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Home My WebLink About4910 FALMOUTH ROAD/RTE 28 - Health 4910 FALMOUTH 0 J Ate' COTUIT A=009-001.003 f. i a Commonwealth of Massachusetts l �` Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information_is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information- 1 Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number I B. Certification LU certify hat I have personally in spected ected the sewage disposal system fy p y p s em at this address and that the 9 P Y c information reported below is true, accurate and complete as of the time of the inspection. The inspection 00 �` was performed based on my training and experience in the proper function and maintenance of on site c:: sewagel disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of r_1 Title 5 i{310 CMR 15.000).The system: c.! .., ® 'Passes ❑ Conditionally Passes ❑ Fails [� E4eeds Further Eval .tion b the Local ApprovingAuthority 8-&13 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional,office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ` t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection B. Certification _(cost..) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 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 it ❑ 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): i 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-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/Z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 4910 Falmouth Rd Property Address ' Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. El ® 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 ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II'of apublic 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-3113 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 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms}: 330 t t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I I Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 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? w ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump?, _ ❑ Yes ® No I Last date of occupancy: 8-8-13Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(9Pd) Basis of design flow (seats/persons/sq.ft.,.etc.): f 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 2011 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach,previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 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 ,M 4910 Falmouth Rd n Property Address ; Adrian Lahteine Owner Owner's Name information is Cotuit F MA 02635 8-8-13 required.for every =- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site,plan): r 1 811 Depth below grade: - feet Material of construction: ❑ cast iron 0'40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): • Depth below grade: 12"feet Material of construction: _ ® concrete ❑ metal ❑ fiberglass ❑ polyethylene. ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No- Dimensions: 1500 gal 12" Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments �M •'v 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 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 ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: o. r 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): -Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 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 4910 Falmouth Rd Property Address , Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA. . 02635 8-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with stain line at 3"off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer, Depth of scum layer Dimensions of cesspool - Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information ie required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) , 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 Lj 39 534. 