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0252 CLAMSHELL COVE ROAD - Health
252 Clarnshell Cove Road Centerville P A = 005 004 -- - - —- - --- - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town 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. A. General Information 1. Inspector: �� a Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 11-20-14 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. t5ins•3/13 Title 5 Official Inspecfion Form: bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cw 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. Cityrrown 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: El Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I ` Commonwealth of Massachusetts _ a Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is Cotuit MA 02635 11-20-14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system.owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes' in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 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 ther 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10-2014 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 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" 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 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 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 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): I 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 W Title 5 Official Inspection Form VVX Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VA M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town 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.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts F Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Plastic Chambers ❑ 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.): Chambers in good working order with no sign of back-up into d-box or surrounding stone. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 page. CitylTown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts = W Title 5 Official Inspection Form 'm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 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: ® hand-sketch in the area below ❑ drawing attached separately 7L ' S T __ a4 1 - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 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: 12+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. 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 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 252 Clamshell Cove Rd Property Address Robert Bothwell Owner Owner's Name information is required for every Cotuit MA 02635 11-20-14 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 T£3jNNN d-B"NSTABLE sac �/l ( : LOCAl�i - a,^ 5 v✓e ST AGE -M # sErrc TAN cAPAcr LEACHINcTA NO.FBEDROOMS • 'P Pt '£I}ATE. eO r tc i]Pe. Separation Distance B .,enthe Maximum Adjustrsl Ccrann�iwater Tabie to the Battam of isactiing Ford{ity :feet Private Wa€er SuPF1Y ell and LeaWng F�c;]aty (f f any gyre sexist oii sits ae vnthitt 2t3t9,fast tsf testung Feet facility) I;d�e of letland and Leachia- l"*aaltty(If any wetlands exist within 3t1f1 feet flf°teachin ,faciliy)' Feet