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HomeMy WebLinkAbout0081 CONSTANT LANE - Health 81 Constant Lane cotuit P' A = 039 062 r � - No. d I " Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphtation for Vsposar *pstem (Construction Permit Application for a Permit to Construct( ) Repair,(�Upgrade( ) Abandon( ) ❑Complete System [ dividual Components Location Address or Lot No. <2 C S �r\ `,o Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Cass IPAA oQ 30=1 Installer's Name,Address,and Tel.No. ��f~ ex esigner's Name,Address,and Tel.No. p,® . to 3x '3-7 Sa m- �Os57- So w`ve� MA ©C S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 'Y�l `A I—r — O,h� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date 6 l3 r Application Approved by C> Date ?A/ Application Disapproved by Date for the following reasons Permit No. 3 I — �U _ Date Issued t-l� - - t No. D011 Fee 0 U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Misposaf *p9tem (construction permit Application for a Permit to Construct( ) Repair(V,)""Upgrade( ) Abandon( ) ❑Complete System �ridividual Components Location Address or Lot No. �( ca Owner's Name,Address,and Tel.No.Sp�o ��- lam. Assessor's Map/Parcel �j :� 3 d r („�t I C ` A Q z <- Installer's Name,Address,and Tel.go. -Designer's Name,Address,and Tel.No. 3 -7 �-a�- Type of Building: e Dwelling No.of Bedrooms ^� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) e p Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ? d (— �U _ Date Issued THE COMMONWEALTH OF MASSACHUSETTS 00 ,, BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(j/j Upgraded( ) Abandoned( )by r C�aC�U t �'�, l Y, A- C_ _ at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. (J dated / Installer 7­77; jam. Designer #bedrooms A 6} Approved design flow gpd The issuance of t 's per it shall not be construed as a guarantee that the system willMtVl /-%as designeDate Inspect No. U Fee (f Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS 30isposaf *pstrm Construction J)ermit Permission is hereby granted to Construct( ) Repair(t,� Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must Pe completed within three years of the date of this permit. Date f Approved by �, TOWN OF BARNSTABLE Aut'dr! CATION *'Fl I�p /I. SEWAGE# v I o Al LLAGE>����i �- ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / LEACHING FACILITY:(type) 6T— (size) NO.OF BEDROOMS N OWNE%. S PERMIT DATE: /1,3/it COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility . Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facilit ) .' (r Feet FURNISHED BY on /loX 5,UaA i ®r, B A3s/3Jr o 3 Naw3 Commonwealth of Massachusetts Title 5 Official Inspection Form cop;le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is Cotuit MA 02635 June 10, 2011 required for i every 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. Important: When filling out A. General Information forms on the `•/Il,lU,U computer,use 1. Inspector: / only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector T use the return key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification 1 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� Title 5 (310 CMR 15.000). The system: ' ❑ Passes ® Conditionally Passes ❑ Fa'ils i ❑ Needs Further Evaluation by the Local Approving Authority l June 27, 2011GO "' -� r st 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. U�,_� �5 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal S em•Page 1 of 1 P 9 P� 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name infourired formation e4 Cotuit MA 02635 June 10, 2011 every 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: Recommend removal of garbage disposal. System not designed to handle. D-Box was replaced upon completion of inspection. Permit#2011-180. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): D-Box is failing and needs to be replaced. Once replaced and inspected by Barnstable Board of Health, system will pass. ❑ 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every page. CitylTown 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every page. City/Town 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" o `no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 00 feet of a surface drinking water supply ❑ ❑ the system is w' in 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system i located in a nitrogen sensitive area (Interim Wellhead Protection Area— IW A) or a mapped Zone II of a public water supply well If you have answered "yes"t any question in Section E the system is considered a significant threat, or answered "yes" in Secti D above the large system has failed. The owner or operator of any large system considered a sig . Icant threat under Section E or failed under Section D shall upgrade the system in accordance h 310 CMR 15.304. The system owner should contact the appropriate regional office of tha epartment. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every page. Cityrrown 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 700 GPD t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 r Commonwealth of Massachusetts Title 5 Official InspectionForm om Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required Cotuit MA 02635 June 10, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2009= 120 GPD g ( y g (gp )) 2010= 131 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 C/Title Gallons per day(gpd) Basis of design flow(seats/p Grease trap present? ❑ Yes ❑ No Industrial waste holding tank ❑ Yes ❑ No Non-sanitary waste dischargstem? ❑ Yes ❑ No Water meter readings, if ava t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10 2011 every 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: Owner records, pumped 2004 Wass stem pumped s art f y p p a p o the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10 2011 every 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: System installed 10/24/1979. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'8" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 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: 8.5'X 4.5'X 4.5' 1000 gallons Sludge depth: 511 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is Cotuit MA 02635 June 10 2011 required for + every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee, and outlet concrete baffle in place. Liquid level at outlet invert. Tank was pumped and cleaned after inspection. Grease Trap (locate on site plan): Depth'below grade: feet i Material of construction: % ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum t top of outlet tee or baffle Distance from bottom of um to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every 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.): 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.): f Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts 93 OF Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every 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.): D-Box not structurally sound and showing signs of leakage. New D-Box permited, inspected upon completion of inspection. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump c mber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10 2011 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-V X 6'w/2' of stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level in leach pit 26" below invert at time of inspection. High water staining 24"below invert. Two coarses of hole w/clean stone visible. No sign of past hydraulic failure. 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 i flow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every 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, Ahydraulricre, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10 2011 every page. Cityrrown 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 I t i , A o p 3' f + Vam"\L a y \p t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is required for Cotuit MA 02635 June 10, 2011 every page. Cityrrown 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: >4feet 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: 10/24/79 + 02/07/2008 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test holes found no ground water at 144" (1979+2008). Base of leach pit at 102".Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Constant Lane Property Address Sabrina Ewing Owner Owner's Name information is Cotuit MA 02635 June 10 2011 required for + every 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOVk`N OF BARNSTABLE LOCATION L—pw �,SEWAGE# PILLAGE ASSESSOR'S MAP&PARCEL C73 INS�S NAME&PHONE NOS SEPTIC TANK CAPACITY c�q p tc�h LEACHING FACILITY: (type) �-e�c�,�.,.. �� (size) NO.OF BEDROOMS D Q w—e- OWNERM YN PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY"--�k , k s. 1 O a 3 liLI.IG `-t Alt �.a --- ------ ------ ---- ------------- ------------- . - - - - - - - - - - - - -- --------- -_ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS / Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Vf Upgraded( ) Abandoned( )by`�'�.n^._.SL.� � y�� at C G C V`t.5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated * Installer Designer #bedrooms A IApproved design flow The issuance of 's pe it shall not be construed as a guarantee that the system will Li as des* . Date Inspector ----------- No. J Fee 17� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair(V Upgrade( ) Abandon( ) System located at <—�?l and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructi must a completed within three years of the date of this permit. Date Approved by f /y q,� cA, - - T n of B ,sable Tlepartlt><ent of Regulatory Services # j Public Health Division H o t0�..