0 a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 4910 Falmouth Rd Property Address Adrian Lahteine Owner Owner's Name information is required for every Cotuit MA 02635 8-8-13 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 k•_ t NO THIS PLAN IS VALID ONLY IF IT IS STAMPED AND SIGNED 1 N IN RED. THIS OFFICE ASSUMES NO RESPONSIBILITY FOR, I INFORMA77ON CONTAINED ON COPIES WHICH DO NOT HAVE ORIGINAL STAMPS AND SIGNATURES /N RED. LOT 25 1 . 13.8ft S 7�756' - - 22.7ft ft EXIST. 90.8 SPIED 16.0' 4&5ft 0 4;ti0 �q g 78.1 ft —1 EXIST. _45►6ft . 77.7ft D8C EXIST. SANITARY L OCA 77ON FROM r L O T 30 LOT 28 PUBLIC RECORDS o o NOTE, ADDITION TO INCLUDE A r� BEDROOM, HOWEVER THE S.A.S. WAS DESIGNED TO ACCOMMODATE J55 GPD, THEREFORE THREE BEDROOM 0.K. ' LOT 29 59246.3E SQ. FT. >.36f ACRES EMSEAfF'NT 1 146.00' - - L=25.00' ROUTE 28 — STATE f,[6!1f .r4.r R=1970.29' , - BUILT " PLOT PLAN R. J. O'He arn, P.L. S., R. S. LOCLOT ,29, 49>O .ROUTT 28 35 Route 134, Swan River Plaza. Unit 2 COTUIT, (BARNSTABLL+) 11�A. South Dennis, Rd. 02660 ASSESSORS A64P,9 PARCEL 1003 I CER77FY TO ADRIAN A. JR. & BRENDA B. LAH7F/NE rge '0-: 1117R AND TO THE TOWN OF BARNSTABLE BUILDING INSPECTOR THAT TO 7HE BEST OF MY INFORMA77ON, KNOWLEDGE AND BELIEF, THE S7RUC77JRES SHOWN ON THIS PLAN yJ�P�1N OF Mgs`r9 vn FEB, 1, 2008 HAS BEEN LOCATED ON THE GROUND AS INDICA7FD o� RICHARD �- AND THAT IT IS LOCATED IN FLOOD ZONE C PER o� J. m a/Mr- LAWEINE FLOOD INSURANCE RA7F MAP DATED 7/02/92 C, O'HEARN No.27e71 0SCALE 1 /N = 50 FT z Z s,NgcisrE�o S�Q DR. er: O Q G� 1 LAN DA REG. PRO S L LAND SURVEYOR SHEET OF 4 COMMONWEALTH OF MASSACHUSETTS "EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL.PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 4910 Falmouth Road/Route 28 Cotuit. MA 02635 Owner's Name: Brenda Lahteine �/ Owner's Address: Date of Inspection: August 2, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the mformattonxeported; below is true,accurate and complete as of the time of the inspection. The inspection was perforin`ed based r my training and experience in the proper function and maintenance of on site sewage disposal systeiiJ. I am 9"DEP<<1 approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000). The s�-,�in: , ✓ Passesr Conditionally Passes c,3 Need Further Evaluation by the Local Approving�uthority� r l Fail Inspector's Signature: Date: August 3, 2005 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4910 Falmouth Road/Route 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2, 2005 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. I Comments: System Conditionally B. Sys y 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 replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: j 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4910 Falmouth Road/Route 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2. 2005 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 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4910 Falmouth Road/Route 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'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_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4910 Falmouth Road/Route 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2, 2005 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 detennined based on: Yes No ✓ _ Existing information. For example, a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 f G Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4910 Falmouth RoadlRoute 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2, 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): nla Is laundry on a separate sewage system(yes or no): nla [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 617100-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4910 Falmouth RoadlRoute 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2. 