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HomeMy WebLinkAbout0221 CLAMSHELL COVE ROAD - Health 221 CLAMSHE-LL COVE RD, COTUIT i A= 005-024 �l Commonwealth of Massachusetts �/ 60 5--0-2- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, f use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation ,Q Company Name 14 Teaberry Lane Company Address iI Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12-7-15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. S� LP t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewag Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Lt5ms Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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 has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 C Ia s e m h II Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 345 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail 2013-82,000galIons 2014- 110,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information owner- last pumped 3-4 years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1'4" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 4° t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 221 Clamshelll Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS 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.): At time of iinspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): c Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ti Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City[T'own State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At time of inspection D-box is in working order with no sign of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM ,0 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 Chambers 12 X32 X1' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Leaching in good condition. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 v Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Clamshell Cove Road Property Address P Y Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 v \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12=7-15 page. City/Town State Zip Code Date of Inspection D. System. Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate.all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z hand-sketch in the area below ❑ drawing attached separately q 6 C j 2 � O OO O Cliec no V . +93 7q• �` b7_ Zq' Cy- 32 41- wt, C5 y3. b3- SI fa' G� 34•c� S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'" 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 138" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: June-7-1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 ®fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Clamshell Cove Road Property Address Mary McGreoch Owner Owner's Name information is required for every Cotuit Ma 02635 12-7-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 00 - C�`a. LY No. 1Y -7 FEE — 9 D THE COMMONWEALTH OF MASSACHUSETTS :3,9e JS7_,9&E- ��6T , MASSACHUSETTS ckpplirattun for Pisposal *Votern C onstrurtion jhrmit Applicatio is hereby ade for a Permit to Construct (X)or Repair( ) an On-site Sewage Disposal System at: Location dre r of No. Owner's Name,Address and Tel.No. 1:o7-&4 CL.A/x5#f=11 Com PLl. a)ESIMeA.)£ C40'Sr&&1 BU/4DE/251 C-e&� P.c,'Box 76 o �EY14Is 117 q. o z(-3 8 so e - 3 8s-84 9Z Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. NNiSWrN 026 a ..5b8 399 -39Z?' Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder(N) Other Type of Building J?r:_Q ENaE_ No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 y gallons per day. Calculated daily flow 34 9. Z gallons. Plan Date TWE 7 y gS Number of sheets pelt= Revision Date Title P&POSED ;L.eT PL a w Description of Soil M40W 2&a) )�n (--4 E S FT Nature of Repairs or Alterations(Answer when applicable) 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 B and of ealth. Signed P Date �� Application Approved by Date r ass Application Disapproved for the following reasons Permit No. /� L�� 7 3Date Issued —o !S h .' r �� . - �� » • • wI - v ra v i .. ,- . a \.y- -.-. ,_ .1f , y.,4'�' )/)p*{ • ..4.... -r'l .. ..I No. - �� 73 FEE THE COMMONWEALTH OF MASSACHUSETTS 0 �A,e,�sr��� (�c�7i , MASSACHUSETTS cXjjylira ion for Bisposal Sgstera (fonstrur#ion Permit Application is hereby made for a Permit to Construct( X) or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. // Owner's Name,Address and Tel.No. L.oT �4� 0-A,* 9'ell cove- 12Lr. �ESrhzo.c�E C4/5r& 1'1 BU144E,z51 ,c>.'5o x 760 ZEN41s Inn. O a G3 8 s•o s - .38s- 84 sz Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. z3sG� uzir6MleN Rdf.•e•lWG- Sa.DENNlS/ rhM. OZ�bo Sb8 _ 398 -39Z Type of Building: Dwelling No. of Bedrooms Garbage Grinder(t4) Other Type of Building 7?P:,!gIDeNc-�- No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 0 gallons per day. Calculated daily flow q. Z gallons. Plan Date SuMrs -LDS Number of sheets bNae- Revision Date Title Re6 PGS E D PLbT Description of Soil h9E1)/1114� Nature of Repairs or Alterations(Answer when applicable) r 4 .. 