�;. 200'Main Street,Hyannis MA:02601 a Time Fee Pd DatrSctledWed ® d Soil Suitability Assessment for.Sew age.Li ;acl, Performed By: Pe% / Witnessed°:By;. LOCATION& GENERAL INFORMATION I.oeation Address g" S -{— Owner's Narnt­r_�� skr i n c�p") t.., C ci Address Assessor's Map/ �p Engineer's Name Pargcl::. ..��9 �t�: '� gi _. . NBW'CONSTItUtr'fION ; fi REPAIR . Tel, hone# 'wG Z-- 3/3F p� Slopes(96) Surface.Stones /n Distanees:from:: Open Water Body�3 ft Possible Wet.Area�3dd ft . Drinking Water Well Drainage Way���� ft Propertrurve.Z� ft Other A SKETCHa(Street name,dimensions of lot enact ovations of test holes:&perc tests,locate weflands n proxittuty=to holes)' r /a<<.. .: N � pill Ga ry 5 G)CIA' (���-��� �3� Parent.material.(geologtc) / Depth to Bedrock < Weeping from.pit pace KJ /A Depth to Groundwater. Standing.Water in Hole: P 8 ;< P3 'TIr Estimated Seasonal High Groundwater DETERNUNATION FOR SEASONAL HIGH WArTTR' Method.Used Depth.Observed:staa ding in obs.hole: in. Depthio Soil'no►!�#s: Depth.to weeping from side of obs.hole: in., (Gmundwater Mostment i Index:Weil# Reading Date: Index W611 level Acu,fketor,,.,,a.e.;;�df tl qutt aq 3 vq1'. PERCOLATE l'LT � tr�.,..:. :s �'6 , Observation - at 4° .. ,-.1 3 Hole:# Depth of Pere ` 7 I%.J Time at5- 7 6" & 'fs <d`Z� Time(0.6")Start Pre-soak Time® i End Pre sonic _ Gz Z_ 2. Rate;M'in,Mch.. Site Suitability.Assessment: Site PassedVC .,... sits Fallen: Additionat;Testing Neede�t 0 servation Hole Data To Be Com leted on Back --- Original:'.Public.Heaith:Division b p ***If percototion test is to be conducted within 100, of wetland,you must fi t f , Barnstable Conselrvation Division at least one(1)week prior to beginning. .. n.roerrt�r^bvol,mvlur INN' DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil Horizon Soil Tcxturc SO Color. 3011 Other Surfact(rn) (USDA? (Mtnselij Mottling ($huatu[e,Stonc,9;tlauWers. `izq 2 F;� 2�� f .!y : u, z j< 1F QERVAON HOLE LQG. Holy �� t Soil Horizo WON TI n . S(USDA lT to Soil Color Soil DiliSurPaea(in) ) (MUnscJl) Mottling (Structure„$tones,Boulder; a - 1 �. Ls t � � u�z _ �s : �ZY-13 S /(A/ .. l + P QI3SERVATION HOLE L0G Hole P ,�4►+ §bid.l!or�zoa Sots Texture:'. . Soil:Coior Soil a©tttet r, Sum 00 (USDA) (MUDSQII) Mottling ($trucwre,Stones,Bouldots. ' VS.: ca ( /Z . . . e51T 6/ > F�SERVATION RULE LOG Hale# D ih from:. Sofl Fidrizoa Soil Tex 3011 Color Soil . p� Su.tfaee(lq) (USDA) .. (Munseli) Mottling (Structuro,StOltcs,Bouldors, • to FloO-`:I MM .cf- . to Man; Atpve10riloodlioundluy' No :_( yes W{thia Solt y t:ovndary No777 Wiftiih�l' yl �flood boundary Nb Yes Dnth ofhtx* y'D arlbPerytouslal Doe:;at leas--hour feet of naturally occurring pervious matarial exist In all areas observed thrpughout tho area`proposed fir the sotl:absorption system? eS _ If'not,whl;t is the depth'of naturally:occumng pervious material? ... _. Crta 16 ertify that on (date)I have passed the soil evaluator examination approved by the Department:of)3nvironrnental Protection and that the above analysis was performed by.me consistent w`�t6 the regtared..' ini peruse acid experience described in l0 CIVIR 15.617 .• Signature Date `Z 2 `C> QA01301116ft" L i 5it141'15dC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION m w Z m r o i C f 7' 9W p�M Syev TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A n 3 C CERTIFICATION MAP --�'°�-R L ® PARCEL :— Property Address: 81 CONSTANT LANE COTUIT,MA 02635 LOT 3� » Owner's Name: GARY BALLDINO - —f Owner's Address: 81 CONSTANT LANE COTUIT,MA 02635 Date of Inspection: 1113103 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes _ Conditionall P. sses _ Needs Furt r r valuation by the Local Approving Authority Fails Inspector's Signature: ; b Date: 11/3/03 The system inspector shall submilon. copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Titla 5 Incnantinn Fnrm 6/1 S/?MII 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section 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. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 1113103 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE,LAST TWO YEARS . _ X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design 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 X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat;or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 1113103 Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up ? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site 9. X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate 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)):-tFe Sump pump(yes or no): NO 22 Last date of occupancy: n/a J J Sa,OOV COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST TWO YEARS. Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if 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): n/a Approximate age of all components,date installed(if known)and source of information: 1979 ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO F r Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 101", Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: I" 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: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERYONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): n/a 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD 4' OF LIQUID IN IT AT TIME OF INSPECTION. PIT HAS T OF LEACHING LEFT IN IT. BOTTOM IS AT 9 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: I1/3/03 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. w SUII Q�a/�l AA k �7 in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT,MA 02635 Owner: GARY BALLDINO Date of Inspection: 11/3/03 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 1.2+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. tt COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �ry. Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Name of Owner VINCENT KADELSKI b Address of Owner: SAME Date of Inspection: 11/1199 /VQ Q Name of Inspector:(Please Print)JOHN GRACI _ 4 l am a DEP approved system inspector pursuant to Section 15.340 of Tdle 5(310 CMR 15.000) TOty,1,0p 1999 a Company Name: n/a yP;17), NS7 Mailing Address: n/a Telephone Number: n/a 4 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further E I ation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: ` Date:11/2/99 The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:l l/1/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not.metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced Wa The system required pumping more than four 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 revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:11/1/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 460 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:1111/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal Flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:11/1/99 FLOW CONDITIONS RESIDENTIAL: Design flow:JQ g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 220. Number of current residents:2 Garbage grinder(yes or no):]I'E;i Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):._NQ Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n1a Sump Pump(yes or no): NO Last date of occupancy: n/A COM M ERCIAL/INDUSTRIAL Type of establishment: n1a Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): MQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:n/a Last date of occupancy: nla OTHER: (Describe) nla Last date of occupancy: n(a GENERAL INFORMATION PUMPING RECORDS and source of information: THE SYSTEM HAS NOT BEEN PUMPED IN THE LAST YEAR. System pumped as part of inspection:(yes or no):MO If yes,volume pumped n/a_ gallons Reason for pumping: n1a TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1979 PERMIT#261-79 Sewage odors detected when arriving at the site:(yes or no). MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:11/1199 BUILDING SEWER: (Locate on site plan) Depth below grade: 1'C Material of construction:_ cast Iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): XQ nLa Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: L" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:.a 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: .4 How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC.TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING-SYSTEM SYSTEM EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nfa Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:-nLa Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: nLA Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wa revised 9/2/98 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR M PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:l l/1/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nl3 Dimensions: nla Capacity: n& gallons Design flow: z9a gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No_ NQ Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n& DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nta Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) l& PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Dia revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:1111/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _n a leaching