Furushed by � � F �}-c— Ll Ao '(0 r w U 0() L/ rr , No. '2 ' 2b� Fee �Dc% THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mgogal *pgtem (Congtruction Permit pficatio r a Permit to Cos Repair( )Upgrade( )Abandon( ) LI✓f Complete System ElIndividual Components Location Address or Lot o. Off' 3, C 1a.fxskr_11 Cooc " Owner's Name,Address and Tel.No. G6lvi1lt ��ck. �`Brien Assessor's Map/Parcel ,St aegD Installer's Name,Address,and`el.No. Designer's Name,Address and Tel.No. Sr. L f1 W R t A/C 6—" �C41011,441 ®t i-cr u,,U M A ®ass 4z2-s�3 Type of Building: Dwelling No.of Bedrooms 3 Lot Size 231570 sq.ft. Garbage Grinder A) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1f0�{��6 gallons per day. Calculated daily flow 330 gallons. Plan Date 44&67 Number of sheets / Revision Date s 23 7 Title S j+r- Ply e1 ".%J Size of Septic Tank / aG//c"T 'I a, i n . Type of S.A.S o 7"/Z�,cAl1 W 1�Cecfii�9 Cdtsr�/st Description of Soil P id4 - S E 1 ®-4 0 4f Z, Fi Z�4 - 14 C tyV a. -rp H Z ' O-3 w „o" o I a, �y °'� 9"-Lo" B"° 7�"-i�4� " °C rr1LP, Sv.� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provision of Title 5 of the Environmental a and not to pV6;W1kM_X, e sysem in operation unti�Certifi- cate of Compliance has been ' e by this f He �� ZG� /-//' Signe Date Application Approved by Date Application Disapproved for the following reasons Permit No. 9 7 - Date Issued .S"- "7" 9 -2 obi voy tv No. ,L=4 Fee COMMONWEALTH OF M+ASSACHUSE4TS41i Entered in computer. PUBLIC HEALTH DIVISION"TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication' for Migogar 6potem Construction Permit A plicatio r a Permit to Construct( IX)Repair( )Upgrade( )Abandon�. ) RIC"omplete System El Individual Components Location Address or Lot No. 1 O r 93 1 G 14 m 514.11 Couc WA Owner's Name,Address and Tel.No. Gotvilt S4dc. O`Qr�ts� Assessor'sMap/Parcel �sZ o4 a9,9 0 Installer's Name,Address,and`el.No. Designer's Name,Address and Tel.No. ¢axi,cr f I�J�t � $I Z hYfa r•� S t. o L 4 k)R z NC L old t// /1� Or- �,�t.� M� ou ss g2Ss-si3/ Type of Building: Dwelling No.of Bedrooms Lot Size Z3,570 sq. ft. Garbage Grinder(Ald t ``�"• Other Type of Building No. of Persons Showers( ) Cafeteria( ) Othe Fixtures YY Design Flow �� �6�/� gallons per day. Calculated daily flow 330 gallons. 1!; Plan Date 4/5/57 Number of sheets / Revision Date s Z3 7 l Title G i.1-r- Ploy` +rev d Size of Septic Tank / 4a//u•, *... Type of S.A.S. 7"- .r 1, 6jj eclu^v -CAo xlrr,-Z Description of Soil Tp -4" a° ' �}"- S "t E Ff - L� Ii ZJF 1� C ►�Y1�D. S*� -rp t'"Z. , O-3 u „Q" 3„— y v�,.•,, 9.i i� B" "-.14 4 a Ids S�vrt� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: F The undersigned agrees to ensure the construction.and maintenance of the afore{described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Qqle and not to p ace the system in.operation until Certifi- cate of Compliance has been is'2d by tthhi_sB© d of Hea / iyf lr.. � 9�/' Signe �7j Date Application Approved by _� h -c�ec ��* Date S",42 2 Application Disapproved for the following reasons Permit No. 9 7 ` 2 D_ Date Issued ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS -BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TQ_GERTIFY,that the On-site Sewage Disposal System Constructed(Repaired ( )Upgraded( ) Abandoned( )by t 1r)(w7i at >tf (J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ..9 dated Installs - __ /Designer_ Xi,r7Y'r i L The issuance of this permit a 1 rntofbe/cco'�nstrWgs"avugglgawntee that the system will ftwction as designed. Date -I Inspector f No. 9 / (10 - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS i� OgaY�epl em Conotruction Permit Permission is hereby granted to Construct( ( )Upgrade( )Abb don( ASystem located at LQJ ( S' p// (,'/(�? G J and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe .it. - // —�� �Date: Approved by 1 i J TOWN OF :OCATION c/'qM S�JARNSTABLE Gu✓C.. SEWAGE # VILLAGE Co y�+ ASSESSOR'S MAP & LOT o�S/CPO`L INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S�Q LEACHING FACILITY: (type)I-CiJ(,�\ 6N4%ev, ei`s (size) l-2 x 3S X cZ NO. OF BEDROOMS BUILDER OR OWNER kr1C/1 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leachin& facility) Feet Furnished by_D1rgect v^ A , w,�c��w (aAr .B Al— 38 BI- yy A;L- y s" n TOWN OF BARNSTABLE LOCA1ONr� ¢/�IJ7{�f (� 1 e� SEWAGi*-# 7 �• (� '� VILLAGE �� (Jl ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. (tea �V,4Y1 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)Z!dt (- Clam cI'S (size! F NO. OF BEDROOMS PRIVATE WELL OR PUBLIC kWATER BUILDER OR OWNER 77S&C IC © ` [ugh f y) DATE PERMIT ISSUED: � ' _ `7 - s 7 DATE COMPLIANCE ISSUED: / 7 VARIANCE GRANTED: Yes No L/ ,y 39" ��'' 02 S a TOWN OF BARNSTABLE LOCATION. SEWAGE # ' a VILLAGE ASSESSOR'S MAP & LOT . Qp L ;INSTALLER'S NAME PHONE NO.� 14Y1 SEPTIC TANK CAPACITYY`�Q C LEAHING FACILITY:(t ) _ YPe (size; 6 NO. OF BEDROOMS 7 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER C k o DATE PERMIT ISSUED: , t' _ '� -] _ 77 DATE COMPLIANCE ISSUED:_ VARIANCE GRANTED: Yes No lb COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 252 Clam Shell Cove Cotuit, MA 02635 Owner's Name: Jack O'Brien A� Owner's Address: P.O. Box 362 .HRNSTABLE Cotuit. MA 02635 ;LTH DEPT. Date of Inspection: January 9, 2002 --' Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 005 Mailing Address: P.O. Box 49 Parcel: 004 Osterville,MA 02655-0049 Telephone Number: _(508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Nee urther Evaluation by the Local Approving Authority Fai s Inspector's Signature: Date: January 13, 2002 The system inspector sha)submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 252 Clam Shell Cove Cotuit, AM Owner: Jack O'Brien Date of Inspection: January 9, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 ears old*or the septic tank whether metal or not) is structurally i eP Y eP ( Y unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 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 CN R 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- 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. 