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HomeMy WebLinkAbout0508 COTUIT BAY DRIVE - Health 508 Cotuit Bay ®rive . cocuir CP �A 055 039 TOWN OF BARNSTABLE LOCATION SOR Carob Rc to -D�SEWAGE# ZO)C.- 4/00 VILLAGE Co-1 u -} ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 4r A FXCaya�-41 on- gTJn - DGS3 SEPTIC TANK CAPACITY f 000 qQJ LEACHING FACILITY: (type) �SOpgcthC.i C (2) (size) 13 x 2 S x Z NO.OF BEDROOMS OWNER -16.6n vats PERMIT DATE: I/- 1q• /G COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY At A2 : zo ,Z 0 I33- y216 „ B C3- 33'L " B 4 - 4 y''7,.- C,4v, 7 Dr, 3 Q c y _ c f' 1 No.4 014 Fee ®® THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes appuLation for V 08al 6pstem ConstTUttion PerZidual Application for a Permit to Construct( ) Repair U ade( Abandon ❑Complete System Com onents P P2;' ) ( ) P YP Location Address or Lot No o nvl r(RAYED e� Owner's Name,Address,and Tel.No. 7 Assessor's Map/Parcel 6,5 o b n 'Tal&n/�L 609`776-.33 2 3 Installer's Name,Address,and Tel.No. Diner's Name,Address,and Tel.No. Q�� &x CO v can 0h-�r77 )&53 fakeer e-crlv,nonme ial sn..362_I 7 Type of Building: Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 1 den U_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date (4- Number of sheets O2 Revision Date T Title 0 E / Size of Septic Tank e,;�0T 1(jr, t" ( / Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OK 2 10. 6 00 GZ 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 Boa, of Sign Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. C '09 ���� Date Issued l L/ No. " Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for i 08aY *pstrm Construction Vermit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ElComplete System Individual Components Location Address or Lot No. Q BTU/t 1/°` Owner's Name,Address,and Tel.No. Assessor's Ma /Parcel Robyn 7a-tan/a.ru 5Dh-776-,3323 p l l� I��ler's Name,Address,and Tel.No. Diner's Name,Address,and Tel.No. ca fr0n -50A-q 77-06 53 +Fa 7 D _ �- C3 �x va ,: hee nv,r'on/>7�� .5 � 3�z J� 7 Type of Building: 4 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) w' Other . Type of Building 1 51 U o— N`o.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 1 1 Tp- Ito Number of sheets o-)_ Revision Date Title ^- Size of Septic Tank ex)—q to�16W Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 2 U OK (2.) iD ,6 dU 90— Q rX-�S Date last inspected: y .t . 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 f e t . f Signed Date 1I Application Approved by J �.. Date Application Disapproved by Date for the following reasons Permit No. c �16C _`/Gd Date Issued 1 J LJ --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned((� )by n^ B`1 4; (_ _ vCC...� f�n at 5 6 LS W1 U (T B p� F(NI", has been constructed in accordance 1 with the-provisions of Title 5 a the 'for Disposal System Construction Permit Now k"1�� dated 1 Installer P 0 b f'.M T 72 I tF rO y Designer 4—10 hez-t`1 en,\I t r on m P.(2i 6J #bedrooms , Approved design-flow 3 3 f✓ gpd The issuance of this permi shall not be construed as a guarantee that the system will(,' nctio designedAx;l Date ( ( If/ b Inspector 1 N0. L{U CJ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted ✓a tfed to Construct( ) Repair(.), Upgrade( Abandon( ) System located at J V T (J t (> �L! kx. (010(T— 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:Construction must be co/mplet d within three years of the date of this permi' t. Date 1� ! J b Approved by 4 Town of Barnstable y�P�Of.VE r, Regulatory.Service5: Thomas F. Geiler, Director 3ARNSrABLE Public Health Division1639. w N ATfOPM�a Thomas McKean,Director -200 Main Street, Hyannis, MA''02601 Office: 508-862-4644` x Fax: 508-790-6304 Date: Sewage Pekmit#`�_ ;2� Assessor's Map/Parcel Installer& Designer Certification Form t Designer: `U LP�t. ( Installer: --�� f' `� 31(Z ��Q Address: Po (�u + Address: • r \)n( moo+�P�g�r. -A 0264, On VGA Ion was issued a permit to install a (date) (installer) septic system at 5 oe rolarr' taNiz— based on a design drawn by. (addres ) 1" I CI \4 1 F .dated -q-1 (d ( signer) _X I certify,that the septic system referenced above-was installed substantially'.according to the design, which may include minor approved changes such as lateral relocation of the distri4ution.box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was. installed with major changes (i'e. greater than 10' lateraf relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required was inspected and the soils were found satisfactory. "OF4q ,. ss DAV!D 9cycN D. Zeller's Signatur FLAHERTY, JR. N( NL., 7pR\gner's Signature Affix Des -e—s Stamp Here) r PLEASE RETURN TO BARNSTA 3LE PUBLIC HEALTH DIVISION: CERTIFICATE'; OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU; gAoffice forms\designercertification form'.doc Town of Barnstable P 4 S~ Department of Regulatory Services s 1ARNS NA a Public Health Division Date 10131114 MAE&& 200 Main Street,Hyannis MA 02601 lED MKS� Date Scheduled Time 1Z&I, Fee Pd.- Soil Suitailio Assessment for Sewage DiIsp osal Performed-By:sk� Witnessed By: ,, ,/ Y4 E LOCATION GENERAL INFORMATIO Location Address �/��(/O, v►7'-67 Owner's Name ^, ) &0 v;7L 144 t f Address S Assessor's Map/Parcel: ``5 //37 Engineer's Name NEW CONSTRUCTION REPAIR Telephone# ti. k Land Use Slopes(%) Surface Stones Distances from: Open Water Body / ft Possible Wet-Area A Drinking Water Well ft Drainage Way ?rl� ft Property Line, ft Other ft SIH+TCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands-in proximity to holes) Parent material(geologic) `�2 � /i lk • g /�- Depth to Bedrock Depth to Groundwater. St ding Water in Hole: / Weeping from Pit Fnce Estimated Seasonal High Groundwater " DETERMINATION FOR SEA ASONALUICH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soll mottles: Depth to weeping from side of obs.bolo: ln, Groundwater Adjustment fr. Index Welt-# Reading Date: Index Well ieval Adj.factor- Adj.Groundwater•Levol, PERCOLATION TEST Dgtt 1�Wd I-LV Observation IL Hole# Timu at 9" Depth of Pere Time at 6" N `� Start Pre-soak Time® Time(9"-6") End Pre-soak - & Rate Min./Inch G�. '• ' Site Suitability Assessment: Sito Passed Site Failed: Additional Testing Needed(YIN) A/ " Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIC\PBRCFORM.DOC �o �s DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soil• Other Surface(in.) (USDA) (Mansell) Mottling (Stnuctum,Stones,'Boulders. Consistency,%'l3ravell 69 L5 f rs DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Zr DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders., Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sol(Color gall Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. Ca Flood Insurance Rate Map: Above 500 year flood boundary No 4 Yes _ Within 500 year boundary No= Yes, Within 100 year flood boundary No-'X— Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? S If not,what is the depth of naturally occurring per taus materiall Certification I certify that on (•date)I have passed the soil evaluator examination approved by the Department of Envi onm tal Protection and that the above analysis was performed by mo consistent with . the required trai ' g,expertis d per nce described in 10 CMR 15.017. Date Signature