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HomeMy WebLinkAbout0060 CONTENT LANE - Health ^1 60 CONTENT LANE Cotuit I A= 040 -033 - o�fo-033 Commonwealth of Massachusetts Title 5 Official Inspection Form -1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =j 4 a � Property Address. J_,)a mfeVI Gvle, Owner Owner's Name l rr, information is b I /¢ Od-6 Z - required for every -- page. City/Town State Zip Code Date of nspection 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 forms A. Inspector Info Lion + on the computer, use only the tab tr Ld4A key to move your Name of Inspector � � � t— /-_. cursor-do not use the return key. Company Name O O J /0�� Ye - 6 -0� — L� Company Address 1�f A a %.0 W.;­ lcpr--- ism City/Town State � Zip Code Telephone L oer License Number B. Certification certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the s 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. :6insp.doc•rev.7@612018 ?ite 5 0`.fidai inspection=om Suosurface Sewage D:sposar system•Page,of 18 Commonwealth of Massachusetts - a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � O Coh- 4 L. 41 Property Address a✓1'e- Owner Owners /'� 2 information is /` 040, ���J� required for every page. City/Town State Zip Code Date of I pectirh C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System sses: 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: 2) 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): A I c5insp.tloc-rev.7R6/2018 Title 5 Of uai mspec'aon=or:Sucsurace Sewage Disposai System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments O �a� L Property Address -7 Owner Owner's Name Q information is O�14 O� /�� hh required for every � �! / page. City/Town State Zip Code Date oAnspAction C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 17 broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: [5insp.doc-rev.7/26/2018 ?ibe 5 Officiai:nspecon Form:Subsurface Sewage Disposal system•?age 3 of 18 Commonwealth of Massachusetts J. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 r..4..A Property Address Owner Owners Name d TNT /f/f� v�information is � /i ✓ ] r required for every page. City(Town State Zip Code Date of In pecy n C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections. Yes No B ckup of sewage into facility or system component due to overloaded or ❑ L'� 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 T',Ue 5 Official nspe=on Fort..Subsurface Sewage Disposal system•?age 4 of 18 t5insp.doc•rev.726/2018 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address U? Owner Owners Name �1 Q information is C04(0411 Vd6-?S /T required for every page. City/Town State Zip Code Date of Ind ectio C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No / ❑ �/ Static liquid level in the distribution box above outlet invert due to an overloaded t� .""or clogged SAS or cesspool ❑ ,LI_? " Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ;/00"" 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 u tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply [� 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 nd chain of custody must be attached to this form.] ❑ he system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑I 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—IW PA) or a mapped Zone II of a public water supply well • ?iva 5 ctfica:Inspection Porte:Subsurface Sewage Disoosal System•Page 5 of 18 t5insp.doc•rev.7262018 Commonwealth of Massachusetts Title 5 official inspection Form r Subsurface Sewage Disposal System Form -Not for for Voluntary Assessments Property Address GNP Owner Owner's Name � Dt�`'/� (' information is L4i b J required for every State Zip Code Date of Ins ectlo� page CityTTown C. Inspection Summary (cost.) If you have answered"yes'to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes ❑ ping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? Q as the system received normal flows in the previous two week period? rt Have large volumes of water been introduced to the system recently or as pa 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 ail 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)] Tilde 5'tdat 1n5p,.7 Cn Fon:Subscrface Sewage Disposal System•Page 5 of 18 t5insp.doc rev.7126/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments el o Co 04e0 Property Address G hel l ? Owner Owner's Name 1 QO� ✓information is N,1 04 required for every page. City/Town State Zip Code Date of Inspection D. System Information ,1. Residential Flow Conditions: 3- Number of bedrooms (design): Number of bedrooms (actual): .330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: doo 6,11em n - so_-� o Number of current residen ts: Does residence have a garbage grinder? ❑ Yes oeNo Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes �10 Seasonal use? Water meter readings: if available (last 2 years usage (gpd)): Detail ❑ Yes No Sump pump? Last date of occupancy Dace Site 5 Vidal!nspecoon=cm.sucsu`ace sewage D spcsa System•?age 7 of t8 .Linsp.doc•rev.71261201 8 f Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 - Cowk,4�- Property Address Owner Owner's Name information is /'�'A ,� S required far every � � b page. City/Town State Zip Code Date of Inspectio D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to.