4 +Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 252 Clam Shell Cove Cotuit, M4 Owner: Jack O'Brien Date of Inspection: January 9, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: I Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001- 156,000 gals.;2000-94,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per 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: Sept. 15, 1997-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. The tank is under a brick walkway. Recommend installing risers to bring covers within 6"of grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 252 Clam Shell Cove Coto, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if resent must be opened)(locate on site plan) P P Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was level. There were no signs of solids or leakage. There were no signs of backup or failure from the leach field. The D-box was under a brick walkway. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (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: ✓ leaching fields, number, dimensions: 35'x 12'x 2'(per design plans) overflow cesspool, number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): The leach field was not dug up. There were no signs of backup or failure in the D-box The bottom to grade was approximately S'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 Map: 005 Parcel. 004 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. A . tnciow —, (5Ar a 3- 10 r Page 11 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 252 Clam Shell Cove Cotuit, MA Owner: Jack O'Brien Date of Inspection: January 9, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: ✓ Obtained from system design plans on record-If checked, date of design plan reviewed: 1997 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: The bottom of the leach field to grade was approximately S'. A test hole was done when the system was installed, and no water was observed at 12'(per design plans). There is no high groundwater adiustmeni for this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 Town of Barnstable P# l/ Department of Health,Safety,and Environmental Services Public Health Division Date 367 Main Street,Hyannis MA 02601 anm+auar8. KAM Date Scheduled s —'�1 7 Time—11,.3� Fee Pd. /00 Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: LOCATION & GENERAFOATION' L INRM Location Ad�d]ress G/a msh c// Co vc .ec0 � Owner's Name ,lack * ?— Address 35 n'»�1 Assessor'sMap/Parcel: __�ln�P.- - rte/ �}• Engineer's Name . BaXscr-f NyG, NEW CONSTRUCTION ✓ REPAIR Telephone# .928 -9/J / ..- Land Use KOa9 r e,Afi a I Slopes(%) D — / `7o Surface Stones /9 dnc Distances from: Open Water Body -Sa ft Possible Wet Area /`f'O ft Drinking Water Well ft Drainage Way ft Property Line /O ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I 7P I �t- � Q 1, 7P dZ j 1 � o t v► � v Parent material(geologic)G laau�I O ui-w aS h Depth to Bedrock Depth to Groundwater: Standing Water in Hole: 4114 Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR`SEASON AL HIGH`WATERTABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date:_ Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST D>ite Time Observation Hole# Time at 9" Depth of Pere .5& Time at 6" Start Pre-soak Time® 1,60 Time(9"-6") End Pre-soak Z4 ��tLws v" iN Rate Min./inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant L v r ' DEEP OBSERVATIONHOLE`LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Fabric 10Y:R 3A ii r70N� _S+b OL; 6 Z4 DEEP` OBSERVATION HOLE LOG Hole'4 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Fi b r'i c 10 Y I? 3/1 3"_ q" 15 Said! Lo a w' 10 Y►? 