t� Q:\SEPTIC\PERCPORM.DOC p o m _ m OFFICIAL U r- Certified Mail Fee nuru $ Extra Services&Fees(check box,add lee as appropriate) i rj ,Q r-I El Return Receipt(hardtop» $ � 1 "•0 I] ❑Return Receipt(electronic) $ PostRtatlC O []Certified Mall Restricted Delivery $ Here p ❑Adult Signature Required $ �� ❑Adult Signature Restricted Delivery$ h7 2016, :O postage A .. v U ru $ rya Total Postage and Fees U$p s — -- _ Robyn Teresa Talanian c 508 Cotuit Bay Drive r Cotuit, MA 02635 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. f^ associate for assistance.To receive a duplicate in Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipients retail associate. signature)that is retained by the Postal Service'" Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders. Adult signature service,which requires the ■You may purchase Certified Mail service with sigaiie to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mal®service. Adult signature restricted delivery service,which in Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specfed ■Insurance coverage Is notavailable for purchase by name,or to the addressee's authorized agent` with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on •For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcaded portion { of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply 1 1 You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Receipt:attach PS Form 3811 to your mailpiece; IMP09TAIFP Save this receipt for your records. � I ] Pss Form 3800,April 2015(Reverse)PSN 7530-02-000-9647 • • • / / D N C.omplete'items 1 2,and 3. ' a ❑Agent is Prictt your Hartle an�J address on the reverse X +-��•9 ❑Addressee so,thalt tnre can return the card to you. ® Attach this card to the back of the mailpiece, B. eiv ( nted N " ) C. Dat ofjj D livery or on the front if space permits. 1. Article Addressed to:— D. Is delivery address different from item 1? Yes Robyn Teresa Talanian If YES,enter defivery address below: ❑No i 508 Cotuit Bay Drive I CotWt, MA 02635 I II i lillil IIII III I I I I I II I III I II I II I II I III II III 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered Mailrm ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted 9590 9403 0521 5173 2829 20 ❑Certified Mail® Delivery ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation TM sired Maii ❑Signature Confirmation 7 01'5 t 115 2 0; 0 0 21. 2 2 7 3 3.401 `t l"`Ir$M it Restricted Delivery Restricted Delivery [—Ps--Form 3811,April 2015 PSN 7530-02-000-9053 Domestic Return Receipt UNITED STATES�SYACOERV CE L. First-Class Mail •'p".I' 7 Postage&Fees Paid USPS 3w.� •^ Permit No.G-10 Sender: Please print your name, address, and ZIP+4®in this box• M Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 USPS TRACKING# Pli01}"1.11 I'll I!7i1I'l,q)diiijiypiiliiiii1i.1l,ii{I,11111itla 4_ Town of Barnstable Barnstable Regulatory Services Department �" >�ST" gQ P , ' Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 3401 May 18, 2016 Robyn Teresa Talanian 508 Cotuit Bay Drive Cotuit, MA 02635 ORDER TO COMPLYENVIRONMENTAL . ,. WITH STATE E R NVI ONMENTAL CODE TITLE 5 The septic system located at 508 Cotuit Bay Drive, Cotuit,MA 02635, MA was last inspected on April 15,2016,by Patrick T. Sullivan a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: •. Static liquid level in the distribution box above outlet invert due to an - overloaded or clogged SAS or cesspool,. You are ordered to repair or replace the septic`system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. BEZURDER.OF E BOARD OF HEALTH e Thomas McKean, R.S., CHO„ Agent of the Board of Health r Q:\SEPTIC\Letters Septic Inspection Failures.or Future Ev1\508 Cotuit Bay Dr Cot May 2016.doc ' I •r`�' • THE T� - ' ^ ,_ ' Town of Barnstable, � ,bm Regulatory Services Department - Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX 508-790-6304 Thomas A McKean,CHO Feb 6,-2007 Rev. 7/6/15 DEADLINES TO REPAIR-FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) m"x"marked in the o is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground • k ❑Pumping more than„4 times during the,last year not due to,clogged or,obstructed Pipe ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of cesspool ❑Any portion of the SAS,.cesspool, or privy, below high groundwater elevation ❑Any portion of-the cesspool withiri•a Zone 1 to a public welI ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool + ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) o.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1): OTHER t Repair deadline: WSEPTICUEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Detail Page 1 of 2 1-7 Is#ah" x + mwt W lyy � le Logged In As: Parcel Detail Wednesday,May 18 2016 Parcel Lookup ' Parcel Info Developer "�""."." Parcel ID$055-039 I Lot LOT 27 Location L508 COTUIT-BAY I Pri Frontage 226 Sec Road 1 Sec Frontage Village COTUIT I Fire District 'COTuff Town sewer exists at this address NOYyI Road Index 10359 Asbullt Septic Scan: Interactive Map , t 055039_1 ���I •' r Owner Info Owner#TALANIAN, ROBYN TERESA I Co-owner ~ I Streetl 508 COTUIT BAY DRIVE I. Street2 I city COTUIT ' state MA zip 02635 Country I®J Land Info__ Acres 0.67` use Single Fam MDL-01 I zoning IRF Nghbd 0108 Topography Level I Road ,Paved Utilities Public Water,GaS,Septic I Location Construction Info gym_ Building 1 of 1 Year Roof . «. .. Ex ;, Built1979 I strua-able/Hip I Wall"Wood Shingle Living Roof- I Roof Asph/F GIs/Cmp .I T AC None I ;eas�1 iPTo Area Cover- ype ..281�: Style FRanch I Int DrywallI Bed Rooms t Bedrooms Wall �. Int Bath 1 5„ BMTT x�° BFif� � Model�ResidentiahI CarpetI Rooms 3 Ful l 0 Half Floor Heat Total I'"""..."".,�..�,..� �, « ��, 21 Gradeverage Plus I Type.Hot Air I Rooms 17 Rooms I Heat Found- stories 1 Story. I Gas I Poured Conc. I o-caB Fuel ation € Z Gross 6394 � Area Permit History _____.:.___-_�.�___. -- - - F Date Purpose Permit# Amount Insp Date Comments 4/2001 New Roof 53572 $8,000 10/19/2001 12:00:00 AM http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=3553 5/18/2016 Commonwealth of Massachusetts6� - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �tiM 508 Cotuit Bav Drive —- -- -- Property Address Rob nn Talanian .� Owner Owner's Name ~ CT9 information is � required for every Cotuit V, MA 02635 April 15, 2016 a _ page. CitylTown State Zip Code Date of Inspection SAD _ IOD Inspection results must be submitted on this form. In' may Inspection forms not be altered in an P Y Y way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return key. Name of Inspector --------- Ready Rooter Excavating Company Name -- -- P.O. Box 89 g T ' Company Address ' Forestdale MA J- -02644 — — City/Town --- -- — State Zip Code 508-888-5055 _ S112_843 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 of Title 5 (310 CMR 15.000). The system.