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measurinje stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f s Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4910 Falmouth RoadlRoute 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm'in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4910 Falmouth RoadlRoute 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: Auzust 2, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. chambers w/4'stone-per design plans 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.): The leach chambers were dry and clean. No scum lines were present. The bottoms to grade were 5'. The covers were 2'below orade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4910 Falmouth RoadlRoute 28 Cotuit, MA Owner: Brenda Lahteine Date of Inspection: Auzust 2, 2005 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. i O 0 C3 3 o'Z 3Y� aco 3 3`f� act 10 f A Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4910 Falmouth RoadlRoute M Cotuit, MA Owner: Brenda Lahteine Date of Inspection: August 2, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours snaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+l-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the system, the inspection and/or this report. 11 z L TOWN OF BARNSTABLE LOCATION 4A I iv 0 el Ax AV 64 ae SEWAGE # /A VILLAGE 7V 7 ASSESSOR'S MAP & LOTOOq—001'OR INSTALLER'S NAME&PHONE NO.GZ0- 2,eJO-8o IA-,c 6 4/'F- SEPTIC TANK CAPACITY �2414 -:LEACHING FACILITY: (type)2 500 NO.OF BEDROOMS_ BUILDER OR OWNER 7,—lAle PERMI17DATE: COMPLIANCE DATE: 00 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist o t r within 200 feet of n site o withi leaching facility): Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet by V) (Y It DATE: TrpWN mF BARNST LE Irc�CArno t ��/D �« //h yw{-� l� _ SEWAGE # A SSESSOWS'1VfA Eic I OT IT1S'1'P,�.I.E `S I�tAt IE OROM N-I SfiP'IC 'TA t`VI CA PACI't" /S �, p �iYPIG TACIL (>rYP !`TKO.OF BEf»!dC1NdS. �UILD R a� PE XTbATE?: I Separation DGstsnee3e;twesn ttae: Ivlaxii�num l ct)ustecl Ct'punclwate�Table to the Bottom of. ;aching t��uility �-«��=»---�F� Privhac; �at�r Sufrty E�fs,ll u��d Y.eac.hangacili�y ( any�ietts exist Ftsn i do saw..ec wrltk�sn.12UA feet of lctzch►e►g feitity) ,--�--=--� Etl�ro cif W.efjand and t,eac6ung Faextity Of any wetlands e' i�ryP.l�ict:1(bQ feed p�itcactiin�fur�latj+� / � r�� . R rr 4 o p c a� DT�07 � 3� 49 51? 0 .TOWN OF BARNSTABLE . ` { , ,. :ATIONl y _fL�rlO�'f� f�8 SEWAGE # VI 1—AGE D f�//` ASSESSOR'S MAP & LOTD® OU T.IdSTALLER'S'NAME&PHONE NO. �• SEPTIC TANK CAPACITY 4'5�0 42e9�4 LEACHING FACILITY: (type ✓`Q�TG• .CAL.C NO.OF BEDROOMS BUILDER OR OWNERS /�� PERMITDATE: O COMPLIANCE DATE: L90 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 :� r j ' 4 — a 43 26 34 ' H nn TOWN OF BARNSTABLE ` LC1C 571ON i'��. R.i T SEWAGE # CtC'' (1y ��Il LAGS C 0"1-(> ASSE SOR' MAP & LOT -0 9- 001 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY -50 LEACHING FACILITY: (type) �O+ q4I. NO. OF BEDROOMS 3 BUILDER OR OWNER LAkTV(V#- PERMTTDATE: 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 leachi g facility) Feet Furnished by to spc�T vr� T Fay Q c�►,M. _ po is 0 oY a 0 (3 3 a 3lf a� 3 oil 39 Y3�` � q No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprtcatiou for Migool *p.5tem Cow5truction Perron Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ['Complete System ❑Individual Components \ Location Address or Lot No. �) /}'`/ � wner's Name,Address and Tel.No. Assessor's Ma cel urr Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �h le,.-2-e- r191�1e,, ;t Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building F&fie-No. of Persons —Showers( ) Cafeteria( ) Other Fixtures A 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) Date last inspected: Agreement: rl 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 he Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuby s. of al oq Signed ' 4 Date `T Application Approved by Date Application Disapproved or the following reasons Permit No. e2 Date Issued 7 c R Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF.BARNSTABLE., MASSACHUSETTS ` 01pprica�tion for Miopoar *pgtem