galleries,number: _WA leaching trenches,number,length: n/a leaching fields,number,dimensions: nla overflow cesspool,number: n& Alternative system: n& Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAS NOT BEEN MORE THAN 1/2 FULL_ CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: x9a Depth of solids layer: nla Depth of scum layer. nla Dimensions of cesspool: n(a Materials of construction: n1a Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:nta Dimensions:Wa Depth of solids: n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:11/1/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a I g p,f CIL cc)C AA 19� A0 ac I/A PP cc revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 CONSTANT LANE COTUIT MAP 039 PAR 062 L 038 Owner: VINCENT KADELSKI Date of Inspection:11/1/99 NRCSReportname: nla Soil Type: n(a Typical depth to groundwater: nLa USGS Date website visited: nJA Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 TOWN F BARNSTABLE `LOGATIOI:T- 1 SEWAGE # 'MLAGE � _ 'i_ — ASSESSOR'S.MAP & LOT INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) (Jolv (size) NO.OF BEDROOMS 2- 'PIM 2211dww BUILDER OR OWNER PERMUDATE: 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 wel4nds exist within 300 feet of leaching facility) I I n Feet Furnished by r t'� W pz N; pAQ m �1D 1,g z C-7! No................ .... FmB...............:.............. THE COMMONWEALTH'OF"MASSACHUSETTS BOARD HEA H GYI....0 F............. Appiiratinn for MqpnnFal Works (fnn.itrnrtinn 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) a3 Jadividual Sewage Disposal System at: .....� �?: .!.? ... �Zz_ .�°_`„ ,:e:� ...............................� ..'. .......�---•--------------..............-••-•------- Location ^� .. .. . W Owne `fir a a rqy,. , '/ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms ............................... a g— E-3tgcirsivirszttic ( ) G ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ....................................................... W Design Flow........ ......6 �....._gallons per person per day. Total daily flow............ _..®................gallons. WSeptic Tank—Liquid capacity./IN .gallons Length......9..... Width.... ....... Diameter________________ Depth...`l_......... x Disposal Trench—No..................... Width.................... Total Length......... ..._..._. Total leaching area....................sq. ft. Seepage Pit No.......1_........... Diameter.._.. Depth below inlet_.._. Total eachin area_2® .......sq. ft. Z Other Distribution box.()() Dosing a Percolation Test Results Performed by.... g; f� Date ,.a Test Pit No. 1......2.,.....minutes per inch Depth of Test Pit............:....... Depth to ground water.................... Test Pit No. 2......:2—..._niinutesper inch Depth of Test Pit-__-�.�---1. Depth to ground water...... tics pi �7 .....__..... liq .............. Description of Soil - /�o-wY� .. U c - ��:::::: .... :: .. -------------------------- W ......................................................................................................---------------................................................................................. UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. ...-•--••-•----------------•---•----------•---------.......------------•--•--.........-•---.'--------...--------------------------------------------•-------------------------------...-----•..------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT .,.,. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.Signed. ti`'Q�`-�....... ...L...--5aA................ ---- Application Approved By........ ........... � ~—.. / ��........... Date Application Disapproved for the following reasons:-----•-•------------------------------------•----------------------------------•---------------•----------_... --------------•-------------.........-------------•------.....------------------------•--•----------......---._............-•----....----------------------------------------------------------.......... Date 442— PermitNo......................................................... Issued-- / .....7........................... Date No...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD . HE L - O =-- ........................ ;4 f Annliration fear Disposal Works Tonstrurtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) dividual Sewage Disposal System at Location- dress .......... 74— ..... ..........•- •--• " -_... .....___ ___- P W E J -- Sl..!.. ..f � * � Own s -� � Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms____.._ iasietttic ------- - aOther—Type of Building .............................No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . - ... W Design ow........ ..... a _._..