- El Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority April 22, 2016 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 sentnttto the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use, t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 WVS 3 1 Commonwealth of Massachusetts _ u Title '5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 508, Cotui t B a r�Drive Property Address Robyn Talanian Owner Owner's Name information is required for every Cotuit MA 02635 A rll 15, 2016 _. _ page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.,304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years/old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration Or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. j ❑ Y ❑ N `❑ ND (Explain below): i51ns 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Cot_uit Bay Drive _ Property Address Robyn Talanian Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2016 required for every P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont. t� ❑ Observation of sewage backup or reak out or high static water level in the distribution box due to broken or obstructed pipe(s)pr due to a broken, settled or uneven-distribution box. System will pass inspection if(with approval of Board of Health): R. broken pipe(s) area e//placed ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below): ❑ 'distribution ox is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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 j❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t i j G) Further Evaluation is Requir 6by the Board of Health: ❑ Conditions exist which requir further evaluation by the Board of Health in order to determine if the system is failing to prot t public health, safety or the environment. 1. System will pass unl ss Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy tem is not functioning in a manner which will protect public health, safety and the enviro ent: ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is required for every Cotuit __ MA 02635 April 15, 2016 page. CityrrTown 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 absorptio99--system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a,,�tarface 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. j ❑ The system has a septic tank and SAS arid 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 wa er analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No M ❑ 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 M El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 99 P ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is required for every Cotuit MA 02635 Aril 15, 2016 - � page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd.. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section Q: Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 'the system is within�2//00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is locyted in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) 0,a mapped Zone II of.a public water supply well If you have answered "yes" to any gGestion 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. l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2016 required for every P 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? Z. ❑ Has the system received normal flows in the previous two week period? ❑ Z. Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth-of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information: For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD l5ins-•3/13 - Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 508 Cotuit Bay Drive. Property Address Robyn Talanian Owner Owner's Name information i e Cotuit_ MA 02635 Aril 15, 2016 required for every _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014= 153 GPD g ( y g (god)): 2015= 140 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): �� Gallons per day(gpd) Basis of design flow(seats/pers/e: c.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pre ❑ Yes ❑ No Non-sanitary waste discharged system? ❑ Yes ❑ No Water meter readings, if availaab t5 ins-3/13 117Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments, 508 C_otuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2016 required for every _ p 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: Ready Rooter records: Pumped 02/16/16 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — - Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 1itle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is required for every Cotuit MA 02635 April 15, 2016 _ 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 1980. System records on file at Health Dept_ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Na feet Comments (on condition of joints, venting, evidence of.leakage, etc.): Septic Tank (locate on site plan): 8 Depth below grade: feet Material of construction: ® concrete ❑ metal " ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.6' x 5' x 4.5' 1000 gallons Sludge depth: 3 t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is required for every Cotuit MA 02635 April 15, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness Distance from'top of scum to top of outlet tee or baffle 0" Owerfull Distance from bottom,of scum to bottom of outlet tee or baffle 14 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 and outlet PVC tees in place. Liquid level 8" over outlet invert. Tank has signs of being overfull. 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{op of outlet tee or baffle Distance from bottom f t ce b tt o sou to bottom of outlet t et tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, M 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is Cotuit _ MA 02635 April 15, 2016 required for every _ p page. City/Town 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 Ejl/fberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons / Design Flow: / / gallons per day Alarm present: ❑ Yes ❑ No Alarm level: j Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc:): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 508 Cotuit Bay Drive Property Address - Robyn_Talanian Owner Owner's Name ' information is required for every Cotuit MA 02635 April 15, 2016 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 8 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box is overfull. Liquid level above top of d-box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump/chaber, ondition of pumps and appurtenances, etc:): * If pumps or alarms are not in Working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located explain why: t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is __�_ Cotuit MA 02635 A ril 15,`2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6' x 6'w/stone ❑ leaching chambers number: ❑ leaching galleries number 11 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.): Leach pit was overfull at time of inspection. System is in failure and needs to be replaced with a new Title 5 Septic System. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration / Depth —top of liquid to inlet invert Depth of solids layer. Depth of scum layer Dimensions of cesspool Materials of construction / Indication,of groundwater inflow ❑ Yes ❑ No t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is required for every Cotuit MA 02635, Aril 15, 2016 — — page. City/Town 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 i/nsofdraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page_14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 508 Cotuit Bay Drive _ Property Address Robyn Talarlian Owner Owner's Name information is required for every Cotuit _MA 02635 April 15, 2016 page. CityrTown 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 � 1 I Form:Subsurface Sewage Disposal System•Page 15 of 17 f5ins•3/13 Title 5 Official Inspectiong p Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 508 Cotuit Bay Drive Property Address Rob ran_Talanian Owner Owner's Name information is required for every Cotuit MA 02635 Aril 15, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 — feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: maps.massgis.state.ma.us%oliver.ph p You must.describe how you established the high ground water elevation:. Slope to rear of property drops below base of leach pit. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 508 Cotuit Bay Drive Property Address Robyn Talanian Owner Owner's Name information is Cotuit MA 02635 Aril 15, 2016 required for every _ p page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. U � 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for 3igpool 6pgtem Comaruction 30ermit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System Dd Individual Components Location Address or L t No. c> CCJ 'E, ej(1l1 I d/r Owner's Name,Addres and Tel.No. Assessor's Map/Parcel x O`y _®_3�+, C I u( imp ` 4�1 Installer's N e,Address,and Tel.No. � 7 `333_T Designer's Name,Address and Tel.No. r� 16� 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 gallons per day. Calculated daily flow gallons. 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) `Rgo�"�, Date last inspected:" Agreement: J 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 Certifi- cate of Compliance has been is y t is ar ealth. ` Signed Date d f Application Approved by Date Application Disapproved for the following reasons Permit No. d Date Issued Za L 'No. o — 0 _ Fee (/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pplication for Migpogar braem Congtruction Permit t Application for a Permit to Construct( . )Repair( x)Upgrade( )Abandon( ) O Complete System D4.Individual Components Location Address or Lot No `50 '�Cl v t 60-Y d� r Owner'sNamne,Add� and Tel.No. 7 � [ Assessor's Map/Parcel Installer's Name,Address,and Tel No. 5�$) °3 �� Designer's Name Address and Tel.No. -S:� n wb� V , gon f,o x Cr Cat tv► v. 1e3 �3, Type of Building: h Dwelling No.of.Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallon per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date , Title �4 Size of Septic Tank'- Type of S.A.S. Description of Soil 2 r Nature of Repairs or Alterations(Answer when applicable) cao �, LYl `h i��r`t���. h �DY.; R Date last inspected: `El Agreement: i 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 Certifi- cate of Compliance has beenI'ssued--b!y this Board-of Health. Signetd !%,, Date (` �14 9 Application Approved by.. �� ��� r, Date o� Application Disapproved'fdr the following reasons Permt N �d ?�'j _ � Date Issued t HE COMMONWEALTH OF MASSACHUSETTS f U" B RNSTABLE, MASSACHUSETTS -�c . _ _�&ert�tf.tcate of Compliance 1 THIS IS TO CERTIFY, tha the O sit"Sewag D�P,4al System Constructed( )Repaired ( ( )Upgraded( ) Abandoned( ' )by .. ft-10 G at e�006 a C ea 1 P)QUI ale has been construct'd in accordance with the provisions of Title 5 and the for isposal System Construction Permit No. -U(Jq' W / dated U Installer ' t-.�.m... Designer n n The issuanc of this permit hall not be construed as a guarantee that the sy`em i)9 function s deb fined. Date I �'v w Inspector • -- F� i, t J No. )—' �---------------�--------- -Fee Jy) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 33igpogar bpgtem Congtruction Permit Permission is here.•by granted to Construct( ' )Repair( K)Upgrade �)Abandon( ) System located at r G� �n f'"6 tE at t/ 'Dr C.CSI V1�" t and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons ction must be completed within three years of the date of this lF-e'n- t. c Date:_ y � P-I At/ Approved by I v 39 J DATE: 3137104 PRO-PERTY ADDRESS:_508 Cot_urt_./3ay_Da- ---__ ------------- R ECE��Ep a2-63-8------------------- APR 14 2004 On the above date, I inspected the septic system at the ab 7-0wN ve 'pTABIF This system consists of the following: 1.. 1-1000 ga eion zept.ic tank MAP 2. 1-d.izta igut.ion Sox 3. 1-1000 gaigon paecast ieach.ing n.it. PARCEL Based on my inspection, I certify the following conditions: J 4, th.iz .iz a t.iti.e efive zept.ic zyztem. (78 code) 5, the zept.ic .3y.6tem .iz .in paope2 woak.ing oadea at th.iz time. 6. ieach.ing pit -iz day with a 48" zta.in eine P,eeow .inveAt 12iRe. SIGNATURE: _ Name:_J.p_ Macomber Jr____- Company: Joseph-P. Maco.mber_& Son, Inc . Address: Box 66 _-Centerville , Ma.-02632-0066 Phone: 508-775-3338 rt. 7 THIS CERTIFICATION DOES NOT CONSTITUM A GUARANTY OR WA1t AnTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIR.ONmENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A V. TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 5 n R r n t„i t 1�GC r� bU2 rnfiilty IIcc�Sb ' Owner's Name: F Q Qgn fro-efae Owner's Address: Date of Inspection: 313104 Name of Inspector: (please print) jo z e 2 h 70, (4a c o m&ea a2. Company Name:. l,.8acomF­e2 9 .S:.on Inc. Mailing Address: Cen teay.c e, azz. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 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 15340.of Title 5(310 CMR 15000). The system: Passes X Conditionally>Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Dater &LL ,31 y 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 owrier.shall submit the report to the appropriate regional office of the DEP.The original should be sent to-the system owner and copies sent to the buyer,if applicable,and the approving. authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 l OFFICIAL INSPECTION:FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 5 n R r n lji 1 f 1?ri y 17 -�A 469 4 4. Owner: Date of Inspection: 3,131104 . Inspection Summary.:. Check.A fl,C,D or.E/ALWAYS,.,complete all of Section.D .A. System Passes: . Q 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:Tho .SO,nfic AUAI1 RM iA 1n 12n.n.12vn wnl7kina o zde2 ai_ B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or- repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not-determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic.tank is-metal and.over.20 years old*or the septic-tank(whether metal or.;not)::is:structurally unsound,exhibits substantial infiltration or exfiltration.,or tank failure:is.imminent. System.will pass inspection if the existing tank is replaced with a complying septic tank:.,as approved by the Board of Health: *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health); broken.pipe(s)are replaced obstruction is removed distribution box is leveled or ieplaced ND explain: Roo;L6 is dizbzigt utioa P.ox. The system required pumping,more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: _ 2 . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPPCT10N:F0RM PART A CERTM- CATION'(continued) Property Address:5 n u r a f t, 14 arj� p ; Owner:. Etten P ' Date of Inspection:3 C. Further Evaluation-is Required uired b the Board of Health: 9 y Conditions.exist whichrequire further,evaluationby-the Board.offHeaith:in order"":toAttermine if_the system is failing to protect public health,.safety or the environment. 