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0221 CROCKERS NECK ROAD - Health
221 CROCKERS NECK W5QP ;Otuit A - 019 - 032 TOWN OF BARNSTABLE LOCATION ZZI (2rc)c�4crS Ncc}<Q SEWAGE# ZO►G - Z33 6"VILLAGE Ct�y�i-} ASSESSOR'S MAP&PARCEL D 19- 0374— INSTALLER'S NAME&PHONE NO. R'k_QCD(C ynA ;on W11 . 0653 SEPTIC TANK CAPACITY /SOO qc�.1 LEACHING FACILITY:(type) (size) 13 x 36 NO.OF BEDROOMS OWNER= CS PERMIT DATE: -/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 Of 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 a� -�o � oz. g3' 39 ' }��I GI`o`f4J1 IVect . 03- 24 S F'RoNT A4 w I ` � No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye' 01pplitation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(✓j Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot Noy%Z) Cro cK Rr Owner's Name,Address,and Tel.No. '&0.5�1 BOLES Assessor's Map/Parcel" CrCGkGC'S rJECk (�� � . Installer's Name,Address,a�Pj Tel. .a Xca.J ►p . Designer's Name,.Address,and Tel.No. V4 TcaScrry 1Fbrcs4Ac-1-r_ v H Assoc Codvi4 Rat Sancto,c) Type of Building: Dwelling No.of Bedrooms Lot Size Z S O O O sq.ft. Garbage Grinder( ) Other Type of Building Rcs,at1Cr�1A f M X No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) t c) gpd Design flow provided a yL gpd Plan Date Number of sheets Z Revision Date Title r Size of Septic Tank f,500 9 a) Type of S.A.S. Lr_%jn i A9 r I G I cL 13 X 31, X .S Description of Soil Nature of Repairs or Alterations(Answer when applicable) A)Etj TA►JK ^ J) JR02C ` Lt+aec�g,n 4 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 b is Board of Health. gn d °i A Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. "- Date Issued t D No. �' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLatlon for�Misposar *pstr a.Construction 30Prinbt Application for a Permit to Construct( ) Repair(✓j Upgrade( ) Abandon( ) ❑Complete'System ❑Individual Components Location Address or Lot N�ZZ.( Cro cKc S E R. Owner's Name,Address,and Tel.No. J o.511 B 01.E'5' Assessor's Map/Parcel:,-•�G. �3 7. �,,. ZZ I Crdckcrs pjEcfe Installer's Name,Address,and Tel.No.a�, Designer's Name,Address,and Tel.No. Forcs-lJ,o.lc.• v H Assoc CQIo',-i R-( Type of Building: Dwelling No.of Bedrooms Lot Size Z $0 O O sq.ft. Garbage Grinder( ) Other Type of Building R c S i of t nA ►o.I No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `� Q gpd Design flow provided a yL gpd Plan Date & - Z g - )L Number of sheets Revision Date Title Size of Septic Tank /300 9 a l Type of S.A.S. LCaIC6 i A q ri c.J�.L 13)t 3 G X . S Description of Soil Nature of Repairs or Alterations(Answer when applicable) /V t W -M O k .D BOX L tct e ,^4 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 b is Board of Health. d .�'{' _ /J9 ., Date "�' L Application Approved by / /, Date /7 v � — Application Disapproved by Date for the following reasons Permit No. Date Issued171611 THE COMMONWEALTH OF MASSACHUSETTS. BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(L/I Upgraded( ) Abandoned( )by XCa\)oj j O.o,,3 at 22 oC KCrS IJ C C K RoL has been cons ed i Pr with the provisions of Title 5 and the for Disposal System Construction Permit No Installer (3 EX Ccz t/a4 1 o-J Designer U. A 550 Z . #bedrooms Approved design flow "" l L gpd The issuance of t.is p it shall not be construed as a guarantee that the system will io j, desi ' e Date 1 � Inspector al ---- ---------- - - "---- -- ~�--------------- - ----------- ------ ---- --- ---- -i , ., ��THE g �No. Fee '� (COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 1 i� osal strm Construction er V p i tnt Permission is hereby granted to Construct( ) Repair(v-*) Upgrade( ) Abandon( ) System located at 221 CroCKCr_s YVcC}e U; and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio gust e c pleted within three years of the date of this permit. Dr Date Approved by Town of Barnstable THME Regulatory Services g rY Richard V. Scah,Interim Director snRrrsrneLe 9 NAMPublic Health Division i639. ♦0 '°Tec tom" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: �� ��� Sewage Permit# Z 01 L - Z 33 Assessor's Map�Parcel O 19 - �3Z Designer: 4 `100 AN6 Installer: Address: Address: On :7 - y7 . 1 L was issued a permifto install a (date) ' ' (installer) septic system at �/�0 �1. based on a design drawn by (address) RA� dated G —Z$ • �G zI (designer) rtify 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 distribution box and/or septic tank. Strip out (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' lateral 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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co nliance with the terms of the IAA approval letters (if applicable) ✓" 4PrA\\OFrttq _. DAVID y r n, (installer's Signa e N1ASOrJ `dam No..1066 0re s r ETA "INITAM a ' (Affix Desi p Here) tit" PLEASE RETURN TO BARN-STABLE 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. ' Q:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable. r# 1 °* Department of Regulatory Services Public Heal�h Division Date KM 200 Main Street;H�nnis MA 02601 J. Date Scheduled i Time Fee Pd.. 7_ W • r `oil Suitability Assessment for Se . ge 'sposal Performed By. Witnessed By. V, LOCATION&GM1EIj,.