512 5�i .2oil Q 5x^J4 Loam 7,5 YR 4�$ C mc.rltSa l0.YR 61 DEEP OBSERVATION HOLE:LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Mao: Above 500 year flood boundary No_ Yes ✓ Within 500 year boundary No ✓ Yes Within 100 year flood boundary No Yes Loth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? y'�s If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature j/�.� — Date -S ZZ/97 / 1 ,432 S.F. COTUIT TOTAL AREA OF POOL & PATIO = i LOT 54 TOTAL AREA OF BUFFER ZONE REVEGETATION = 2,878 S.F. � CRAWFORD ROAD W W TOP OF ov z 2,878 S.F. AREA- TO RECIEV rp i COVERo 0 20,� COASTAL BANK BUFFER ZONE PLANTINGS PROPOSED:4'WIDE k 4' DEEP DRYWELL oo� o (4N/2' OF CRUSHED STONE) � J N87°32'50)p Locus ` � W � �_ - 185'± NOTE: POOL DISINFECTION BY OZONE INJECTION qS / � N M r yob t, . N / fV T R y ,POPPONESSET / Jg. Y� Mj Co Q AFF��'y BAY 0 LLJ p o ` / �1 1. / Q �..... O r7 �. I L,J .... :.:. . . . . ..:. ......'�........� VED �_ 0 : o LOCUS MAP l '' ' ��vl CDr7 N o : o : ': '::' Ln GATE — 36 I -' : ... �... GRAVEL Z / n I� �.. f w I > a IF- a ' ,%it" I I � .. 1:`':.....:.... ��:� ;: DRIVE v) i Q / '.>''. .'.'. ... :. ..... . o GARAGE I I I>- I _ ; 0 EXISTING PIER .'.' .. .. .. .., RAMP .& .FLOAT _.._. / — — ` c to,I PROPOSED (4 ) FENC .. .. �1 z '.� . � c,J rQ� I \ f a) I x �I X 00 i W pv Q ii �ii /-y w SHOESTRING � '��� 2�a 5 2 � J. o , I I poa^ ,��� f' ? ' '': '' \ BRICK ;�, ,� 30.3 O i Z (TIDAL) o Q �'�� o0 Cv I / • : PATIO :% BAY o I 1.... . . . GRASS IF '► ' w I '•'':':'::'•':.' : :':':'... ' U :: ' o I I I I / . . . . .. .. . . . .• AREA W NOTES: w ( / : . p LOT. 5 3 N I U 1) BASE PLAN BY MACDOUGALL SURVEY .• •• • • •• •.• 2) ELEVATION DATUM (MLW) EL:=0.0 I I 'I .� I I .'.'.. .'... ' LAN REF: 223/39 I co i —�._! 1 lEED REF: 14742/54 25 . . .. . . . `3S TONING: "RF" S87`3.2'.5.0"E ' ,SSESSORS MAP: 005 PARCEL 004 TOP OF ;ESOURCE PROT. OVERLAY DIST. COASTAL BANK 50 COASTAL BANK .BUFFER; 2O0'� LOT .5.2 GRAPHIC SCALE: : a } �� . .: . S r rr<i£r.p:..:"' �=6Eu7`. �. ''f' t� k=b 8 tA1 M}t#v 20OF 0 10 20 40 $0 p H; tim s2 Yi xU ti 2fi , gym'gee PROPOSED POOL PLA .�n�, * � �.�� , ������ ��G. � . .:r. O,fG� LOCATED A K» ? wr ? EDWARD � - SC . ... - ,. .. ...... ....... ..v., .. .,. .. _.; .. .. ,. - CLAM .. .' .., ... - 25 2 C LA M SHELL C 0 VE ROAD , u, .t. AsO, fC•, -. :..(. . FEET ).. . � .CIVIL NO 32001EdWaxd CO.TUIT 1\�A. + 1 .•inch ft~ - ... '. .. PREPARED: FOR ,:A PLICANTS. '�cisT�-°• 4,5t1 RAY,MOND,:; Q PLl(MOUTHy MA '02360 REVISED. March 6 2008 ROBERT Bc SUSAr BOTH WELL 9206 ascef�comcast net` Phon'e 508 7r43 v cellSA`B-$3`3:-.7:.6.30 FAX.50:8 .T43 `0:311 OCTOBER 3; 2007 SHEET 1 OF .1 J#1103 t . Bothwell Residence Cotuit') ma. Floor Plans Interior Renovation GENERAL NOTES: 73'-0' 261-01 - ---- UP 11 R09 vy % - 10re9-' i { r .+ X----F�f• ------ ------- ------ -------- II 26 Barnstable Road FESTYLES DESIGN I o I _ 7._p. I q Hhp50,M752�G5 - 2 5'_5" .--' I 5._4. __ 5'-5• •__ .:' " 6'-B" 6'-6° 7-0• I � 1 f : - - 6 j 1 fox: 5 8-775-7758 -�--- I - b -- '-- -- ------1 - r �. - bm®helinteriors.com 1 - J - I I I-0•. I cell: 781-953-2849 hinggham .. -- �---- •-- -� I tom @yaho o.com 111 - +---• +-- ;: i cell: 7 1-72 -8482 NO WORK IN. CONSULTANT: THIS AREA j o , m i I -------- - ----- - - - OP ' 13R/12r i - -- -- - -- -r ----- - ---- — -- — I I . RENSIONS: - 2'-11" 2'-11• 18_p• 10'-B• B'_5. 