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 ibis Board of Health. - 1• Signed _ Date Application Approved by Date ;LQ- � Application Disapproved for the following reasons Permit No. /r���� 7 Date Issued - � THE COMMONWEALTH OF MASSACHUSETTS aA/eh157'4QcC:.- ,MASSACHUSETTS V� %Certifira#.e of Clomylianre r THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced( ) on by for at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated yUse 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 on DATE �.•h - L- q � Inspector THE COMMONWEALTH OF MASSACHUSETTS No. c 11.� 73 BA9 L - C / , MASSACHUSETTS FEE PisVosttl �5g8#Ent ons#rnrtion jermit Permission is hereby granted to �-1 �� ^-•-� to construct p<) or-repair( )an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. DATE �Iz - 2 :2 -2rL Approved by f 4Lt_4d� FORM 1255 Rev.3/95 A.M.SULKIN 00.-BOSTON,MA TOWN OF BARNSTABLE LOCATION j#22/ -'�k15 �/l C�cs_y�' /",cSEWAGE # 9,r- Is�� On5-_ ® ;..� VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �lel,y9,w) ts�i :vc- ���-byyy SEPTIC TANK CAPACITY /S&o GS ysYc�E'�4t°o LEACHING FACILITY:(type) y_Jsize) /2 5132 X I NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Icy jMa&Lc- Cos mac/ ue(�1F.�S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ p�OY 3n of 77-47 _ S vw D I i In N 9 C-ro c-'o C-ro c A—ro / - z 2•G C7-o rl- ATo I3 To 2- 6® B`m9� Z9� e6 7-o 3 - 57-9 Li -re, Y- /-7-6 6 7-o S-- 3/— t F 9 TOP OF FOUNDATION 20 FT. MINIMUM SOIL T ST - -- - i --- DATE OF SOIL TEST ' 0 EL EV. _ '�' 10 FT. MINIMUM - -- _ __- CLEAN SAND SOIL TEST DONE CONCRETE WITNESSED QY � COVERS 4" SCHEDULE 40 PVC PIPE OBSERVATION HOLE 1 OBSERVATION HOLE 2 MIN. PITCH. 1/8' PER FT. .-ELEV L ' PERCOLATION RATE ►SIN. NCH. 7J rin r_ 2" LAYER OF �� /I ELEV-- PERCOLATION RATE IdlN,�N(�{, 1/8' TO 1/2" ! ( Zl DEPTH HORIZON TEXTURE COLOR MOTTLING OTHER DEPTH HORIZON XTURE COLOR MO ING 0 ER 6' MAX. WASHED STONE 4" CAST IRON PIPE -- VENT "Z ca.v1 _ (OR EQUAL) MINIMUM T— VuT i S�at+v T.SY>?�Y F.., ► ��+n y . YR�` PITCH 1/4' PER FT. 4 A CU. FT. OF _ n M<c Y / Y<asp j CONCRETE ) -!2 fq. D S %, 7 ,A-V j_FLOW LINE _ --- a> ELEV. _ 22 I 10" 1.� l-r�i G' '� �,,• n�8 y� !r 5��� xr MIN. 19' o o C7 C] o C] o 0 o .• Y /4 20 LEVEL co 0 0 o m a o 12" ' ra-I3P I Y��� `. f •• r y V ! ° o o ELEV. s 7 G 3 574� ,r? c ELEV. _ ELEV. _ �� 6' SUM ELEV. = 0 0 0 ° ° 0 0 0 DISTRIBUTION ° ° : o ° o ° ° °° ° ° o ° ELEV. BOX ��i (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED 1500 GALLON IF MORE THAN ONE OUTLET 11 X "`''` Z WELL� WATER ENCOUNTERED AT ELEV. _ % l "' WATER ENCOUNTERED AT � -~ w _ ELEV. � •'�� SEPTIC TANK i ZONE 3/4" TO 1 1/2 INDEX WASHED STONE ADJUST I LEGEND: DESIGN CALCULATIONS SEWAGE DISPOSAL SYSTEM PROFILE BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. = EXISTING SPOT ELEVATION 00,,0 NUMBER OF BEDROOMS OBSERVED WATER TABLE ( / / ) ELEV. = _ EXISTING CONTOUR ----00---- GARBAGE DISPOSAL UNIT 777- NOT TO SCALE FINAL SPOT ELEVATION TOTAL ESTIMATED FLOW FINAL CONTOUR- ( ' � GAL/BR./DAY X BR.) % ' GAL/DAY SOIL TEST LOCATION REQUIRED SEPTIC TANK CAPACITY GAL UTILITY POLE -4- ACTUAL SIZE OF SEPTIC TANK GAL TOWN WATER —W=- W-- �- - - EFFLUENT LOADING RA - GAL/DAY/S.F. CATCH BASIN ®� LEACHING AREA i=x Z) 'r w X _ SO, AS LINE G - LEACHING CAPACITY (AREA X RATE) GAL/DAY RESERVE LEACHING CAPACITY GAL/DAY I NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6 OF FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN d 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. (T 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. U 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OER OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 6. UTILITIES MOWN ARE APPROXIMATE ONLY, EXCAVAIM CONTRACTOR IS TO CALL/ PRIOR 7 COMMENgN'WORK AT 8 -322-4844 AT LEAST 72 HOURS y 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. 8. PARCEL IS IN FLOOD ZONE _ 9. LOT IS SHOWN ON ASSESSORS MAP _ AS PARCEL r'A .. � �.� '} �f,f,"�� ��✓ ,� , fir'.. � � 1.4} �' N� fi113 � •� yj APPROVED: BOARD OF HEALTH aceA DATE AGENT `� PROPOSED PLOT PLAN rt FOR f 1 PROJECT LOCATION ,• T � � +a lop SWEETSER ENGINEERING _ 235 GREAT WESTERN ROAD 40 GP SF �1 f 1 ' 398-3922 SOUTH DENN S, MASS. 02660 1 f Ii L n ( t0 v .:J // SCALE _ - 111 n DATE { i `J REVISED REVISED 1 - - ` �y LOCATION' MAP Joe No. �J .; ,.a,,; ]I [ SHEET OF 01995 SWWEETSER ENGINMR1NG wr.. �...AtakA5Pr'.e u ,..+ . :.-. f:, ..sWl.�liRm Y+'�..�ax....�.NYna: 1R.:u _. .. .. _..._. .,...... .. ,I '• { ' A -Tm,a L- I\']b'kI'Mi.�.�RWFn..{'Yr.YiRdYte'+iV..31;r�x�i FWD:��• �:6MLvprt.�W4C�#.Y���'�Ga •,6. I. .. .... ... ..- .. ..... ..._ __ ..___ _ _... }