�L MORMATIO Location Address .Z �vp Cf C�S /V`e d 1 Owner's Name -/,/k 'yl Address '7_0 G �/�u1II/Pfl � tA/'/w�/ , `�� Assessor's MapM4tnei: / Z EnglneWx Name v r/ if X NEW CONSTRUtLON REPAnt _ ` Telephone# �� U Surface Stones y� Land Use •t:s t'h /� Slopes(%) Distances from: Open Water Body ft Passible We i Ara ft Drinking Water Well ft Drainage way `— ft. Property line Other ,SKETCH:($treet name,dimeasiods of lot,exact locations of tel§t holes 8c pac tests,locate wetlands in proximity to holes) Z— s N � V\ / 22 Parent material(gedlogic) �Q Gl� i�SG� 41 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: _ • + Weeping from Pit Pace • ri _ Estimated Seasonal iiligh Groundwater„ qZ f D VERMIN TION FOR SEASONAL HIGH WATER TABLE Method Used:- Depth abperved standingfin obs.hole: lo. Depth to saU ttlottltta:_. la. �. e, t.. clou ldwho Ad)u�IltnMt ° ft• 7 i Depth tofweeping how s:.+a�-�.:.e /d =�—�g-�y }helot > � AcU.Or�t:�d':.•a��r�N•i....� Index Well# .Reading Datrt 47 Index Well levt �" PERCOLATrON TEST Data xlme Observation• I 7'iine at 9" Hole# --- 71m at 6" --- Depth of Pere `rn lime(9"-0) Start Pre-soak 11me.0 �• y v — -- End Pre-soak r , Rate Min./Inch Site Suitability Assepsment: Site Passed �/ Site Failed; Additional Testing Needed(Y/N) Ori oaL•:Public Health Division observadod Hole Data To Be Completed On Back --- 8i ***If percola ion test is to be conducted within 100'of wetland'-.You n mst first notify the � 5 Barnstable COOServation Division at least one(1)week priorto beginning. DEEP OBSERVATION HOLE LOG Hole#�_ Depth from Soil Horizon Soil Texture Soil Color Soil ' Other Surface(in.) (USDA) (Mllaseli) Mottling (Stn►cW;Stones,Boulders. 4 eorrl 7 (!_ /00 DEEP OBSERVATION HOLE LOG Hole# �- Depth from Soil Horiwo Sell Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. ConsWency. l� 9 zo P,• � S z s �. s i r . DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil• • Other Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Moil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones.Boulders. Flood insuraice fete Man: •Above 500 year flood boundary No— Yes Within 500 year boundary No✓ Yes Within 100 year flood boundary No t� Yes r Death of Naturally Occurring Pervious Material Does at least four feet of Naturally occurring perviotp material exist.in all areas observed throughout the area proposed for the soil absorption system? If not.what is the depth of naturally occurring piivious material? Certification I certify that onA I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with ' the required training,e ' e and expene cc described in 3.10 CN R 15.017. Signature v� Date CO OFFICIAL USE Certified Mail Fee IIr $ �5 BRA 0? Extra Services&Fees(check bar•add fee as appropriate) 0 ❑Return Receipt(hardwp» $ r3 ❑Return Receipt(electronic) $ - Postmarjt,� r3 ❑Certified Mail Restricted Delivery $ �" rB C3 ❑Adult Signature Required $ ❑Adult Signature Restricted Delivery$ Postage ru $ USQci a Total Postage and Fees Sent rl To n/L,/,/t S- EM L.e , Stree andApt. o.,or o No. Crty, toe +4 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). r for an elelctronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■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 signee to be at least 21 years of age(not Rrst-Class Mail®,First-Class Package Service®, available at retail). r, or Priority Mails service. Adult signature restricted delivery service,which ■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 specified ■Insurance coverage is notavallable for purchase by name,or to the addressee's authorized agent. with Certified Mail'service.However,the purchase (not available at retail). f 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 barcoded pardon of delivery(including the recipient's signature). 'of this label;affix it to the mailpiece,apply You can request a hardcopy return receipt or an, appropriate postage,and deposit the mailpiece. electronic version.For a•hardcopy return receipt, ,•..11 . i complete PS Form 3811,Domestic Rotum,_ +N .o, �, Receipt attach PS Form 3811 to your mailpiece; IMPORTAN71.Save this receipt for your records. Ps Form 3800,April 2o15(Reverse)PSN 7530-02-000.9047 ' SECTIONSENDER: COMPLETE THIS COMPLETE • ON DELIVERY j ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse PPAddressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, .1 Z or on the front if space permits. D..Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No, ` ao Wal-Liam � �i 3 m� ��� =Ser�vlcepe Certified Malis 0 Priority Mail Express'" 4 ❑Registered f 8t Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery r 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Aran (transfesfe" 7615 1520 ` 000D` 1968 ' 9644 r PS Form 3811,July 2013 Domestic Return Receipt UNITED STATEQ: SFiIIVICE First-Class Mail - ; Postage&Fees Paid USPs °:16 Permit No.G-10 • Sender: Please print your name, address, and ZIP+4®in this box* r. .S , Town of Barnstable Q Health Division j ��°;�•� 200 Main Street Hyannis, MA 02601 Vs i I i i Uwe ram, Town of Barnstable Barnstable : .�. Regulatory Services Department v IARNSTABM 16 59. ,� Public Health Division m 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 0000 1968 9644 June 20, 2016 Albin S. Emberg 206 Waltham Street, APT 113 West Newton, MA 02465 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 221 Crockers Neck Road, Cotuit was last inspected on 06/03/2016 by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic tank is leaking. 0 Any Portion of the SAS, cesspool, or privy below high groundwater elevation. You are ordered to repair or replace the septic system within one 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. PER ORDER OFT BOARD OF HEALTH mas McKean, R.S., CH Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Evl\221 Crockers Neck Road Cotuit.doc f Q: Town of Barnstable Fa 66. Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) - An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ 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 or cesspool Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ 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) ❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER I<<r f 'Repair deadline: -Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Detail Page 1 of 4 mac' ► '-(wf .( 4 �1 'a 4 TH@ A .. . B,;.atrsTa111�. �. - y� ' V MR11 t%�!G0ti Logged In As: Parcel Detail Monday,June 20 2016 Parcel Lookup Parcel Info Parcel ID 019-032 I DeveloperLot LOT 144E Location 221 CROCKERS NECK ROAD I Pri Frontage 1115 I Sec Road GROVE STREET I sec Frontage 1280 I Village Cotult f Fire District COTUIT Town sewer exists at this address NO ......,...I Road Index 0383 Asbuilt Septic Scan: Interactive 019032_1 Map �- Owner Info Owner JEMBERG,ALBIN S I Co-owner Streetl 1206 WALTHAM STREET,APT 113 Street2 City WEST NEWTON I State FMA-1 zip 02465-1751 Country Land Info Acres 0.57I use Single Fam MDL-01�I _ zoning IRF I Nghbd'0106 Topography ,Level Road Paved utilities Public Water,Gas,Septic Location Construction Info Building 1 of 1 Year 1949 " Roof Gable/Hi Ext Wood Shingle Built Struct p �I Wall g Living 1322 I Root Is/ m Ac None _ Area cover GC p p I Type I Style Ranch ( wali Drywall � I Bed Rooms 3 BedroomsI 1i Model Residential I Floor.Carpet I R oms 122 Full-0 Half Dq4 , 12 Heat al OP12 O1 Grade Below Average I Type Hot Water I Rooms Rooms . Ii Heat Found- Stories 1 Story I Fuel�GaS I ation Blk/POur Ftgs �I Gross 2 I Area097 Permit History Issue Date Purpose Permit# Amount Insp Date Comments 6/18/2003 New Roof 69579 $5,000 11/6/2003 12:00:00 AM REROOF STRIPPING OLD http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=681 6/20/2016 Parcel Detail Page 2 of 4 9/1/1973 I Addition I B16611 I$0 16/15/1974 12:00:00 AM I CO ADUN II Visit History Date Who Purpose 1 0/16/2014 12:00:00 AM Pamela Taylor In Office Review 8/6/2013 12:00:00 AM Denise Radley Change of Address 2/27/2013 12:00:00 AM Robin Benjamin Cycl Insp Comp 2/17/2005 12:00:00 AM Paul Talbot Meas/Listed-Interior Access 8/27/2002 12:00:00 AM Paul Talbot Meas/Listed-Interior Access 5/3/2000 12:00:00 AM Martin Flynn Drive by inspection only 7/16/1999 12:00:00 AM Frederick Stepanis Meas/Listed-Interior Access - Sales History Line Sale Date Owner Book/Page Sale Price 1 11/25/1996 EMBERG,ALBIN S 10499/81 $1 2 5/16/1963 EMBERG,ALBIN S&LAVERNE G 1201/329 $0 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2016 $76,300 $14,900 $11,000 $142,800 $245,000 2 2015 $87,400 $15,900 $10,900 $143,000 $257,200 3 2014 $87,400 $15,900 $11,200 $143,000 $257,500 4 2013 $81,600 $15,900 $12,100 $148,700 $258,300 5 2012 $81,600 $15,500 $11,000 $177,300 $285,400 6 2011 $98,200 $3,000 $7,600 $205,800 $314,600 7 2010 $98,100 $3,000 $7,900 $217,300 $326,300 8 2009 $92,600 $2,400 $6,300 $263,300 $364,600 9 2008 $107,900 $2,400 $6,300 $250,900 $367,500 11 2007 $107,600 $2,400 $6,300 $250,900 $367,200 12 2006 $101,000 $2,400 $6,500 $247,100 $357,000 13 2005 $92,100 $2,300 $6,700 $172,200 $273,300 14 2004 $74,500 $2,300 $6,800 $172,200 $255,800 15 2003 $71,200 $2,400 $7,000 $77,700 $158,300 16 2002 $71,200 $2,400 $7,000 $77,700 $158,300 17 2001 $71,200 $2,400 $7,000 $77,700 $158,300 18 2000 $59,400 $2,300 $7,400 $47,200 $116,300 19 1999 $59,900 $2,300 $5,900 $47,200 $115,300 20 1998 $59,900 $2,300 $5,900 $47,200 $115,300 21 1997 $63,000 $0 $0 $47,200 $115,600 22 1996 $63,000 $0 $0 $47,200 $115,600 23 1995 $63,000 $0 $0 $47,2011 $115,600 24 1994 $59,300 $0 $0 $53,100 $118,300 25 1993 $59,300 $0 $0 $53,100 $118,300 26 1992 $67,600 $0 $0 $59,000 $133,300 27 1991 $71,700 $0 $0 $62,900 $143,300 28 1990 $71,700 $0 $0 $62,900 $143,300 29 1989 $71,700 $0 $0 $62,900 $143,300 30 1988 $54,500 - $0 $0 $30,100 $92,800 31 1987 $54,500 $0 $0 $30,100 $92,800 32 1986 $54,5001 sol $0 $30,100 1 $92,800 Photos http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=681 6/20/2016 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd z Property Address W Stanley Emberg ,,M Owner Owner's Name Ci information is COtult 3 required for every Ma 02635 6-3-16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any_.".. way. Please see completeness checklist at the end of the form. Important:When A. General Information fillingte out forms onnthe computer, V use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return key. Name of Inspector B&B Excavation r� Company Name 374 Route 130 Company Address fekm Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-3-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ���vs Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 221 Crockers Neck Rd Property Address Stanley Ember Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•P 9 P Y age 3 of 17 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owners Name information is required for every Cotuit Ma 02635 6-3-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owners Name information is required for every Cotuit Ma 02635 6-3-16 page. Citylfown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): No design Number of bedrooms(Actual) 3 plans DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owners Name information is required for every Cotuit Ma 02635 6-3-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ® Yes El No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2014- 1,000gallons 2015- no usage Sump pump? . El Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. Cityrrown 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: Last pump unknown Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owners Name information is required for every Cotuit Ma 02635 6-3-16 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: 1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet. Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: 1000gallon Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. Cityrrown 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 34" Scum thickness 0 11 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? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is leaking and needs to be replaced. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 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: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 in poor condition. Liquid level is below outlet invert. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberq Owner Owner's Name information is required for every Cotuit Ma , 02635 6-3-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is below high groundwater elevation and must be replaced Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owners Name information is required for every Cotuit Ma 02635 6-3-16 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f . et Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately FRONT A!-29' 8 -340 C1.i8l C2-431 L15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit Ma 02635 6-3-16 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: 8' below grade feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A hand hole was augered to depth of bottom of leaching and water was present showing SAS is in ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 221 Crockers Neck Rd Property Address Stanley Emberg Owner Owner's Name information is required for every Cotuit _ Ma 02635 6-3-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE 1 OCAT ION, i SEWAGE ,90 VILLAGE Ce�) 411 : ASSESSOR'S MAP & LOT INSTALLER'S NAME. & PHONE NO.� � / SEPTIC TANK CAPACITY /0 D O Oal LEACHING FACILITY:(type) alZIO (sue) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 3 DATE COUPLIANCEISSUED: / �/ U VARIANCE GRANTED: Yes No �- - 1 I 0, 616K o � i r � © o No: •-G- - ----- ---- Fsss ..................... THE COMMONWEALTH OF MASSACHUSE17S BOAR® OF HEALTH i TOWN OF BARNSTABLE Applir a#ion for Disposal Works Toustrurtion thrmit Application is hereby made for a Permit to-Construct ( ) or Repair (Individual Sewage Disposal System at Z . .._.. kn� .. G��. - - d �- --------........................................................... r ocatio -Addre s or. Lot No. ••------ f... ----------------••----- Owner Address Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers Cafeteria Q, Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length.................Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.................... •-=---------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ a -------------------------------------------•---- ---•-.........-----•--•--•---------------•-•--------•-•-•-•-•--•••••---....-•------------••...---_----- 0 Description of Soil...............................................................................-•--•---•-•--•---•--••-•--•-.......---------•-----------------•---------------------•--- x Utore o�E Repairs or Ahter ons—Answer when applicable-_ ......Z Yt_s. ._-.-_r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance,hWenissu by the board of health.10 Signed ------ ---------------..------------------ ��1 ....! -------. ��� Daze Application Approved BY '� " �� -------------- - - ..................--'---..-..._ Dace Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------- ----- � ---------------------------------------------------- --- ----------- --- --------------------------------------------------------------------------------------------------------------------- ----------- ----------------------------- -------- Dat 1 e Permit No. --- -------------------------------------------------------------- Issued .-------... .�7.....'-.:��-....---------- Dare Fes ............................. THE COMMONWEALTH OF MASSACHUSETTS *rM ` BOARD OF HEALTH - �� ._ TOWN OF BARNSTABLE Appliration for Uiiprnsal Works Tons rnnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or R pair an Individual Sewage Disposal System at: C �/ v �f��.p c�............................. .................................................................................................. Locati n-Add res or Lot No. , �� •-- �-� ....••--•-....---•.................. ............•----•-......----•-•..............-- ••-------•-- ....-•-------------••- W / / y Owner . / " �t t ress Add `/ � Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --------------------------------------•---••- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. I Septic Tank—Liquid'capacity......_._...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..................".................... Test Pit No.,I............:...minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No.'2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -~ ---------------------------------------------------------- -..... -.... -------- -------------------- ----------------------- .---------------------. ---•-••-- 0 Description of Soil...............................................................................=........................................................................................ U .............•-••-•••••---•----•-•---_... ------------......---------------------------------•---------•-•-----•---•---.....--------------•--......................................................... W .................... -••------•---•--••••---•--••-•-------•-------•••------•-----•----------------- ............................ U Nature of Repairs or Altera •ons—Answer when applicable vV�Y 'L1y, ..P�n Y i ----•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli c&ha a issu • by the oard of health. Signed . --------------- -----------------------------------------"'-'--'--................. ..........r.Wit.------.D----- Application Approved BY " " ....... ' ... : Date Application Disapproved for the following reasons- ............--------------------•-------------.......................................................................................... ............................. .....................'--'-....--'---..............----------------------"----"----...--....-..--------- ......---..:....--------'------------------------------------ ��•%--------------Date.----------------. Permit No. . ''�a-f/�s-------------' ........ Issued ------.--//�`'� _��....--------.. v Date THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE 011Ex#ifira e of CEoutialinure v� THIS IS TO C RTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) � Instale aar ............ ' ... /0 c' �- �----------� .... - .................................C.�.............../..................... ............................. has been installed in accordance with the provisions of TITLES The S�a��Ew"ironmental CO)e aasde-scrjO in the application for Disposal Works Construction Permit No. ........................................ dated ....�....4....-................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--" ------l j.-6..7.� Inspector ector ................---'..................... ------- . .......