14,_5. 22:_4" Existin Basement Floor:Plan DATE: 06 February 2012 SCALE: 11e=1'-0" DRAM BY; Torn Maloney - e CHECKED BY:Brenda Meara SHEET TTLE: Floor Plan Renovations SHEET NUMBER: A.dl Z/ AiOl SST Bothwell Residence I Cotuit, Ma. I I Floor Plans Interior Renovation 1 T 4'-0' GENERAL NOTES: I 1 I HOT TUB 73 0' 6-4- 1 fi'0' POOL 17.0. NEW ENGLAND LIFESTYLES DESIGN 1 =1 26 Barnstable Road 4X Hyannis,Ma,02601 _ POST :::::: •._ 47 3/4 75 11/8 fax:5 08 775 7 58 LI G 1 4R RO ce® 84M 781t953-29 tomhinghamgyahoo.com m MASTER i t -- - CONSULTANT'.- - cell: 781 724 8482 FAMILY _ . .:.. _ . �� � .,...- _V BEDROOM - NRAISEDH I i I I ROOM RT w I : I� m pT --� `LINE OF BPLCONI'ABOK 2'0' _IN I 13'-7 3/8- BUILT BOOKCASE I 486 53 1 37 73 3/8 POST w LL + RaRmrm f I larxeww CLOSET GA AG _4 4 POOL REVISIONS: . i HOUSE MASTER — 4'-0' s-r 13•-1. BATH - 6' �i --- - Q 3'-6' 4'- -4 I�' 26'-2' ? e 0 iIP rtnTn i i I - N _ Q SE 9-0' 9'-0' S-2' 1 fi'-a. 3'-2' DATE 06 February 2012 14'-5' 22'-4' SCALE: 1 le=1'-0- DRAM BY: Tom Moloney CHECKED BY:Brenda Mearo SHEET TITLE: Floor Plan Renovations 2 Ex i stin First Floor Plan SHEET NUMBER: A.ot 1/4 1'-0' A. 02 Bothwell Residence Cotuit, Ma. Floor Plans Interior Renovation GENERAL NOTES: 73'-0• --------------- I ------------- !- --- -- - - -- - _�.:.�.,..: ; NEW ENGLAND LIFESTYLE$DESIGN Barnstabl e a Road - 2 I • � �` MBE OW M I I li I .e Hyannis,Mn.02601 h: 508-775 7756 - fax: 508 775-7758 Jf `------------ -------------------L----------------- -I .__ ,- -- -- bm®nelinteriors.com IP 781-953-2849 fi- I BEDROOM \ I 5-+ tomhingham®yahoo.com BEDROOM ~( j I I \` I I cell: 781-724-8482 w 0 m ' , CONSULTANT: I I � I •`I x-0 I BAL¢ONY \ jl IIR I -- r I i FA ILY— — ---- ' 1 CRAWL CLOSE b I SPACE I I I LT OPEN BE TH 0 I I BATH I BUILT L�___ - DRESSER BELOW --_ll - - - - - -- — - - - ---= (r— I q - I I 10-R' ,•T. ; �( ,� I , I'' � II �� I I I RENSIONS. II , CRAWL I I' BULTH SPACE a i i I( mu-i /OPE TO\ aoDxcE I j KIT HEN �\ �li I i I — = BELOW 11 L I I I I I I LiI' 11'-2• 11'-2" 10'-9" 9._6. 14._5. 22•_4• 7s-o DATE' 06 February 2012 SCALE: DRAwH Br. Tom Maloney CHECKED BY:Brenda Meara Existin Second Floor Plan FEE'`nnE' Floor Plan Renovations SHEET NUMBER: A.01 A. 04 Bothwell Residence Cotuit, Ma. Floor Plans Interior Renovation i 5'-0' IL 4'-0- GENERAL NOTES: HOT TU Y. ---------------------------------------- POOL 17•-0• ... •i / SE COUNT ,,••'.;.,•„ W BINS ILO � ! m SE G CC EW N FIELDSTONE F ES ATTACHED To EXISTI ^ NEW ENGLAND LIFESTYLES DESIGN BRICK NEW WIDTH I :. VARIES,Tn FR To RQ0F L - 26 Barnstable Road - LINE - i )w '• N BUI h0 Mo.02601 , NEW STONE 4X Hyannis,:• .: FACED RAISED POST __ _ i. HEARTH e" ph: 5 -775-7756 I / fax: 508-775-7758 ' i III a UP 14R bm®nellnteflOFS.COm LIVING I I o b�B "`" cell: 781-953-2849 � � I Sce .wu - - - -- 'I nm t 1 _ tomhingham®yahoo.com ✓�,� RT - cell: 781-724-8482 GUEST BEDROOM 01aR NEW BUILT-IN URRO NO.Name ! 