- Industrial waste holding tank present? Yes 7 No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): n 3. Pumping Records: 3 (�(,v�-✓ Source of information: Was system pumped as part of the inspection? ❑ Yes ' o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: [6insp.0oc•rev.72612018 noe 5 offiaai inscec on=orm:suos�rface sewage Disposal System•?age 8 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 ~`f Property Address aN� Owner Owner's Name C �' AIXO`ACt 63S n information is J ` 7 required for every page. City/Town State Zip Code Date of Inspect n D. System Information (cons.) 4. Type of Sy 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): Approximate age of all components: date installed (�own)an so�g of„nformati-3 & J� ory�0 129 /71 Were sewage odors detected when arriving at the site? ❑ Yes L_, o 5. Building Sewer(locate on site plan): l" 0 Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): 6 0 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): ciai inspeon Form.SUnLrfaCe Sewage Drsposai system Page 9 of 18 ori t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 C04-hot-k C; Property Address qN� Owner Owner's Name /' information is / � Q�63S required for every l� page. City/Town State Zip Code Date of Inspectio D. System Information (cost.) 6. Septic Tank (locate on site plan): Depth below grade: feet Materia 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 or certificate)_ ❑/YYees ❑ No J(' x. O Dimensions: ll -IL Sludge depth: �� fl Distance from top of sludge to bottom of outlet tee or baffle - sum 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 — How were dimensions determined? C Comments (on pumping recommendations, inlet and outlet tee ortbaffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): l✓1 on �oN ��/ovI • Title 5 Jffcal Inspecucn=ccn:sucsurace sewage Disposal System•?age 70 of t8 t5insp.doc•rev.7/25/2018 C Commonwealth of Massachusetts Title 5 Official Inspection Form '1 i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0" 'F�v�7' CV Property Address Owner Owner's Name oo-as /1 / information is � / (� T required for every page City/Town state Zip Code Date of Inspectio D. System Information (cost.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction.- concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 'Ti ght 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 Tile 5 cffiaa'.inspemon Fo.^:5uosurface sewage Disposal system•Page i i of to t5insp.Coc•rev.7126i2016 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i9i" oti-64� Property Address Owner Owner's Name ll / information is G4 I Qdb required for every -S page City/Town State Zip Code Date of Ins ctio D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): L Depth of liquid level above outlet invert C— 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.): x so - Page12of18 71qe 5 pifical!nspecnon Form.puosu'ace Sewage Disposal system t5insp.0oc•rev.7262018 4 Commonwealth of Massachusetts r. a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 o� h �- Property Address � N-e— owner Owner's Name information is required for every C O 4C41 page. City/Town State Zip Code, Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: t7 t leaching pits � number ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length.- ❑ eaching fields number, dimensions: overflow cesspool number: I ❑ innovativeiaitemative system Type/name of technology: --- -me 5 oflaa;:nspe,:uon=om SUDS,=ace sewage Disposai system•?age 73 of 18 Sinsp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 610 O✓l-levt� Property Address Owner Owner's Name -- D 1 / r information is C041 pF b J required for every State Zip Code Date of in pest n �� page City/Town D. System Information (cont.) 11. Soil Absorption System (SAS) (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): o ✓1 V1P/4 sit 4 a-e N ae Gt�i 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -,tie 5 otfaai Inspection Qom.suosudace sewage Disposal system•Page 14 of 18 t5insp,,oG-tev.728/2018 Commonwealth of Massachusetts Title. 5 Official Inspection Form qSubsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address G?N� Owner Owner's Name information isSA/W required for every _ V "V page. City) own State Zip Code Date of I spec n D. System Information (cont.) .13. 