--'---v--............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....�...............,.. FEE........................ 'Disposal nr - ��n Wrini# Permission is herebygranted......._. ���-.-----......_.------..--•-------------•-------.----......... .................... to Construct �.-�) or epairik/i)an Indivi-d�a�I S�ew,�'ge Disposal S�st i v •--- . ..._ ...•-• ..... --•..... ........ Street •Q Q as shown on the application for Disposal Works Construction Permit ... sated _ �./ ' Board of Health �r DATE................................................................................ FORM 36508 HOBBS&WARREN,INC..PUBLISHERS LO CAT 10laZ E. A PER.MI N VILLAGE INSTA"LLER'S NAME & ADDRESS BUILDER OR OWNER CM�Z2G DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 9I/I�f�l /7kk t N .f.�.l .c. (�..... F�a..... ..:.:. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH OF.:........................................................................................ ApphrFa#ion for llhipaa al Works Tomitrurtiun rawit R � i Application is hereby made for a Permit`to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............................•-----------------------------------.................--------------- Location-Addr or Lot No Owner Address a ............................ lr A....... --.........0!4R..�.................>?? ..�' ' Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ---------------------------------------------- W Design Flow............................................gallons.per person per day. Total daily flow.........................._.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter----------------.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................." (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------•---••----------•-----••----•-------------------------------•--......----•-------....------•.....---•-•----•--•------••-•--•--•-•-•-•------..--- 0 Description of Soil.........................................................................................-----------------------------.:......-----------------•--.........----------•- x V ..................... ----------- --------------------------------------------------------------------------------------- ---------- --------------------- ------------------ •---------------------------- W U Nature of Repairs or Alterations—Answer when applicable______-_-Q�....t _.._._..... .�4_ ?....._.........0�s__ __________________ - - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the boar ealth., Si ned-- ��--� Date Application Approved By----.<___.�C!<C_-.�: /� -- -----•.!�f�%f - --------- .......................•-- -- Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------•-------------._ -----------------------------------------------------------------------------------------------------------------------------------------------•---......•-----•--•-••------------••-----•••------------ Date PermitNo....................................................... Issued........................................................ Date •au , M N .1...a`�..._�D..... Fxs..... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..-•.....................--...._..----.....O F............................................... Appliration for Uiipoottl Works Tontrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � � �� •-_---_..�..�..............................................................C.. �C. �"� - ........ .. .... ..... ....._...---............._. -- �n Location Add r .�. ............ ----......_ d .�..t~.....or -- Lot.Nl.!. . ':.......................... Owner .,. Address - Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building _____________ No. of W YP g --------••----- -•----•----.Persons------•---...--•----._..----Showers ( ) — Cafeteria.(...__). d Other fixtures ______________________•--•-•-•-•_---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank-Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--__------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by•-••-•-•-•--•-••-•-•--•---••••-----•---•••--•----•-._..-----•-••----•---• Date................... t ............ W Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water_-__-..--_--_____-___--- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 .---•-••-----------------------------------------------•---..__....---.__-•-----•---••--•-•-•-•_............................................................. ODescription of Soil..................................................................................................................................... ................................. x U -•--•••-•••-••-•-••••••-----••--••--•--•-•--•••----.....••-••-•-•--•-••-----•-••••-••----------••--•--•••--•••--••----••----••••------•-••--••-•-•--------------••••------......