1. System will pass unless Board of.Health determines:in aec'ordance 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: Jno►o Cesspool or privy is within50 feet of asurface 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).determines4hat the system is functioning in a mariner 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 withint.50 feet of a private water supply well. The system has a septic tank and SAS and the-SAS is less than 100 feet..but 50 feet or.:more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be.attached to this form.. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOTTOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM:INSPECTION FORM PART A CERTIFICATION(continued.) Property Address:5 g Owner: C g gg.q JQgah g Date of Inspection:3/3Z• ;4 D. System Failure Criteria applicable to all systems:. You must indicate,"yes".or"no"to.each:of the following for.all inspections: Yes N _ Backup of sewage-into facility.or system component.due to overloade&or clogged SAS,,or cesspool 90 Discharge.or:ponding.of effluent-to the surface•oF.thaground.or;surface:waters due to an:otyerloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due Iola overloaded or clogged SAS or cesspool _ Liquid depth in-cesspool is less than 6"below invert or available:volume is less than'h•day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped d 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 as cesspool.or,privy is'within e Zone`1 of&public well... Any portion of a cesspool or privy is within.50 feet of private water supply well. Any portion of a cesspool or privy.is less.than 100 feet but greater,than.5.0 feet from a private water supply well with no acceptable water quality analysis. [This system..passbs: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..fr..om:.that:facility.and.the presepeeofammonia 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.] (Yes/No)The system fails.I have determined that one or:more.4o€the..:above.failure.,criteria exist as described in 310 CMR 15.303,therefore thei system.fails.The system owner.should contact the Board of Health to determine what will be necessary to convect the failure. E. Large Systems: . To.be considered a large systemahe:system must serve.a::facility with a design flow of 1,0i000 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 the system is within 400 feet of a surface drinking water supply _ ►V�� the system is within 200 feet of a tributary,to a surface drinking water supply _ NO 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. Page 5of11 OFFI7CIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SURSURFACE'SEWAGE RJSPOSAL-SYSTEM:IN p"ECTION FORM PART B CIIECICLIST Property Address: 5 0 8 C o.t_ L 11 13a u da. Owner: Date of Inspection: 3 Check if the following have been done You must indicate"yes"or"no"as•to each..of the:following: . Yes No — y 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? Have large volumes of water been introduced to the system recently or as part of thisinspection? Were as built plans of the system obtained and examined?(If they were.not available mote zisN/A) x _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? k 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 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 n'9 Existing information,For example,a plan at the Board of:Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J • s Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST X INSPECTION:_FORM PART C SYSTEM:INFORMATION Property Address:g n R C n t t Le a e;cLct, ro#ua�, P1n.s.s_ Owner•FPpo n i?a r h o Date of Inspection: 3/3/_/0 4 .� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN.flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ?�-i 1 o=3 3 0 g. P. D. Number of current residents: 1 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage.system(yes or.no):,-tee [if yes separate inspection required] Laundry system inspected(yes or no):ryes Dy 1 Seasonal use:(yes or no):no_ ZoFj�.= StI00 q reIIuhS_6. P 0 — / Water meter readings,if available(last 2 years usage(gpd)):dLD3 z"3Q1 gO&M5 6-,P, 0 'I c/ Sump pump(yes or no): Last date of occupancy: C M OM ERCIALfINbUSTRIAL , Type of estabj�hment: n..� Design flow(biased on 310 CMR 15.203): nQ gpd. Basis.of designflow(seats/persons/sgft,etc.): Grease trap present(yes or no): o Industrial waste holding tank present(yes or no):-A Non-sanitary waste discharged to the Title 5 system(yes or no)na Water meter readings,if available: nu Last date of occupancy/use: . na OTHER(describe):. na. GENERAL.INFORMATION Pumping Records Source of information: a• P. llacom&e.zRSon 12uml2ed tank 8127102 Was system pumped as part of the inspection(yes or no):__&o If yes,volume pumped:_gallons--How was quantity pumped determined? n Reason.for.pumping: n¢ TYPE OF SYSTEM y_"Septic tank,distribution box,soil absorption system �zn Single cesspool _aa Overflow cesspool .¢o Privy a Shared system(yes or no)(if yes,attach previous inspection records,if any) 1a2 Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) a Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1nhk, rJ.;Ain1f.ufinn f.nx, Ponrhing nif 1979 Were sewage odors detected when arriving at the site.(yes or no):_ 6 III Page 7ofII .OFFICIAL INSPECTION-FORM.—,NOT FOR VOLUNTARY ASSESSMENTS SUBS- 'ACE SEWAGE DISPOSAL SYSTEM,YNSPEC'TION FORM PART C " . SYSTEM INFORMATION(continued.) Property address: 508 Cotu.iL 13r„/;. d z. Owner Date of Ins:pccilonr �0:- ._•_,,_^._ BUILDING SEWER{I:ocateon site plan) Depth bclpw gmdc: Materials of construct on:-.4-W-031 iron . .-40 PVC Xother(explain); Distance from pr Yau wo*supply well or suction line. Comments OR condition of joirus,venting,evidence of 45e,ctc,): o.intz u . eaz .t.i ht. No gviagnCoins vented th zough .the houze vents. SEPTIC TANK! y(locate on site phut) th.b.cl e: n _ Dap o grad 6.,,_.._,. M.ucrir{.of conswction:,�,,concretc„,,,metal;,,_,fr-berglass,_,^polyethykna. It wdt is metal 11s1 ap, !s ale conCirme.d by a Ccr3lf5caie©t`Cgrnpl.anec(yes or no)* (attach a copy of D{rncnsions: P, 6, Lwm 4 !ro w• e. S �/ �. Sludgy depth: ];rc-� . Distance from top of sitidge to bottom of'outict tee or baffle: Scum thickness:j 00'6a-,l,, r Distance froth top of scum to.top of outict tee or baffle:ILML-P-_ Distance.r om bottom of scum to bottom of outlet ice or baffle:_ a How wire dimensions detctmined: >k9� Comment;.