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.): t5insp.doc•rev.7/25/2018 True 5 Q`fioa Inspection=orm.scosurface se»age Disposal system-Page 15 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Co Property Address Q H Owner Owner's Name / /� information is 171 11T0d(0�;j required for every page. City/Town State Zip Code Date of I spe y n D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks.qp benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil * g. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I I i I Fro n I 009 'Il'oh Par 0 s ip /. VC 1✓S i I f+ ' Sell- 1 r« I i I I 4-�-30 i i I Time 5 officaj iospecaon-cm:Sutsurtace Sewage Disposal System•Page 16 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name r �� information is ct7 t required for every v Of bSAh Y page. City/Town State Zip Code Date of In pecti n D. System information (cons.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 'eet 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: Dare ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked with foal Board of;HrIth - ex-lain:!G0S /CST �OI,Q ❑ Checked with local excavators; installers- (attach documentation) ❑ Accessed USCS database -explain: You must d 'be how yo established the high gro4,10 water elevation: /f �H�qN ro k✓1 GN�'�'� /OC-w C. s07Z e� • S �s �oAE Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.doc•rev.7128r2018 `tie 5 071cal;nspewcn=crm:sjbsur?ace Sewage Disposal system•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ro _46, Property Address Owner Owners Name information is ��6,� required for every o N`� page. Cityrrown State Zip Code Date of Inspe tion E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. 01"C'ertification: Signed & Dated and 1, 2, 3, or 4 checked C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (F re Criteria) and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included ':tie 5 ofSoai insxcuon=0T:Suosurface Sewage Dlwosai System-page t 8 oft 8 L5insp.doc•rev.7/26/2018 �., TOWN OF BARNSTABLE LOCATION L o? �'Trh7' ��". SEWAGE -17�— c� � �3 VILLAGE C f'!L� ASSESSOR'S MAP & LOT 0-Id—033 INSTALLER'S NAME & PHONE NO. Jahh Ar �fp SEPTIC TANK CAPACITY ✓_, LEACHING FACILITY:(type) (size) eplX149 NO. OF BEDROOMS 3 PRIVATE WELL O UBLIC WATER\ UILDE R OWNER �ap4 l�14i�S� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes r c> No----217.11,6` FEB ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . N . OF...............................� �r!- ._... ............._......._. J- Appliration for Dtspuiittl ams Tonstrnrtinn runtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........................ ...__.--�..... ..................._.. . -------L40 ........................----e..... ........_.� ......................... Location-Addre o Lot No. ------------- :. ------. ------------------------------- -•--•---•------------•---•---•-•-.•---••--- .............................................. OW?e, .................................Address --••-•.......................•.Address installer Address QType of Building �\ Size Lot.._� Z_P._.__._Sq. feet Dwelling—No. of Bedrooms_____________ ........................Expansion Attic (N� Garbage Grinder Other—T e of Buildin p, yp g .__. ___A�_ill___. No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .._......_ w Design Flow..................___... _......_ allons per person p r c6.y. Total itpw.__.__.__.__.__..............................� gallons. G: Septic Tank—Liquid capaciliameter :.I b ,llons Length.``•a�-_- •_ Width..__._._ �.. Diameter___U..a__-_- Depth.. .__ •.•._�-' ul+. d w Disposal Trench—No.......� _4� Width___ Total Length Total leachin6 area...__.. s ft. ��7�' x P 1 �; g 1 t� a q Seepage Pit No____________________ .._...�.... Depth below inlet.... Total leaching area" q. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Resul�j Performed by.................. ...L,, _......__. .. ......_........ Date...... 2' .� ®.�_ .. a Test Pit No. 1....4........minutes per inch Depth of Test Pit.................... Depth to ground water-----P®___•ram fi Test Pit No. 2.... 4...minutes per inch Depth of Test Pit.................... Depth to ground water............. 9 �--------------------- --- - ---............_.....• -----•----•--•-•- -T.................. - --- -••--- O Description of Soil........... o.. ._ _rL____ _ SCi+i._..pm►��e_....... .- -•-- �0-- --_1 Z,•q.-- Th f-plq!?�. S�r> x , . --------------- 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 i ILE ;of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b is ed by the board of health. Signed....... ............ ................................. . .