-----.....•-•••-••---••. W ----------------------------•--••-••--••---•--•••••-•-•--••--•••••••-------•----•-•-•--•-•-•--•---••----•--•--•------•---••••-----•-•••-•••••-- U Nature of Repairs or Alterations—Answer when applicable..........__oaf -- _____________ j 1nOU _a - -•------- ............................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of THI T..E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the boar ealth., Signed_ ..:. ... _._ C?/!{I _''LC7.-1. /t��,/' ell � Date Application Approved By..... f��!-��:.!..._ -.'/�'®��1"' Date Application Disapproved for the following reasons:--..................................................................... ......... ..........I................ ...............................................................................................................................................................................................------- Date PermitNo......................................................... Issued................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. •.......OF.......-6?w�..................................... (Irrtifiratp of Tontphatta THIS IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by................... ......... ••-•••-•---------- ----------•-------------------•-----------------••-------•-••-•---••-•-•-••------••--•--------- _ . Installers _ ,r at........................�--• _/......--- -— IZ4 cl .-�r.r.�fx _ p 5 of The State Sanitary Code as described in the has been installed in accordance with the provisions of TITLE r application for Disposal Works Construction Permit No. .05;�.1 - 2.,4_________________ dated---------------------------..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM •WILL FUNCTION SATISFACTORY. l DATE....---••----------------•--••-------.....9. .................... Inspector__..__.... ,% _i_f� lr ................................................ THE COMMONWEALTH OF'MASSACHUSETTS BOARD OF HEA,LTH ........OF...... „.�rrL.-.... n �rG No... /t•. �f,_- FEE..... 0 _._..... Disposal Works Ton tr ion prntit Permission is hereby granted.- `---------- ;�r,�:. ...... -:+�iaa,�,:�---------------•--------•-------.....-_-_-....-•---...----...........---•----- to Construct ( ) or Repair ( an ndividu Sewa Disposal Systemyy Street i as shown on the application for Disposal Works Construction Permit No..................... D*d-- - ------------- .------- ......... . r -- ------------ --- DATE....................... ° B. of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS LOCU 9� ASSESSOR'S MAP: 1'6 �/ — GENERAL NOTES: G NOTE: 5 Removal of Unsuitable PARCEL: 32 Soils (A/E/B) around and below s S 1. VERTICAL DATUM: _ med_ �„ REFERENCE: PL. BK. 94 PG. 47 Leach Field to an approximate su Scho Stree �� °°� depth of 23", as needed along 2• MUNICIPAL W is AV A ABLE. FLOOD ZONE: X (0.2% Annual Chance Flood) 3. SCHEDU PVC PIPE TO BE ED THROUGHOUT � westerly end of field. Replace with o % Town of Barnstable I SY UNLESS OTHERWISE NOTE . ° o clean fill per Title 5 specifications. `D °' y,p #25001 V0752J (07/16/14) PL PRECAST UNITS TO CONFORM 0 N AASHTO: H=10 & 20__ �e<5 Rd 5• PIPE PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. Gt°c essett ,.:.,}�43j 6• ALL CONSTRUCTION DETAILS TO BE I CONFORMANCE Pop°r WITH MA ENVIR. CODE (TITLE 5) AND OCAL LOCUS MAP N.T.S. k. REGULATIONS. 7• CONTRACTOR TO VERIFY LOCATIONS OF LL UTILITIES PRIOR TO CONSTRUCTION. e a 26' ' , LEGEND: o �- ` PROPOSED CONT UR 0 13 46 9s PROPOSED SPOT ADE ,; o ce 14. :_..... 1 LOT 144 B — 40 — EXISTING CONTOUR ln e o�.• , P°�e�e R��\ F .•j. : °> � 3, X 30.23 EXISTING SPOT GRAD f � a � SF o � 25 041 Edge 12.44 Gov ' } TEST PIT 2 44 3 68 EXISTING WATER SERVIC 12 _ 0 0 1 WORK LIMIT LINE �. 1 2 4. X 1 '238 12 4.38 (D Remove existing leaking " 1j S/7 9• No// �, e 7330 — 4. 1 �jj Co septic tank and failed �� 28 ubs y F,ra F w ' `�1S 4.26 WOt r 4sk%6 '0 -I, cant urinated soiach pit and ls within :Ct. ' 4 3� �' �s 32 3S OH Ut�1Jtjes �6, }� 3Ar '3S* eter ,i, p; 5' of proposed leach field. 447 46 Itsx�F2f 6,P o ��4 1 - _ oo Caution alon r : :. , }�1• i�jp'ne 8 ; ;S /4.; l X ss 4 O GaSllne g 8'�Oxi- zl44 a`a• OW, , n9. . ppine 483 1548 g5' NOTE: This plan is to be used for septic °'` F 3 222 s stem purposes only and is not to be it Y P P Y °`e '':y::....:k A�'=: :..:,. /2o u/l 14a ree 'S7, 'Ss1 used for any other purpose. ��°rj '`13. 9 '•. 4 IT , s•` �A S S ... x 1S 4,. n e IC 40 ::i: 3• / `:; 14. 5� 15 69 221 CROCKERS NECK ROAD of 'as �..