__gallons per person per.day. Total daily flow..... loos. WSeptic Tank—Liquid capacity/A!A_gallons Length......+�0_____._ Width._. ....... Diameter________________ Depth--- ........ x Disposal Trench—No_____________________ Width.................... Total Length........_ ___i___._ Total leaching area....................sq. ft. 3 Seepage Pit No.......If............ Diameter..... Depth below inlet_._ _iQ' Total}eachin area.�4,' ._sq. ft. Z Other Distribution box A ) Dosmg.t ) a� �1�� 1)'�, ��' Percolation Test Results Performed by.-' y _. ._..: -----••'•••---• Date_ "C Test Pit No. 1......'r►......minutes per inch Depth of Test Pit__._ __.__. Depth to ground water_.__.._! ".!! „ 44 Test Pit No. 2......2,.....minutes per inch Depth of Test Pit____�3�----- Depth to ground water...... Description of Soil.... - r: G. '`yi•+ d..t t U ----••--•-•---•----•-•-•--•---•-•--•••----••-•-'•••-------•-••-------•-----------------------••-•••---....-----•.-••------_•--- W U Nature of Repairs or Alterations—Answer when applicable.....................__________________________________________________________________________ -------•--•-•-•-•-••-•---•----••-•---••---------•-••.............••-•----•-••--•-•--________----•_••---••'--•-•-•-•••••••---------•-•---•-•-•-•••••-•----••---•••--•••-•••--•...._._••-_____•---•----•-- Agreement The undersigned.agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LI iE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed _...:.: : . ?! - ----=_-•-_---• •- r Date Application Approved By...... r_. ....................... ---J.!nAF/..71­A.......... Application Disapproved for the following reasons:---•--------•----•----••-----•--••-------•---------------------•-------•---•--•-___..::;--- Date----••-••-:- ..............•-------•-•--•-----•---•-------••-•---••-------•-••-•-••---.....-----------....-----...------------------------•------------------...----------------------------------••••---•--••---=- �. Date PermitNo......................................................... Issued....................................................... Date t', THE COMMONWEALTH OF "SSACHUSETTS d BOARD F' HEALT ' .......OF........ a44i ........................ Trrtif-ratr of Zootnlianrr THIS I TO CE F :hat the Ividual wa > osal System constructed ( or Repaired ( ) by --------------- ------ r 1 Installer; I has been i stalled in accordance with the provisio s of F 5 ofjh State Sanitary Code as described in the application for Disposal Works Construction Permit�o. _ dated__ .. '. ................... THE ISSUANCE OF THIS CERTIFICATE SHALT: NOT BE CONSTRUE® AS A,GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................... .:. ;z...: l THE COMMONWEALTH OF MASSACHUSETTS BQARD ,O HEAL H a..... '.I...:...OF..-... _._.... ••....:....... .......:...... ........ .r.ram FED •••---i........... No._... :.7/.... �3 i n�a*`d�* idZlAage 0 k tr ion rr ,f Permissionis hereby gra ted.t: •••. = ••--- ---••-_... .._ --••• _... ...._.... to Constrr pair ( ) Disposalemat No... % :.... , � G l............- • .. --:................. r� Street .� as shown on the application for Disposal Works Construction erg o. ___ Dated---- 1 ''�q'-.. ""Pe DATE. �• x oard of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS J L.OTAT�4ON .__ SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS S UILDE R 0 OWNER DATE PERMIT ISSUED 3 - 7 y DATE COMPLIANCE ISSUED��,a �_ 7c� �M ;--, , ` �� Q� r� � �� �; � � � � . v� _ � � �, 0 /� o�� � �� VV No. Fimic THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH L..(1 Cl - ................0 F.. ................................. ApplirFation for Uiipnsal Workii Tunutrur#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..... L.� am / ........ orati ddres Lot N Owner Ad s .......... ,Q.�..l.. . :....................... ... . ..... .. staller Address Type of Buildin Size Lot._ � l ..Sq. feet U Dwelling No. of Bedrooms.... -----------------------------------Expansion Attic ( ) Garbage Grinder ( 7'1y� '04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria Pa Other fixtures --------------- -----------•----------------- W Design Flow. ...............................gallons per person per day. Total daily flow...... .�f.................................gallons. WSeptic Tank Liquid capacity/al1P.gallons Length................ Width._..__.......... Diameter................ Depth................ x Disposal Trench—No. .............:...... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....L............. Diameter.10_.._..__..... Depth below inlet.... ff .._. ot�al,l"eaching area... ft. Z Other Distribution box Dosing t )/� n �w e-, Percolation Test Results Performed by..... =-•------------------------ Date.Z_:Tn .......... Test Pit No. 1....: ..minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___•-_____-_---_-___. �^ f / /� O Description of Soil-----....G�.