1 ,` _ oth well Crabsh ck NO WORK W AND CHIMNEY SURRO NO ro TIE I O , ICE MICR. THIS AAEA 4X INTO EXISTING CfSEW�RK I c I I .. __ ___ ____________ _,r___________ _ _ I ___ I NOTE:ALL DIMENSIONS TO BE P� 2t z4 !OF KITCHEN I CUBBI FIELD VERIFIED PRIOR TO ANY 6 + c�_eaP OWE UNE I CONSTRUCTION I T- B&OONY ABOVE , DN.r R 2 0 EXISTING BUILT-IN 11fl PREP 9NK I L— EgONC4g REFRIGERATOR I i /F� DRAWERS 4X6 V� PORT I ,- -Y 4 NEW 3-0 X Y OWN COLUMN --- -- ON Y-e'X 2'-6•FOOTING. , 4X8 , F 36 fib 36 i G,QR,QGE _.. :. ' . EP=WALL REMDVED MD OPENING CUT TO HIGHEST i I ELEVATION. REPLACE WALL NEW BUNT-W GAS CHANCE DOOR I �b REVISIONS: WOH COLUMNS,TO MATCH AGAINSWNG TO OPEN EMSTNC AS SHOWN.- COUNTER ABOVE SHELVING B UP AGAINST WALL HOUSE COUNTER ABOVE NEW 1PM�M NINOONE 2R LI��� BUILT-IN TO 36' ATF5O14 ABOVE CABINETS - G I LILk•L ICI RELOCATE EXbll1& _NEW BUILT-IN_ —_—_ _—_ ___ 4'-0• B'-1• T3-1' N7�17'EJ\ PIPWG a1D Q ENO 0.t1T'RKREA IR' I 3'-6• I DUCTWORK 14'-8• < -4- 6'-4 � ,26'.2' / THI - Q S A \ \ I I I T-NEW BUILT-I N iLIFE T11E\.� I QATJI- .m ART I I \RIYVfrASF '% R I IRIS•NQ,IN �� N CHANCE DOCP�.3 SWING TO OPEN REMOVE CERAMIC TIE AND REPLACE WTIH AGAINST STAR WOOD FLOOR To LTATCH EXISTING. I REVISED i CUT SEAMS IN TO EXISTING To SREA(UP BUILT-W EXISTING LINE 1'-11• BENCH W/BACK NEW WINDOW WITH TRANSOM ABOVE TO VIE I 9'-0' 9'-0• I MATCH DOSTWG REM IMNG ROOM WINDOW DESIGN 3'-2• 1fi'-o' r-z' DATE 06 February 2012 18,-0' 10'-B' 9'-6' 14'-5' 22'-4' SCALE:, 1/4`--1'-0' I", DRAWN By.. Tom Maloney CHECKED Br:Brenda Meara SHEET TITLE: Floor Plan Renovations 11Revised First Floor Plan SHEET NUMBER: A.01 A. 03 Bothwell Residence Cotuit, Ma. Floor Plans Interior Renovation GENERAL NOTES: 73'-°• 17'-0' 18'-0' 22-0• 7,-0' -------------------- ------- REPLACE t__-____—__________--__________— s•-a' - ! NEW CP�.SQ - _1_-_. :L I WOHUA NIUM DOOR.NDOW �I NO veErsD°�e°NE LIVING ROOM i I�-:T_-1! RANSON.ADD ae )NY ' ATTACHED TO NEW B(1WIDEws we BRICK FRONT BALCONY W ENGLAND LIFESTYLES DESIGN E%IENSIONI !nLw WmTH E"� i4PERI I 6 Barnstable Road TO ROOF UNE FACE OP FROM L`___- __ N - --eEW LSICAN1tL_. Hyannis,Ma.02601 __WE�� __ ___ py_.pt___' EM?OOM RO 8 SME FOR - TO MATCH I SIDE 5'-4' h: 508-775-7756 - 1r� DaSTNG q NO K IN 6•-0• P BEDROOMv~w I - n05 \ °yy fax: 508-775-7758 T NEW T bm®nelinteriors.com Na WORK IN ALL NEW WALLS A TER BE ROOM THIS AREA AROUND STAIR OSET ( cell: 781-953-2849 m �~ i ENCLOSURE TO BE OO - U I INSULATED FOR s0uN0 _ I 'q - tomhingham®yahoo.com --------------- -- ------- --------- RREOCATTD°TO TAUDW FOP3'-0- T---- I cell: 781-724-8482 , 2'-T BAL ONY NEW PARTITION in III-- ONS/ __- —__—_ _ - - ___ _ 9, i flALCONY,7, NEW PARROON TO BE M NEW NG CONSI TO HATCH /I I II--- I C L7ANT: WOOD BOOR I To FOR FELLARGESTLOCATEDMASTER LOCATED TOW 6• •EKISIING WNSIPUCIION I ---' ________ I �� � CRAWL O LLLL� 4 LLLLLLL LLLLLLLIEL I SPACE ICLOSET ILi4L LLLLLLL LLLLLLLL`LLLLLLL ! OPEN TO !BATH I 2' L L LLLLL LLLLLLLLLLLyLLLL BATH I I L= INO WORK IN LLLLL,L L L�LILe BELOW TMIs REA I LLLL L Q - I I( II 10•_g• , BUILT-IN STORAGE -I m B TING I �� 8• I III EXISTING r E%6IING ACCESS BUILT-IN BE RELOCATED TO P110W - / I BOOKCASE r OPENT\ n FOR NEW PARnnON RAW u KITCHEN \ SPAC II I i - _ -- REhss o" --- } -- ' ------' -•- -. B - OW ! POP-UP DORMER O -. FOR SINK AREA TRANSOM _ WINDOW ABOVE MIRROR - - 11`z IB'-D' 10'-B• 9'-6' 14'-5' - 22'-4' - 75'-0• DATE 06 February 2012 vsed Second Floor Plan X S�1 CT � C.) SCALE: 1/4'=1'-0' Rei 3 Re DRAM By.. Tom Maloney CHEICKED BY:Brenda Meara . N SHEET TITLE: . 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