� : Ty $ $ 2 'S s2 H C 0 TU I T, MA 1 : AMY L. 9�yG 4.30 Benchmark: Top associates PREPARED s VON HONE ', is of Stoop Corner at si:Pnc sYS7EM oEsicNs FOR: B �C B Excavation y El ev.;�16.0' a n d 320 Cotuit Road No. 1068 '4 58 �� Sandwich, MA 02563 AFC EO 508.833.0041 Ember g 1STER `` so *NOTE: Existin' co er lines for I ,S g 2 pP Surveying West Newton, MA 09 // basement sink7, and washing machine to Y k1s be replumbed into 4" main sewer line. AHOjalaSurveying 47 Arne H. Ocala,P.L.S. Existing drywelal to be backfilled or used DATE REVISED SCALE SHEET NO. 0reet 0628 16 1S3S for roof runoff or basement dehumidfier. wept eomscoblbi 211 Maple si e. Mn 2668 / / 1 = 209 1 oft Provide Riser over D-box NOTE: All components to be marked with NOTE: To prevent breakout, final T.O.F. (FullCrawl) to within 6" of final grade magnetic tape or similar prior to final cover. grade of EL. 12.44 to be carried EL. 15.5 (Cover to be watertight) out a minimum 15' beyond edge F.G. EL: 13.0-15.0f F.G. EL: 14.5 -Maintain Min. 20 slope over leach facility to of leach facility. Breakout elev. *Installer to Existin f- F.G. EL: 14.0 revent ondin F.G. EL: 13.2-14.0 below Crawl Space Floor. confirm Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or elevation of Geotextile Fabric outlet to within 6" of final grade Inspection Port within 3" to grade existing 4" . L=10' Access Covers min. 20" diam. per Code) 3/4" - 1 1/2" Double Washed St e 4" SCH 0 P L=10 L=5' Top of Peastone or Geotextile Fabric EL 12.44 Cast Iron Pip _ 4" SCH 40 PVC 1'4" SCH 40 PVC 0.005% slop located below @S=(1%MIN to 11 ®S=1.3� 1� Cap Ends - EL. 11.93 crawl space 14 U�ZEL. 12" @S=1.8% 0.5%MIN 6' Effective Depth dirt floor EL. 12.5 EL. 12.37 12.2Bottom EL. 11.43 a rox. EL. EL. 12.75 Install Gas BaffleEL. 12.11 Use Leach Field approx. PROPOSED DB-3 13.0t. Raise H-10 DISTRIBUTION BOX 36' Long x 13' Wide x 6" Deep 5' Plumbing to Watertest for levelness min. EL. 12.85 (Install PVC Inlet & Outlet Tees) if more than one SEPTIC SYSTEM PROFILE PROPOSED 1500 GALLON (preferrably outlet EL. 6.43 H-10 SEPTIC TANK Adjusted Groundwater TH-1 & 2 EL. 13.0) if � N.T.S. needed. NOTE: Existing 1000 gal ADDITIONAL D I TI 0 N A L N 0 TE S Septic Tank to be pumped, DESIGN CRITERIA SOIL L 0 G crushed and removed. 1. Contractor to confim soil suitability prior to installation. Contact BOH and Design Sanitarian in the event of varying soils from original Number of Bedrooms: Existing 3 Bedrooms SOIL EVALUATOR: AMY VON HONE, R.S. S.E. #2517 INSPECTOR: DAVID STANTON, R.S., BOH soil test. Soil Type: Class I DATE: JUNE 24, 2016 10:00 AM 2. Pump and remove Failed Leach Pit. Any contaminated materials Percolation Rate: <2 min/Inch PERMIT: #15086 PERCOLATION RATE:<2 MIN/INCH IN C1 within 5' of proposed Leach Field to be removed. Pump, crush, and remove existing Septic Tank. Daily Flow: 110 G.P.D./Bedrm x 3 =330 G.P.D. Design Flow: 330 G.P.D. (Min. Required) TH - 1 TH - 2 3. Water line to be sleeved at any sewerline crossings and within 10' EL. 14.13 �, EL. 14.13 Garbage Grinder: of any septic components, as needed, per Water Department Not Allowed c°n A�1✓'...'..::`: c°n requirements. Contractor to verify lobation of water line prior to .,.Loamy San-d-:: Loamy San-d....: �, construction. Leaching Area (330)/0.74 = 445.94 S.F. 1OYR4 :... Required: 13' / 13.05 13" / 13.05 4. and raised to a minimum - '� Existing Sewer Line elevation to be verified330 G.P.D. x 200� - 660 G.P.D 9 it B B ' ' EL. 12.85 referrable EL. 13.0 for 2� i e itch to se tic tank . Septic Tank Required: Sand.'.. .'''Loam Sandd.':. (P pipe P P ) Minimum 1500 Galion (Proposed) y y ....7.5YR4/0.1•:•:•:•1•: 21" ... 12.38 23 12.21 5' Septic Tank and Distribution Box to be placed on 6" crushed stone Use Leach Field: Sch. 40 Perf. PVC with 2X Washed Stone: C1 C1 Perc or compacted, level base. 36' Long_x 13' Wide- x 6" Deep Medium Sand Medium Sandli 0 2.5Y6/8 2.5Y5/4 34" Bottom Not Allowed I: Sidewall Area: 36' x 13'= 468.0 S.F. 39, Bottom Area:Total Area: 46 8.0 S.F. Desi n Flow Provided: 0.74(468.0 S.F.)= 346.32 G.P.D. j i 221 CROCKERS NECK ROAD 92" Ad'. Water 6.43 92" 6.43 34, I C 0 TU I T, MA Fki to8' S.13 O Div i�tn g associates PREPARED �" 108 120" 4.13 o op Fndg SEPTIC SYSTEM DESIGNS FOR: B CX B Excavation 5.13 Groundwater Observed ® 108" (EL. 5.13) /Adjusted Groundwater ® 92.4" (EL. 6.43) c5`. �" iev. �5 n' 320 CotM Road a n d Sandwich, MA 02563 E m b e r Well MIW-29, May, 2016 Zone A (Water Depth 7.68') = Adjustment 1.3' �' O 1 S 508.833.0041 g <9" ® 14:01 minutes PERC RATE: <2 MIN/IN. ( C1 Horizon) West Newton, MA I, Amy L. von Hone, R.S., hereby certify that I am currently approved by 11'iI surv"ing by. the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and 23, ( AHOjala Surveying that the above analysis has been performed b me consistent with the ArneH. O'a1a,P.L.S. ys p y + � DATE REVISED SCALE SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I have a 211 Maple Street , successfully passed the Soil Evaluator's Exam on November, 1994. west Barnstable, MA 02668 06/28/16 1 = 20 2 of 2