-`--�1�. 1�sJ. f! .. 1,z... " .. ...- Q4!.. ..-C ......... ...4 .......................... W -•-•-•-•--••-•--•--•---•••-----•-------•---•------•-•---•---------•-•--•-----------•-----------•-•----•------•-•......-••-•••••----•-•--•-•---•--•••••••-•----•--•---••--•..................•----•---•- UNature of Repairs or Alterations—Answer when applicable.___............................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLILH �p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ' -•.........................•---•---....------•--------•---•••.----- Date Application Approved By....... Dat Application Disapproved for the following reasons: -----------------------------------•................................................. ............................................................................... .... ••- __•-------------------- _- --Y-----------` ---__----__.-------------•------- 7 ` � Date Permit No.... .... ........ ssu ...-----•---- Z_-...7 ------------- Date Y a Nl_ THE COMMONWEALTH OF MASSACHUSETTS BOARD,10F HPALTH 1...f✓. l>' ' ................o F.- mx,�--y.; �� _-................................... Appliration for Disposal Works Tonstrttrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at - oca dre Lo Na.� : ---- --r � ...- .. .:�....... ----• .......---••- Owne staller Address U Type of Build in/ Size Lot._ t�' __Sq. feet �. Dwelling K No. of Bedroom Size Attic ( ) Garbage Grinder ( : j %► Other—Type T e of Building No. of ersons____________________________ Showers � YP g ---------------••----------• P ( ..-)--- Cafeteria ( dOt er fixtures --------------- ------------•••-----•-•-•••----------'--•-•-••-•-----------•------------••------•---_.... WDesign Flow_ ................................gallons per person per day. Total daily flow_.___- __... .........._..............gallons. WSeptic Tank Liquid capacity/6944_gallons Length................ Width......_......... Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area____._.________. sq. ft. Seepage Pit No...../............. Diameter.�lt�___.......... Depth below inlet__._: :____ ._._.. otal leaching area._m _ sq. ft. Other Distribution box Dosing�t, ! U b.0­4 ! ' Percolation Test Results Performed by-___ � _ �:__. �_________________________ Date_. :" . ''_ _ ._...._... W Results, Performed per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No.' 1_._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rr f . ......... ... __.. Description of Soil___...__ �__ . 1�.... , ' d'`? :e .-• F ►--:------ V ----------•---------------• --- ............................................ UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -- ------------•---•-•-•••----••-•---------•----------••••••-•--•----- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign. - -•--•------------•••-------•• ..__.... ------- --•-- /'�� /� Date Application Approved By_.-. �, t,.�� =••- ,,:._....... �""' ------ 1 Application Disapproved for the following reasons: ---------------------------------------------------------••••-•------Dat ......•---•- ..................••-••-•---••-•---------•--••-----•--•-.._....••--------•••----••--••--•--._...•---•-....--•...----.._...-•••----------••••-----•-------------••-••----•-----------•••-------•••--••--- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........oF............... ......:.:._.:...................... �rrtifirtttr of f�ont�li�nr�e �,,,,�-- TH,h S TO CERTIFY hat th n ividual Sewage Disposal System constructed ( ) or Repaired ( ) by-•--- . �`r .._. -------- ....-- --... -•---....._ f/� y ..........� st�Jler has been installed in accordance with the provisions of T j of The State Sanitary C de-as desjib in the application for Disposal Works Construction Permit No•-._.__. _":_ _ .1.j_.__..... dated---_----------- .7--------_-_ THE ISSUANCE OF THIS CERTIFICATE(SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY- DATE.......... / u---•----? �1= --- Inspector......�C y V THE COMMONWEALTH OF MASSACHUSETTS BOARD O H�E�A,LTH .OF.............. ..................................... _.. No.......- _l_t...... FEE........................ Diopoo orkg Ton nrt' zrrntit Permission is reb .granted_:.... ' � -- .................••-•- to Const -ct (, t`lov epa/ir ( ) an In. �Id 1 Sewages s tem r Al Street w as shown on the application lication for Disposal Works Construction Per 0.....Z. a d..... . „3 7 --/i}F �c� Board of ealth ' DATE....----•-----------(---(/..�-•-----../----•.....................••--•--------- FORM 1255 HOBBS & WARREN, INC.; PUBLISHERS i c �. fit::-.s ��.-�...i.#'• � a .�..+.-..�...�� _ __--��.. .,+.r.�r.wwo..