(on purn.pin.g re.vommcnclations, lei and outl t tee Orbaffie.condition,structural integrity,liquid levels i s related,to out.1.0 invcn,gvi:dence of•l*.sgc,etc* puma I - T i-(zrP h p. (/I7k JA Ai nl/r i r� 0e�/ �i�:rn i•`.t �in�� .c{�n�i n r.a 4-. , G...a �.._ evidence o� ieaka�ge. f GREASE TRAP: ' 115�(locate on site plank Depth below 8744t::1YD. Material.of onsuvition:u-concratc imetalufiberglass apolycthylcne,,other (ex.plain): D.imcnsion's Scum thickftcssi NA Distance tom top of scum to top of outtel(6 yr baffle ?' Distance from bottom of scum to bottom of outlet tee or baffle: Date of last ptunpw.j: Comments(on pumping recormondatigcts,.inlet al'td outlet tee or baffle condition,sncwnl integrity;liquid levels as related to Outlet invm,evidence ofae4knc,etc.): (inbn.to fnnn nnf nno.cn»f Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SIBSURF,A.CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: _508 Cotu.it / ay da. ( nf�ii rzAA Owner:- F-P-1 an Ro the Date of Inspection: 3 31W,10�4< TIGHT or HOLDING TANK: (tank must be pumped at time of inspe'ction)(locate on site plan) Depth below grade: ,\ Material of construction: concrete metal fiberglass---polyethylene other(explain): Dimensions: Capacity: gallons Design Flow-: gallons/day Alarm present(yes or no): .Alarm level: Alarm i:n working order(yes or no); Date of last pumping; Comments(condition of ai.arm and float switches,etc.): tight oa hoed.in .tanks not /22ezent. DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no 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.):. rU,ALziLLLLion fox has two &teaa.P.s. no evidence o� zo 2.id s ca zay ntaud.inu Sox Nezdz to Re ae/s ace PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or.no): Alarms in working order(yes or no): Comments(note condition of pump chamber condition of pumps and appurtenances,etc.): 12UM12 chamge2 not /22ebenZ. 8 . i Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 508 C o t u.it Bay 62. Cotu.i.t, Owner:. Ei en /2o the _ Date of Inspectic a-, 3/31 SOIL ABSORPTION SYSTEM(SAS):_-(locate on site plan,excavation not required) 1-1000 pn.P n A,?ornAf Pnrinh �nif If SAS not located explain why: Type leaching pits,number: 1 ao leaching chambers,numbers _0a leaching galleries,number: {1_o leaching trenches,number,length: Aleaching fields,number,dimensions: overflow cesspool,number:. 4a 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.): --� .Foamy .sand .to dine .3and. No evidence o�l hiadzau.e.ic ;a.i&,zle 02 .Rond.ina. So.iiz aae d2y. Vec�e o i_h o�m�i P. 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 cesspoo Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ce z12oo es aae not /zae sent. 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.): P'Zivy .is not /laeient. °9 r i Page 10 of 1:1 OF` . CIAL INSPECTION FORM T*NOT FOR,VOLUNTARY.,ASSESSMENTS S BSUREA:CE SEWAGE-DISPOSAL SYSTEM.INSPECTION:FORM PART C SYSTEM INFORMATION(continued) Property Address: 508 r o bj i f d/t. Owner:u z e n R a c h o Date of Inspection:3/_3.1 40-1,L-_ 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. J r- -- h Y G 67v /7 f/AY dR. -10 Page 1.1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C' , SYSTEM INFORMATION (continued). Property Address: 508 Co.tu.it Bay d2. Co1u, , Na z, ` Owner: Date of lospection: ��4. 704 ;.. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3s� feet Please indicate (check)ali methods used to determine the high ground water elevation: i ; —Obtained from system design plans on rec'orld r if checked,date of design plan reviewed: _ Observed site (abuning property/observation hole within LSQ feel.of SAS) —�—' Checked with local Board of Health-explain: Checked with local excavators, instal ers• attach documentadori) _Accessed USGS database-explain: P:�� ToWYI You must describe how you established the higgh ground water el vatlorj, u.aed: Qhe2.ty & Ni.e.�e2 Modei IV 1 /94Gaound waze2 eie-va.t.ionz agove sea .levee used: QkAafluaiion wep.e data une7�V2 -- —_ used: Tonhnie-nD /3,1_�,PP; .jn 92-000- Ipea:te#2 A nnud i 2angez o g iag aQga,rttf ;nnA 9nnuaitu 1992 r up ur vroUn ------------------ 1 Leaching Pit II :cc( Groundwater: t cct Below Bottom of Pit High Groundwater Adjustment i.8 rt per Frimptcr Method nerefore, the vertical.separation distance between the bonom of theleaching pit and the adjusted groundwater table is 1I �:!•T.nT,.^/,,'ITr—.T^ iR:Rn'n TTrtITT'rd•t+T.T•.1if•.�'T TJTT:TiTrir:TT TTSTZit1'A'4'T�C'r:RTt . .T'R•TlT 1f�*�..�-,r� TOWN OF Barnstable WARD OF 11EA.LT11 � SUBSURFACE SEWAGE I)ISf'OSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ...�....T..•..•: ^�. .��rnmrm•rt'frT+t�':r.sltlTlTr•.r5'r•tn+l�an'mr-!�"TRR�:rs m'NImTST�R'RT7 t�fnl•mrRr'STr*TR+r'rrr•.+•trrr•r•�• •�..� -TIP! OR PAINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 508 Co u.il_ Rau ra ve ASSESSORS MAP , BLOCK AND PARCEL # 055-039 OWNER' s NAME PART D - CERTIFICATION _ 1 NAME OF INSPECTOR Joseph P. Macomber Jr COMPANY NAME Joseph P. Macomber &''ion Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Tovm on Uty Stet• CIP COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at Idorpolankthis address and that the information reported is true , accurate , and omplete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne ; f .ram � � i ,:e... • ZSysteM PASSE y= ' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I hflve eo U*0 ted has found that the system fails to protect the j)ilblic health and the environment in accordance . with Title 5 , 310 CMR 1.5 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form., Z�Inspector Signature . Date% ff � - �:. Cn6e copy' of this�,�cificati.on must be provided to the OWNER, the BUYER ( where applicable ) and Che BOARD OF HEALTH, * It the inspection FAILED , t<hNe owner or "O-pGrator, shall upgrade ' the eyetem within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 , L partd . doc n ��WAuE; 1N5r1":<1'IUNS LOCATION . D�s� , ,r DATE Q VILLAGE_ ASSESSOR'S MAP & LOT USS0 3 C, .INSPECTOR,3cueP ((Fn//'? IIIst-2r SEPTIC TANK CAPACITY dt UCk� ( rc`/rn LEACHING FACILITY: (type)!/J e0 G. Pi � (size) DO NO. OF BEDROOMS-3 BUILDER OR OWNERI:LEL �OClrl e OWNER MA/I�LING ADDRESS W s �' C Olt) 17 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L-. .V.#0.................0F...... .. .... 17. ', /- ........................... Appliration for Ui iposal Works Tonstru.riinn Vamit V/ Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst t: ................................... ........... ..--•------•---_.. .........� :.................-----........••------- 8 Loca s C Lot W Owner Address ,-� ......................... _ :...— - ---------- G� i�lf/.� .5 ----------­--------- In it Address lel Type of Building ,� Size Lot__�SXj.4_f__K....Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures --------------•--•-••-•------•-•- �� ��..... -- Desl n Flow......................... : ... G gallons peropcTsen per day. Total daily flow............................................gallons. . 1:4 Septic Tank— x Disposal Trench iqu�d�capaclty./...._Widlthns LengthTotaLength idth....-- Diametery_. Tal leaching area__-I..epth.....q:=.ft. W Seepage Pit No........ ............ Diameter.......e�d....... Depth below inlet.................... Total leachingarea �C._s . ft. Z Other Distribution box (� Dosing to ( L , q Percolation Test Results Performed b ____-_.. - - . 0, n 'l S Date._' A �'.22 Y --------•••------•---• ................... �''l �I .. �e_5 P Test Pit No. 1.j^,,,_minutes per inch Depth of Test Pit......l9........ Depth to ground water_... d,�._ (s, Test Pit No. 2gt__Q•__minutes per inch Depth of Test Pit__ __. Depth to ground water________________________ O �... T /a.�................... ,fin ................ Description of Soil-----._.._Q.:-�°� 6�..•-• ----------------------•---.-------••-- w •- VNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation ufitil a Certificate of Compliance has been issued by he d of he th. Signed_ . J��G ------ - _. Date ApplicationApproved By........ .:��..._................................................................•--•-•. ---------•- " ?�•-- Date Application Disapproved for the following reasons:-------•--------------•-----•--•----•------------------------------------------•-----•-•---•---•--........_..... -----------------------------•-----._.....---•----------.._....------------•----•----------•---------------•--•••--•-••-••---•••-•-•----••--•----------••--••--••--•---------------•------•--••••------- Date Permit No--- ---r�----•------- ------------------- •-------- •... Issued_..-------•--.�! •1 ............................ ' THE COMMONWEALTH OF MASSSACHUSETTS t. 4ti BOARD F HEALTH C .. .................OF. Appliration for Bispvii al Works TonlitrWiun prififit Application is hereby made for a'Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System�t: ... G°' ..... ...... ... ._._._... ............ ........------•--....................._. Coca s �j o Lot o J ......................___... .._...-•--•-• .-• .{•----•---- ................................................................._....:..._ Owner Address a - - .: .. ............... .••--------------C'�C .1fic�J 4 ___-_............................................. r Ins alle Address dType of Building Size Lot._2_2,__S�% ...Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `k Other—Type T e of Building ...____ No. of persons............................ Showers CtiI YP g --------------------- P ( ) — Cafeteria ( ) aIOther fixtures .................................... --•••--•---•-•---•................... W Design Flow........................./, .td.__..gallons per per day.. Total daily flow........_.__.__..__....._-.____ ...........gallons. WSeptic Tank—Liquid capacity!Oqgallons Length....... . ._ Width.............. Diameter......._........ Depth...... x Disposal Trench—No. .................... Width.................... Total Length_..___._.._.r __ Total leaching area....................sq. ft.. Seepage Pit No.........0........ Diameter.....:._���........ Depth below inlet........ ......._. Total leaching area.... _.sq. ft. Z Other Distribution box ( Dosing t n� Percolation Test Results ; Performed by........ !` S Date.. V.,P*2_ ,r a Test Pit No. 1_.� _�.mmutes per inch ' Depth of Test Pit______ _________ Depth to ground water--- .-/ . _. (14 Test Pit No. 2_�_;__Z...minutes per inch Depth of Test Pit_._ :._. Depth to ground water........................ W ---'-p:....... ..... ..................._.._ 1 D Description of Soil.......... _ __ _._...__ .�'"---• -- . ' `.. - ................ . . - x W ---------------------•- -• -�,,2- / ':� - ---•---------------------------------- U ----------------------------------------------------------------•---------------------------------------------------..........-_._...._..----------------------- Nature of Repairs or Alterations—Answer when applicable............................................................................................... i, ------------------y....•-•--•---•--••-•--•--•.._..----••••-••-••••---••---•...••-----•--••-•--••----•---•••••-•-•---•-•-.......--•--••--••-----•-•..---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL:_ 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. �l Signed.... ...• r.... . .... ........•.... •-•-- Date Application Approved BY f -°. ..._ --- -- ------ .._ ._ 1� # n Date Application Disapproved for the following reasons:.............................................................................................................. -•..........................................•------•-----•-----------•-•-------------•-----•---------•----•--•-•••-•••-•-•------•-••-•-•--•=-••-..._••••--••------•.................................... Date ` !f f� ? ., Permit No....:�.��.�=-----------------------------------------_ Issued.--------.......----"--•---------.....----•------------ �,' Date THE,COMMONWEALTH OF MASSACHUSETTS Fy '" BOARD OF HEALTH ......... GG`"s"........OF.....' ,9li,e sT/EY�z'�Lr. ;x ....................................................... .. . �rx#ifartt�,,itf flrant �i�anrr ..; THIS IS TO CERTIFY, That t In"�idu evyage Dis Ssa S stem constructe3 ) or Repaired ( ) bY-------••---------40'" .....-- . �� ��.�1�-'? -� #---••--•--------------------------•---...._...-----....----._...._. Instal' at ---•... el�_.�tr.. r f'�p ,gad'V - _ ....14 c has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No == : ..4...__ �'.- .dated 1!..A_ . THE ISSUANCE OF THIS. CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........: .. ,2-0- 7 �. ...........•••••-----•-•--•--_... Inspector........el _._It ' '4 THE COMMONWEALTH OF MASSACHUSETTS,, BOARD OF� HEALTH l 7 ?� �� tits :......OF.................! ��YSIr No._..... 3!: .. FEE....r':. ............. �-. a.. �i��r���al ��k� �nn� n �era�ti • Permission Is hereby granted........__--�f1__�..__-------- r_.��age_..��•.�`.. - ----- . ...................................... to Construct ( ,) or. Repair ( ) an Individual Sew Disposal System Street as shown on the application for Disposal Works Construction Pe011. rriut No � c....... Dated .._ � .. t., ." Board of Heath DATE _.:... / ;;•; _--• /ff ,'FORM 1255 HOBBS & WARREN, INC., PUBLISHERS .� t �,.,5'�r� f .x d x�� 7 • •k. Jk - ( .�' > 1 7 ... 4 y "' P r�., yyi�"�AF`(��E �4+" + .f:.. R t, }- 4 N; �' Al i Ye x'"'�t'�* ri'�� 1' k� " 5 » 2,1•.• j r,, ':d� �ir 'w r to tp s}r� w 1a.� ,�d I y" k r i r 'F f. -O' � i 1l � t •, �' i { �' .. 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LAND SURVE . , 00 PL•l # , t •i 1 ' hy. i , �7-a R ,�,, .SEPTI 7'.41itlA DR C GE.�►•cH/VC7.-A—N .4:A'Et MORE THAN /2"BELOW /r9/ p, 'xr, oi�il®E .A ¢ ,D/.4M ET.Lc�' G'ON '.�'1FTE CO 'Sm .4'4 B.E 'avoiGTA:bE.�A/V.EXTRA 1 tit=y 4~P1/C P/PE r CONC.R!'TB hrEAVY CA ST IRON COk✓�R Sf�.4LL QE USE/ w CIC /OG MIN. T P/ CN COWERS � , 74 1V _C'ONGRLCTE a T •� � 45 •4oE :;COVE=R CLEAN .SANG �J r • � RO N S c+�z�ti • ,6 M'/N. P/�TLN. GAL. " % y.,o •.�.�,,;_ • • • • p •� o. Y _ %4"PAR vT S,EPT/C TANK _ ST o WA Sh/FO STIJNE' D/ I • • o • ' • • • • • p o n 5 or FFECT/VE . ? ' . _ • ° o i 1 e DLPTN • • 1 ' `��o 1'V SH TONE �•...e yra+. � e v • 1 • i • • • • • • p ` n c -, - n ° • • . e • • • • • p — PREGaST.S'F�A^ _nj a v• ° ••Lp - lNVeA-r &r4ZI1 T/ / �3�5 a o • • • • • • • • • e. o P/T`OR "U/V A oN s /� e v p a4 INVERT A7' ?//,ii.n/N// S QG— FT. VIA . y� C EE TABULATJO/V> -'INLET SEPTIC T.4NK 3 FT•. O/JTLET SEPTIC TANK 4f3.3 FT.' - ' INLET D/sTK/d(/T/ON BOlc r� © FT � �*_ r GiQpuNO {4�iTER TA(1L .. Y yOF' • E OUTLETD/STR/BUT/ON BOX '9 F7 t S�yyAGE O/SP4SA L SYSTEM 4 ss INLET LEACHIlVa P/T�` 9.s'Fr, � t L EACH/NG P/' TASIILATI ` Sc.4LE % • /� .D.. p/MEN.SY o1v DES¢ GN C.ri i i cr. .r► 3 a *v 40/MEN540 O/MENS/ON- G FT. NUMBER OF BEDROOMS• ti � t v � - SO / V/-.!(Vn �. Ii.��,^��.'. ... • •I {. "Se /r'. /'L. a f..rOV ' '!.. J L } •� y S©�L TEST TaTAL 8T/M.4TEO` FLO`(/ 3 4 GAL IDAY, SO/L TE5TO/ $O/L TEST#*2 _ ' /� lUM RZe OF 40ACNI/Va PITS__ fELE✓ 9• '� f`�ELEY. DATE OF SO/�;,TE3T ' J' S/OE LGACH/NG PEK P/T ' a" t ^I RES[/LTS I t/JT/VSSED BY 1 BOTTOM LE�ICH/IvG PER P/T- 7 SQ:. .,CT. Pt`RCOLAT/ON /LATE DOE/ �4F -Vt •`Yy//Vj�IIVCFI ' TO TAG LEACH//YG '•4REA SQ,' FT. 4 �S o� "F,; fPE•ICC04A7'1O/V R 4yE RESERVE LEi4CNl/VG AREA' 2 E L' 'SQ. FT,,E,' r - O�\� -♦,�. ��.'4 B .ir;�3 r�]- 4,�"� / �,: � �,�� ..t �,y' �� r,. �,g..