•. Date Application Approved By.......... ................ ......... °' ' Date Application Disapproved for the following reasons:............................................................................................................... ..............................................---------••-••............------••---- Date Permit No........ ®I 5 Issued .----•-••-------------------- Date No................_.(.....� C \� � - 0;�j FEE...................... I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH au�?.......................OF.....I........ �,ElILN .' .t!4 ..................... Appliration for Uiopoial Mama Timotrurtion Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: II e�� �, •Loocation-Addre �� ot�Lot No. _....... ............................................ ...........-----•........................... ..............---•--...•.....................• Owner Address W Insta!ier Address Q Type of Building Size Lot...`M...I...................Sq. feet U Dwelling—No. of Bedrooms............. Expansion Attic (�c� Garbage Grinder (�}� Other—T e of Building a yp g ....... . .._l�.>�.... No. of p ersons showers ( ) — Cafeteria ( ) Otherfixtures ....... �`�' ....................................._...... .... ......................... ...._...---• -•-•.......... . W Design Flow...................=-Ff5.-..... ........ allons per person p r c�y. Total it pw...............�> ©................ llons. W Septic Tank—Li uid ca acit .. - ,(�allons Len th.8�_ _ Width........ a_ Diameter...4 _ De th.- .-_ 1f �-� Ala P q. T P � �•u�'� g -• - - a----• P -•---� x Disposal Trench 'too.............�..... With._....._...._...... Total Length......._..,_----i__- Total leachingArea......_ ___ .....sq. ft. Seepage Pit ?�?o......I_...... �._. Depth below inlet....��v..._. Total leaching area....�Jl? ._...sq. ft. >ameter...... ... z Other Distribution box ( ) Dosing tank ( ). aPercolation Test Resul Performed by................ ..... .. Date......a Test Pit No. I....12........minutes per inch Depth of Test Pit_.....� .__... Depth to ground water.....!V.': .. 1J ccNa1 Test Pit No. 2.---1 h...minutes per inch Depth of Test Pit.................... Depth to ground water.............I......... ...................... .... .k... •--•...........................T--.----------- -I -- -- ------ 0 Description of Soil...........per o. ! 2.:.. .j ....Tc�Sca`la..�...Eoc�-........# .'06- 1 9:s — 12_,.d.... _.m Diy!►m. Sa+u� V .................•---.................................................................--•--•............................-••................._............................................................ W ----••••••..-----•-------•----•--•-...•................•--.....••••-------••----•-----......----•...-•-••--•----...•....•---•---••--•-•--•--.........•--................................--••............ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -----------------------------------••-----------....................--------.....--••---•---•--.......................-------•------........................-----........................••-•........... Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of TIT L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e issued by the board of health. 7 6_-3-9-.3 Signed...... L ..------•.................••••........................ .......................... Date ApplicationApproved By.....................•-••-----•••......................._..................---.................... ........................................ Date Application Disapproved for the�l'toie�ng reeasont�,t^=.- :: .. �.1 ..............................•...........................---_._. �.:.. ...........................•---•--...........---................-•-•---••-•---....................---•--•................--••----....------•-----•-•-•-.......----••---------------•--...---•-----._..... Date Permit No.... Issued....................................................... 3 )�j Date r / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH d..�....'V.....OF.........�...9..'�..w. .........................................�� (9rrfif irtttr of Toutpliana THIS IS TO CERT' •--- IFj,, That th� dvidual Sewage Disposal System constructed (�or Repaired by•-•................•------....._...../...-• --....a..... ji....60:..-•--•• .... -••.........................................••-••---•-•--••••............_......--••------••••. Installer at....................................................................................................................................................................................................... has been &Wle�irbacc r ii yy thepWwisions of TI IE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL IpjBE CM HUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. q DATE.......................i19 ;--.