Conotruction Permit Application for,a'Permit to Construct( )Repair( )Upgrade( )Abandon( ) Ek"Complete System O Individual Components / Location Address or Lot No. wner's Name,Address and Tel.No. :Assessor's Ma cel ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ` Type'of Building: Dwelling No.of Bedrooms 17 Lot Size sqf ft. Garbage Grinder( ) F' Other Type of Building /~ +-No.of Persons Showers( ) Cafeteria( ) Other ixtures Sid /F� l Design Flo ,.",` ; ' % 11otis per culated daily flow gallons. Plan(Dte `` Y �� ' 1fTv of sheets Revision Date r v Tide, r �Sizelof Septic Tank Type of S.A.S. Description of Soil i i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system '� in accordance with the provisions ofstle 5 the Environmental Code and not to place the system in operation until a Certifi- ,cate of Compliance has been is y� s of"a],,Signe ..�f`l . - <A Date Application Approved by Date Application Disapproved or the following reasons Permit No. Date Issued ------- ------------------- ----------- THE COMMONWEALTH OF MASSACHUSETTS d/ BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE , that the On-site Sewa Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoqep by LHIQ at has en constructed in accordance with the rovisions of Title 5 and the for Disposal System Constructs n Permit No. dated Installer Designer The issuance of s p t hall not be construed as a guarantee that the syst"-*7-, // tT* dene BDate Inspector � I f / __ - I . -9� Ij V_:1V - ---------------------------Fee-�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE MASSACHUSETTS `$ Eck "+�� ° ��}� � oar4ipgte ,c�o �tructionerrtYtt - ..: Permission is hereby granted to Construct( )Rep )Upgrade(J- )'A-bandou System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be -mpleted within three years of the date of Date: "' Approved by No. 97- ?6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes UBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ^/ 01pprication for Migont *pe;tem Construction Permit Application for a Permit to Construct(d)Repair( )Upgrade( )Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No. ,MID �L�104�.1A ( Zg Owner's Name,Address and Tel.No. ��-�� Assessor's Map/Parcel cl 1 f 6 2 T 0v i-c� oaZ Installer's Name,Address,and Tel.No. n�Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms �_3 Lot Size 1 55 01�6?QSq-ft� Garbage Grinder( ) Other Type of Building No. of Persons (a Showers( ) Cafeteria( ) Other Fixtures Design Flow 55 < 30 gallons per day. Calculated daily flow 355� gallons. Plan Date A,t >_- 1 9 Number of sheets ` Revision Date Title ae,.,, r, Size of S ptic Tank 1 SO 0 T pe of S.A.S. >;cat2a=Q^crn gl In Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his Board of Health. Signed G Date Application Approved by Date Application Disapproved for the following reasons Permit No. 3 Date Issued No. r,. Fee ! THE COMMONWETTH.,OF MASSACHUSETTS Entered in computer: UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS >YeS 3ppfication for Digonl *Pgtem construction vermit Application for a Permit to Construct(V)Repair( )Upgrade( )Abandon( ) L'1 Complete System ❑Individual Components Location Address or Lot No. 4q ldz0 Owner's Name,Ad ress and Tel.No. i1 Assessor's Map/Parcel (GO 7 1—v � �` Ma °i� C OD 1-0d'Z 35'. am 9syv,a 1, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I� - .�► �+� She Type of Building: Dwelling No.of Bedrooms J Lot Size 5! aC(elCsq- , Garbage Grinder Other Type of Building No.of Persons (o Showers( ) Cafeteria:( ) Other Fixtures / i Design Flow �i 5 / 330 gallons per day. Calculated daily flow gallons 4t Plan Date_A 1�B Number of sheets Revision Date U- Title Size of S ptic Tank 15O U Type of S.A.S. yt7 �xaQ� M L-C IA.1r,1 IA Description of Soil _ Nature of Re pairs or Alterations(Answer when applicable) S. Date last inspected: ; Agreement: ; The undersligned a4 ees 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 issued b his Board of Health. Signed C? Date k Application