� ._ �• • IL b All t0`)Lt/o� E EGTI� tb� i ONilp3• 0, •� � � tee, �lsi', �o�C �� • • t l + 1000C;At� coast._ VA U1i to'4'SacaCP PUG — _-16EDt~odi'ur-- Cp—OW Pazq % `f o�� Sf9�y� ' WALTER fi o E• -- — A —S ,:15zz8JJ_ y. b S �. ,�ssoc 1 NC. t�l1�i��! < - �� �o �� t X rSTEP ,� SCALD d `— -o` PP—IL f . • [�IST.Bok a i / �1ct, Dipim I !c c: r r. �..�A.'.G•.1�1�.i-lr►JC� �►'►' 4-5,7S oar SF_P T I C T^wI c_ a ,car' 9 I"LI was�,�d:s- AMP Gor 48.E �, KA Dome LO: ' w fi = `' ''�` ,' �.C�b G �.. tom-►c Cfl� G pp 84m f Iu �•• .'� �t�ter:. , • 3�f N Lr38 Caf�,,+co"®,vs i TYPICAL SYSTEM . PROFILE AREA PLAN FINISH GRADE= 62-055 NOT TO SCALE it FDN TOP r FINISH SCALE : I 3� : FINISH GRADE: OVER TANK= .� GRADE OVER PIT= LOT - 3 OLD I LL ROAD-REGENCY DR I VE vLYNX HOL � .;�. ...:.��.. = C}a� PVC OR ® p �. ,.,4 9, J o • • • e a- �C. 1. TEES BSMT3 :' .- ., •�: o...•.4•.- 'o. • a::. • .•.o• 0 � e o • . • e • ° ° ;. FLR 1{ GAL. 4" A9. 2-5 ° • • • • • • o ° o e REINFORCED DIST. BOX • e +if , • • ® o 0 0 • o `' CONCRETE 8 > ° o • • • • • ° e o e TO BE INSTALLED ON o A LEVEL STABLE BASE ° ° o o • o 0 0 ® , a -., x 4$h t SEPTIC TANK • • e o # . •r • • e • ° ° i �0 �fx :3 x $' 40 TO BE INSTALLED ON A ° LEVEL' STABLE BASE • o • o ® • • • o e c. 2 -I/8 - 1/2 WASHED PEASTONE ALL o • • • • • ° • ° • • ' BRICK a MORTAR COURSES AS AROUND FREE OF IRONS, FINES ° ° ! • • e • o e o e �, �rwoff REQUIRED TO BRING COVER TO GRADE AND DUST lN PLACE LEACHING_ PIT r. �`7 24 "C.I. MANHOLE COVER Bi 3/4 "TO 1-1/2 "WASHED CRUSHED LOP` � FRAME - SEE DETAIL STONE ALL AROUND FREE OF - BASE TO BE LEVEL ' IRONS, FINES AND DUST-.IN I2.a PLACE I ` IV LOT 3 (�A) � I TH, HOUSE)— FOR FIN. GRADE SEE SYSTEM PROFILE SOIL AND PERCOLATION - -41 t _ DATA AV->P IZOA i t,�c,�,•T * U PRECA5 cor c1 LF\CHIM �„ PERC. RATE : � �. MIN.�IN. LOC,�a,T1 a N ` _ � � „ . . . - . _ — — , . --�•oT '- tE AT L 4 FOR INV. ELEV SEE L�.:.. .wETA.Ii» C. D. SPOHR r ; PIT INLET _ , . SYSTEM PROFILE TAKEN BY 0 BY: LINE ►����Wit" ,r����= �r ; • : : LINE 1' got . . WITNESSED BY, . OPENINGS W/4-1/8 OUTER:DIA. a 1 -3/4 ,; DATE. I A I o INSIDE DI A. TEST PIT-GND ELEV. ti e —Ik >w7 : 0 0 TOTAL 1 .rZ-ADI , `, I- • _ -4 ��E.M tt LIB! �[2$— !7.t) . 6 0 .0 ----- �� �} _.._-.m r _...�._ , , • . • ,AREA o :,_ V�G: �,tali I� :� t ,.� Y4 EN Am 4 o 0 r } , ti ter• > c I. T, 0 I sJ w 0 0 ICOO OAS -�, 2m o 0 F I - o t� '} i TiPIiP 1ST �46x • ' G 2 IN QA I 6 DIA f " EFFECTIVE D I A DOWN BOT PERC HOLE ]^• /� LEACHING PIT,. - SECTION + yy Ire I . NO SCALE DESIGN DATA : U. NOTE: DO NOT RUN HEAVY. EQUIPMENT OVER SYSTEM " NO. OF BEDROOMS DISPOSAL - y;_. LEACHING PIT NOTES: ' d � , , _ EST. TOTAL DAILY EFFLUENT GALS. �y�r� I CONC. TO BE- 4000 P.S.1 a 28123 DAYS . SEPTIC TANK GAL. 2. E x 6 GA. W.W. M. m* t .# ., 3.. 2 AND ;4 SECTIONS ARE AVAILABLE FOR GENERAL NOTES GREATER DEPTH' REQUIREMENTS ,. . ., �} � I . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN M NO NOT r ACCORDANCE WITH TITLE OF THE STATE SANITARY CODE EXCAVATE TO ELEV. OR LOWER AS ' --- DATED JULY 171977 8, ANY LOCAL RULES APPLICABLE. •.� 'e .,/"�I�,.:.,.., REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING . .. . t ; •,ry. y 2. ANY CHANGE TO THIS PLAN MUST BE APPRD.rBY THE Aa 7T" . ; a , }: MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL - ; - r_ f z ,,,, . - �. . BD• OF HEALTH AND CHARLES D. SPOHR. �- * , :,•. 1 �T .. :• ,CPC � - . _.. WITH CLEAN CLAY` FREE GRAVEL, MECHANICALLY -• ' 1 ;fI?:h 5. T I I COMPLETED P COMPACTED IN PLACE. . 3 WHEN CONSTRUCT ON S COM LE ED, PRIOR TO BACKFILLING, I L ,- ` ._ , TI FY FOR INSPECTION. L L NO THE ENGINEER 0 S I DE AREA S.F. 4 S.F.IGAL GALS ,��� r: -i}- 4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED. g BOTTOM A EA= .F� . R��'�.. �.; '..' ', $ , . _ . ., R S. S GAL GALS. .: .. . . 1�` . _,, : - ; _ . : • ,�- _,'.... „ . 5. THESE ELEVS: MUST 11I�OT BE CHANGED WITHOUT WRITTEN , a ,f A AREA �' :85 � TOTAL R A S F TOTAL GALS ��„ . .: ,. ,-,:• '' —� APPROVAL BY CHARLES D. SPOHR. ° r .: . w . . m r ... , 6. FOUNDATION E ,,,x 3,,.�,.... .�„�.� , LEGERID _ FOU TIQN INSPECTION .READ. WHEN EXCAVATED. ., .. . •�•, ._, ' Y 4 it�.::,. J ,..,.. �..rr ,t + 50.0 EXIST. GROUND ELEV.,. n yi • . ,..�.�� ,-'•-�k ,,�, �� �.;,�. 50.0 FINISH GROUND ;ELEV. ,UNDERLINED , REV. DATE DESCRIPTION 1475 0 PIPE INVERT. ELEV. • 0WI E S. �` LOT-&3 _ D TEST PIT LOCATION SEWAGE DISPOSAL SYSTEM „ FOR W H A L I�'t*I o O SEPTIC TAN K AP EA PLAN . - A L EXANDLER.- _L._ W HAL Ex DISTRIBUTION BOX ""`� 1 LOT •L I LL Ra, REGENCY DR. 1, lI � 4 C. I, PIPE , . .,, ,A STOIL m I L LSq •. -tttH-t-l-t-t- 4 BIT. FIBER PIPE -FIGHT JOINTS � , �brt ?: �Y r DESIGNE'Q: C,D.SPOHR DATE: D R A W I N G NO. -- - PROPERTY "LINE vf , DRAWN: SCALE:ASSHOWN � � • MAP SEC PCL _ LOT MIN. CODE DISTANCE '` cHECKED: C. D. S .