• 4, $ ', Iti .�.I�....A h _ _ Mks s`. �t .. _ v j\V�'L.1\It ,1 - u� S y. ,� .,�.' .a 7 -G '.y,.�.. •"wS t x rs` :) a aa',x- < �. BUNIK(S ' �. � � G` � t �. !. ,e-.. —a.•. Nn 1(!n rY �. re'.4�-..a-.,»5d-..n-•%nd...✓ .•U ��r IVIDOW mmc* �1 , G'. ....:. .;; '/ ..,>. e.u'7d a„ �• ✓ :ia /4:J/Y"r8T 5 r r N p G/gTE At 8 2SYl:'rA `ss E�� 17Q 6R� �N .. i4Y15'R JVCUrY9s'd.ed �y. ,g •P,' t +ga r' e ..a x , ? +....+<',cser ONAL >_ s .e-; .. r,n.� '� •• .r, '>-`r-�7- R � ..,- � �.,�� � >s - � ;r,. �,�er _•� � ,` //may ='7 - off: • r U ..� .�Yi...,�r... .,.._.-:,rw .. .-.. •.H.;....,, � _.-+�.. ;::...,: .,..:,.:: .. � ..:•e a ...., -� �"b'a:'.��t,� tire..' ,w., $7 .?� s ...». ! .r.'Yk-. .-..�z,. .-.....r �.��,.., , ,'z .r,A+,'�x..... -..�. . _ .a�'s"gi': :ri-:� .y,a�'a:'•^L _ts..",a� .4�F���.s.,�.. 'i., �..x.,_.,.a'.,. r ,. _ .-.. �w:.��J.i..E ., d4..a»qc __� B®USF'IELD SANITARY SERVICE 17 Burbank Street Sa ndwiich,'Massachusetts 02563 Name Sewer Permit No.-ZZ`�— Location: a1DT 7 Co✓`ur - �'�%v�% Builder4 s Name and Address_ jq tte i2 Date Permit Tseued: Date Compliance Issued: 9nC20=79 7 , s J COVERS TO BE WATERTIGHT AND SEPTIC 1 SYSTEM/'! I�RO/ �L� TOP OF FOUNDATION BROUGHT TO WITHIN 6"-OF FINAL GRADE Flaherty Environmental Services EL, 56.0' EL. 50.0' (not to;scale) INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. BOX 81 `. 2'f of ear to bay DOUBLE WASHED EL. 48.0 YarmOUth POl1�, MA 42675 PEASTONE OR GEOTEXTILE 4" CAST IRON or E4UIVALENT - - MIN. PITCH 1/4" PER FOOT FILTER FABRIC • 1 • 4" SCHEDULE 40 PVC PIPE ;•,,,;,;„ 4"SCHEDULE 40 PVC PIPE - - , f FLOW LINE] ENT IF.REQUIRED (first2'to be/evel) '' ' rT 60 L.EXIST. 14" TO. : Dueq �0 00000Ooc ,• .. _�EL.EXIST 0 0 0 0 0 6 0 0 0 0 0"n"` �� o o0 0 0 ���� p (p� 0 0 0 o eEL,46.3' o°000°o 0 0 °o LJ o000°0000 o00 ®��°o° o o°o°o° ® °o°o°o°c L.44. o °0°0°0°0°0 � � Q . o°o°o°o°e2.0' EL.44.5' o000000000° t� 000cocoe00OO O 0 OO OOC OO O O O O O O O O 0 O O o 0 o EL.42.5 '4 ve.j 6"CRUSHED STONE OR (D--sox SOIL ABSORPTION SYSTEM IOOO GALLON SEPTIC TANK MECHANICALLY COMPACTED s (2) 500 GALLON CHAMBERS 6.5' (DATUM: ASSUMED) (EXISTING) 3„ �� WITH 4' STONE AROUND IN A to 1G DOUBLE WASHED STONE 83'W X 5 0'L X 2'D P X 2, 2 CONFIGURATION s EL..36:0' p' A TI\/ \ BOTTOM OF,TEST HOLE EL 36.` LOC ON MAR USGS ADJUSTMENT,.N/A �P� GROUNDW O E N• TH ATER EL V: N/A 8 r _ y Q� k • bp w - _ LOCUS _. GARAGE a- - ^ ' DRIVEWA Old Post Rd. BENCHMARK: TOP.:OF FNDN EL 56.0' NTS 59,3' N i\A OF 4 xa BR LOT LOT, 27 SS9C k f DWELLING 4 0.67 ACRES* , H J PATIO 12 - i�„ 0 47.7' G V� Sq`NITT E� w u.• r 4 15' TH-t DATE:111912016 REVISED. a 2 x _ ' . 1ytip 4 SD 4a �, SITE AND SEWAGaE'PLAN FOR - B �'a B EXCAVATION, INC.S - 46 .. ROBYN TALANJAN, 46 508 COTUZT BAY DRIVE SCALE : 1 . = 40', ¢ (corurT) BaRNSTABcE, MA ° REP LCP 3216-C SH-4 PAGE 1 OF2 ..................................................................................................................................................................................... .................................................................................................................1............................ ............................................................................................................................... GENERAL NOTES DESIGN CALCULATIONS SYSTEM DETAIL Flaherty Environmental Services - P. O. Box 89 1: ALL PRECAST COMPONENTS TO BE H-10 Yarmouth'Port, MA 02675 RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 3 774.994. 1166 ALL COMPONENTS WITH ANY ANTICIPATED VEHICULAR TRAFFIC TO BE GARBAGE DISPOSAL UNIT NO H-20 RATED. AL E TI 2. THE DESIGN OF THIS SYSTEM DOES NOT TOT S MATED FLOW 110 R/DA GA YX 3 BR 330 GAL./DAY ALL W FOR THE USE OF A GARBAGE GRINDER. REQUIRED SEPTIC TANK CAPACITY 660 GAL. 3. MUNICIPAL WATER IS AVAILABLE. 4; ALL CONSTRUCTION TO CONFORM WITH • SIZE OF SEPTIC TANK 1000 GAL. (EX/STING) - 310 CMR 15.000 AND ALL OTHER r ` APPLICABLE LOCAL,STATE AND FEDERAL SOIL CLASSIFICATION 1 25' CODES AND REGULATIONS. 5. INSTALLER/CONTRACTOR.TO REVIEW& DESIGN PERCOLATION RATE <2 MIN./INCH VERIFYALL ELEVATIONS AND•DETAILS ::;•.;,�:,.:-;,.;,• ;; :r:..•..;...}::.::;,. AND REPORT ANY DISCREPANCIES TO EFFLUENT LOADING RATE 0.74 GAL./DAY/FT1 DESIGNER PRIOR TO CONSTRUCTION OR "-12;8 3' LEACHING AREA 0 !: ASSUME ALL RESPONSIBILITY. (2)x(25.0'+ 12.83)(2) = 151 SF J <...:.r.:•: ;..:`..; 6. INSTALLER CONTRACTOR IS 28.0'x 12.83' . =320 SF RESPONSIBLE FOR MAINTAINING SAFE 471 SF x 0J4 =348 GPD, WORK AREA VERIFYING ALL UTILITIES- AND NOTIFYING "DIG SAFE" USE(2)500 GALLON CHAMBERS WITH 4'STONE (1-888-344-7233) 72 HOURS PRIOR TO AS DIAGRAMMED INA25.0'X 12.83'X2'CONFIGURATION CONSTRUCTION. F 7. ANY CHANGES TO OR DEVIATIONS FROM RESERVE LEACHING CAPACITY N/A THIS PLAN MUST BE APPROVED IN WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH, 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS) t ' UNLESS SHOWN PER PLAN. 9. ALL ABANDONED SEPTIC SYSTEM , COMPONENTS TO BE PUMPED DRY AND SOIL EVALUATION FILLED WITH CLEAN SAND OR REMOVED resrHOLE#1 P#15201 TEST HOLE#2 P#15201 t AND REPLACED WITH.CLEAN SAND. Evaluator.- David D.Flaherty Jr.,RS,REHS Evaluator- David D.Flaherty Jr.,RS,REHS 10.ALL COMPONENTS TO BE PROVIDED SE#2755 sE#2755p� i WITH WATERTIGHT ACCESS PORTS BOH Witness: David Stanton,RS BOH Witness: David Stanton,RS WITHIN 6"OF FINISH GRADE. Date: November 7,2016 Date: October6,2016 11.ALL SEPTIC TANKS, DISTRIBUTION rH-1 ELEV.47 o' TH-2 ELEV.47.0' y g BOXES AND PIPING TO BE INSTALLED o WATERTIGHT. 0"-6" A LS 10YR 3/2 0"-6" A LS 10YR 3/2 12.N0 KNOWN WETLANDS OR WELLS �h WITHIN 100 FEET OF PROPOSED c"-24" B LS 10YR 6/6 6"-24" B LS 10YR 6/6 LEACHING. 13.THIS IS NOT A CERTIFIED PLOT PLAN AND UNDER NO CIRCUMSTANCES IS THIS PLAN TO BE USED FOR ZONING OR SITE AND SEWAGE PLAN BUILDING PURPOSES. l cert/fy that on November 12,2002,l have passed FOR 14.LOT IS SHOWN AS ASSESSOR'S MAP 55 24"-132" C MS 2.5Y6/4 PERC<2 minrnch 24"-120" C MS 25Y6/4 the examination approved by the Department of . 5/o ravel 5 ravel 9 /a Environmental Protect/on and that the above analysis 9 ys B LOT 39. B 8c EXCAVATION� INC. Y has been performed b me consistent with the — P 15.LOCUS PROPERTY IS NOT L ROBYN TALANIAN O LOCATED C re uire t in" n 4 d ram ex ertise,a d ex enence described G.W.ELEV.N/A G.W. 9 P P , ELEV.N/A h i 310 MR C 15.0>82. _ WITHIN AN AQUIFER PROTECTION �� 8 50 COT IT BAY DRIVE ,Q U DISTRICT ZONE II), aoroM rH-1 EL EV. 36.0 BO TTOMTH 2EL EV.-370' (COTUIT) BARNSTABLE, MA PAGE2 0F2 ...............................-...............................................................................:.................:.............................................................................................................. .................................................................................................................................................:........ .....................................................__........_................................................................... ........................................................................................._.................................._....._...................................................._._...._...__....._......._..._........._...