=...... •-----.............. Inspector.-....... ..I. ---•-- ...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o w.ti...OF............fJ. i1/ S._.T... ... ..sx' FEE........................ 73 "/75 Dispo,gal orko Toro ttdiort "prrntif Permission is hereby granted................-�•......-----` q�`v_..-•----•----•----.........-•-•----•---........................................_.... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System \T ................ f_ sweet as shown 6-,tf?e applAt9n for s ibis brk�'C istruci�o R� f-f No..................... Dat ......................................... ... .... ............... ................... •-- r— �............................ Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i AsBuilt Page 1 of 1 C., TOWN OF BARNSTABLE LOCATION L0-r o2 D o�7cn7- Lh. SEWAGE # ?3-17s— VILLAGE Cti°�lL� ASSESSOR'S MAP & LOT U-033 INSTALLER'S NAME & PHONE NO. �j4h SEPTIC TANK CAPACITY ./3QOG LEACHING FACILITY:{type} P t (size) 0'X1, NO. OF BEDROOMS 3 PRIVATE WELL O UBLIC WATER 1 _ UILDE R OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes i 0 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=040033&seq=1 3/13/2019 EL 49.6 TOP OF FOUNDATION' 20' MIN. - - 10' min CONCRETE CODERS 2.LA YER OF 1/8''-112" 4 7 2 f CONCRETE COVERS WAS ED STONE 12'ilfAx 4" CAST IRON OR SCHEDULE 40 4" SCHEDULE 40 P VC P v.c. PIPE MIN. PITCH 1 8 PER FT DIST 1 12° S=0. 02 Box M N. -rlAjflaA LINE ��5' MIN PITCH 114 PER FT. _' _INVERT D= j2 _S=O. 02 !'RECAST 19" 4 .. -- -- LEACHING PIT OR INVERT ' q o EQUIVALENT INVERT EL=^44.81 LEVEL 45. 06 o` b oe INVERT INVERT INIfER 3�4., TO 1 1 000-_GALLONS --1---. EL:=_�44^71 EL. 4 _54 EL.=_44.38 0 Q� ASHED STONE SEPTIC TANK W 0 EL. 38. 4 LEACH PIT �- 2' _ 6' "� ,T PROFILE OF z0'DIAM.--- SEWAGE DISPOSAL SYSTEM NOT TO SCALE BOTTOM OF TEST HOLE OR USES PROBABLE WATtR TABLE EL= _ 34.:8� SOIL LOG f WITNESSED BY: D. MIORANDI I HEALTH OFFICER - ALL ELEVATIONS ARE ASSUMED CrE'1VL''RAL NOTES TOWN WATER IS AVAILABLE PERCOLATION RA _ MIN./ INCH 1. THIS PLAN IS FYIR CONSTRUCTION OF A NEW SEWERAGE DISPOSAL SYSTEM. P�8029 2. PLAN REFERENCE L C. PLAN 22824 D, SH 2, LOT 20, BARN REG. DEEDS. DA TE' 3 .10193 DATE 3 30 93 3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM TEST HOLE 1 TEST HOLE 2 AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES D SICN DA TA. EL. 46.8 E'L. = 4 7.2 ! 4. ALL WORKMANSHIP AND ,MA TERIALS SHALL CONFORM TO D.E.P. TITLE_5 AND THE TOWN OF 'BARNSTABLE' RULES AND REGULATIONS FOR THE SUBSURFACE. DISPOSAL OF SEWAGE NUMBER OF BEDROOMS 3 5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN TOP & SUB 44. 2' SOIL 0. = N© 12 OF FINISHED_ GRADE GARBAGE DISPOSAL 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME, `UNLESS NOTED`BY FINAL CONTOURS. TOTAL ESTIMATED FLOW 330 OPO 7. ALL COMPONENTS-OF THE SANITARY SYSTEM SHALL BE CAPABLE _IIO__GAL/BR.,/DA Y x _: 3__ BR. OF WITHSTANDING H--.10 LOADING UNLESS THEY ARE FINDER OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING MED. SAND SEPTIC TANK CAPACITY 1 000_ ,SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING. UNLESS NOTED. LEACHING AREA REQUIREMENTS 8. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL EL=34.8 12' 12 EL=35. BE MORTARED IN PLACE. SIDEWALL AREA :5� GAL./S.F. 9. 'NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM : ARE _1.0� GAL/S/F DEEDED'OR ZONING REGULATIONS. 'OWNERIAPPLICANT IS TO LEACHING CAPACITY ('BOTTOM & SIDEWALL)_,.5 GAL. OBTAIN SUCH DETERMIIVA TIDN FROM APPROPRIATE AUTHORITY ( 3.14 X6 X10 X25 ,� f ( 3. 14 X52X1. 0 � 10, THE EXCA VATOR�CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES PRIOR TO ANY EXCAVATION. THE WATERGATE WAS NOT FOUND, THE GENERAL RES`ERVF, LEACHING CAPACITY _549- GAL. CONTRACTOR SHALL VERIFY LOCATION WITH WATER DEPARTMENT. RO UTE 2 FALMO UTH ROAD _-__- ------- �_-----_ ' T Ty --- --_ N62 4N?0"E' 160.00' 4- LOT 20 o / AREA .27,520. 0 S.F' LOT 19 � ASS. 'MAP 20. LOT 20 v O LOT ;21 4 7`8 58. 0' 4 8 ! 50.8' 51.2'--- i o PROJECT LOCATION 0 � � �� © _i 20 CONTENT LANE 24. 0 / 20.3 COTUIT 4' 7.8 13. 7 �\ SERVE Mll�t' 100 G L ; NAIL AREA SEP IC TANK 0 APPLICANT FRED DA VISON fN SE'T U10' �a \ y S ��� � �� 428-0084 TREE i 10' o - \ r TIC rT ``� �Y ASS ' 1 R i MIN. W / U �� Jor�N LL''� \` f \ P l � LANDERS-CAULEY r' UII' S0 00 ; Box ;�, o �' , Cron_ ° S62 48'20"W 160. 00' 101 YANK.EE 'SIR VEY CONSULTANTS 'n�FISTV �`�� 4OB INDUSTRY-ROAD _-_ 1=---�-----��._�.��_----- ss � UNIT 5, E T. � s P. O. BOX 265 MARSTONS MILLS, MA. 02648 CONTENT ROAD TEL. 428-0055, FAX 4,20-5553 AKA CHOKEBE''RRY ROAD. SCALE 1' = '30 DATE 4 2 93 PAUt. �s RE [REV- A. , mr--RITHEW N 4 No.3209f! P,�s ►ST Quo JOB NO. 50,2:94 � SHEET 1 OF 1 J s'oaac u►�as