIPES IN THE SYSTEM TO BE •710N RA 2 MIN. INCH PcRGOLr, , CAST IRON OR SCHEDULE 40 P.V.,.: ���' OBSERVATIONS BY ED BERRY N/A 3. REMOVE ALL UNSUITABLE MATERIA': .;' BENEATH THE INVERT ELEVATION - ,r;. L7/11/91 , � FOR A RADIUS OF AND BACKFILL DATE :• STED: rn 43.01 ° I WITH MATERIAL WHICH MEETS T}L` TITLE. /..SECTION 15.255 REQUIREMENT. : 4: ALL BACKFIL. SHALL BE CLEAN ,.,-'.1 o R ,A �� _ �� AF_1PLICANT: MARILYN 0 -BRIEN COr,R5E ��.��IU�,�rc �.�r,��RIA� FRF. I' FROM DEBRIS & LARGE STONES' ' A PROPOSED D 11TU j 5. CHRISTOPHER COSTA & Assoc. ING LOCATION ` ' MUST BE NOTIFIED WHEN THE : SETT AGE SYSTEM LOCATION SYSTEM IS INSTALLED PRI'OR TO PROPOSED SEy A . YS A N BACKFiLLING FOR ItiSPECTION.. 6. UNLESS OTHERWISE NOTED ALL �T �3 SYSTEM COMPONENTS SHALL RE LOT 2 7 Cl E R.L� "l TEE ROAD INSTALLED IN ACCORDANCE WFITI MASSACHUSETTS TITLE V SANITARY ► �, ' SEWER. CODE AND LOCAL. RULES ��� w BARNSTABLE (COTUIT) MASSACHUSETTS �1 %sue y��� a> ��ass�,, WHICH MAY BE APPLICABLE 1N A I E P 'LAN VIEW �� may\ � � WORKMAN-LIKE MANNER. �_ ( 1 P' r �� :; a, s s NOT I FLOOD PLAIN. SCALE: 1' 30. DATE: 12/6/95 OBRI-L27 LEGEND SCALE: -20 o co . �'� I , 7. THIS LOT I N THE L D c^ r - . T4 j 8. A GARBAGE GRINDER WILL NOT; BE DRAWN BY: A.B. CHECKED: JJ/CC JOB NO.: PROP. SPOT ELEV. _ �5 305 = o INSTALLED ON THE SYSTEM. �� ; - q /STER�a �T� r EXIST. SPOT ELEV. = 36. . 1 No SURv�y0 '.y ;;;,�� 5����. 9. NO CHANGES SHALL BE MADE TO THIS PLAN ter, ' �- _ CHRIS 1 OPHER COSTA & assoc. PROP. CONTOUR = 42 ' <. =: ''' r�'' WITHOUT PRIOR APPROVAL FROM CHRISTOPHER EXIST. CONTOUR = q 2 COSTA & Assoc. P.O. Box 128 / 465 Main St., East Falmouth, Ma.