Approved by Date q/—/7 9 ' Application Disapproved for the following reasons i Permit No. " 7 Date Issued 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 at y 9/o /��/wait, IGL, ri(. ., Go d-v i has been constructed in accorda ce with the provisions of Title 5 and the for Disposal System Construction —3 6 S_P on Permit N . I? Y • ' fated —/2 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system ill function as designed. Date :7 Inspector d No. 7 ,(��— -----------=—---------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS mig0.5al & item Construction Vermit Permission is hereby granted to Cons t( Repair( )Up rade( )Abandon( ) System located at y�� lH'lcv `LD� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by ,I 19y8 14:15 7781472 LINDA HILLER PAGE 02 i I I II I I o whom it may conaprne It is acceptable to the Barnstable Board of Health that no perk test shall be required on the oiece of land Identified as map/parcel 009/001-003. Developer's Lot #29. If the system placed at the front of the lot than pert. test nos p-565i or P--5652 both dated June 13. 1986 are applicable. If $he soil absorption system (SASS) is- placed at the back of the lot then the installer shall dig a ten toot deep hole 4djacent to the SAS to verify that the soil conditions are iMe same as in the pert. original test. The design engineer 4ha►ll witness the test pit and If the conditions are different than the design shall be changed accordingly. i i Pubtta Haafth Otrtston TOM Of Msuble P4 Sox 534 Hyannis,Ma5adtmas 02601 Fax(508)775-3344 I i C, TOWN OF/ BARN'STABLE LOCATION / ��/i�G' f'I �O SEWAGE VILLAGE (.0//U// ASSESSOR'S MAP 6z LOTILL&i ,a INSTALLER'S NAME 6z PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY 11J' Cam+ LEACHING FACILITY:(type(3)-Oa 6-q/R)Lw2//S (size)Jam'3x l S X X NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 12 d b °fyr✓ Cgb, .41 i DATE PERMIT ISSUED: 4 DATE COMPLIANCE ISSUED: '� -21 -9 S j VARIANCE GRANTED: Yes No z� 37 0 Jj 7 ki 1� 00 - '' l 70` GjA- kA , 7?0 �o - x s/ 7y ai I, 41 1 1 Y - w t: `. i W q j-, .�� •:l.F'�Y�s,+€. �� ," •//� � � ._._., - : � - t. �, - .. _ F.. � r to /.S�' �+,"°. i i�•.Y ��+ �, .'s + .. i >a Li 777777 _ k CAC ol i _ r y _ ywo Tf�� y P/y ?X/2 AMOR Jo/Sr I . I —.2y-- ! ; IN rt: FouAIDATiON a , -F-__EXISTING— EXTEPlO_k W,4Lt leg z H, ,\\,\ - ; ,M .=:Q-.•.... 4,. � • ire, lL, .Yr " � _ a � o- .r { M "R E mo vE - . :. ' • .. .. .-. ..,..... ..: a.: tr ..t: 'tom .. .., q' - - - - c E.XLS7141..�.��lSCI�T.QT/D!t/ '%'' l .:«^M.�.'i�>Si .r f• � , .. .y�,-�- . - ' ^\ , r ��car i .n r� �'y /� „ .r'�' 4 i +-r• '4` - _ - - y �-,m j _ 4 SCALEY- .:� - :ae�c -s+»+F`•.. .. -.. 3>�•=.�_":"MR'c"--�:c'r-:,..,�„t,:'aw-:`-.r�.n-..�. .:, � ,;:,.x..A:nr^. .a-.-. ,,.a:.. - - --- ._-.�,,.ea.a-..a-:w,c- -- 9 fA i i .Aj� tt 'f f ins; I � I o>< .3-OAT- i ------------- zi ----- I -- i :I -- -.... ---- 77771 40 FkONT UI EW FPoICIT + T - t V/ATr0 NJ SCALE DRAWN BY / :I , . ��/e REVISED DATE APPROVED BY DRAWING NUMBER i I e l 9 1 i - i { pyyFS 44 F �r tt Fi� 1.li'� t • r M .•-.-.. .-. Y r r. o I i r _ 4 V �`..... \•{,�•, _��_ ___ ..._._.___�•-ram. _� II � II� I i m V I C W n tt i • .6 cRysIALrNit �Y^ t i x 4 f 1 S-. 1 , i'V-o" I . ax as - - - -y ILK1 ; C�OSEj --.D�ESS/NG' ' I M A S T E.R A TIC v Ed O F F GB E Dkoolm V 1 } E t 2-10 k MAS7F� -$ED1�0 �M o � \ o yoxso v 31 I k ' i I � � ' t SECOND ELOOP�- PLAN i -...__. - 10 o , Tf K�-ITCHCN 1 tI1 lol QI- y \ la woov. ^1064S ; \ Llol ol II II BATH p to DINiNG II - w Lu va o "F40ea HALL c> v:o� Q , up F -1 �� T rrLC� � r:�._ ._-PLAIN _ - ---. --- ------_---- �r PtST - SECOND FLOOR ?LANs aE DRAWN S� .� REVISED S YS TEM PROFIL E NOT TO SCALE TOP FNON. FINISH GRADE EL . �- FINISH GRADE OVER FINISH GRADE 7e -� FINISH GRADE OVER , OVER TRENCHES DIST. BOX �i, o SEPTIC TANK �,s o a.op ` o.QA4 12 MAX. ^ !o 0 6' �o4a. �e .e:::n• ;va'°o'a� d'::a•gyaep e�ti'e'OQ:::•'. .e�o. LO • OUTLET PIPE LEVEL TO TA L ENGTH OF TRENCH -� 3 FOR 2 FT T. MIN. .1 0 •4 , :j O O Oi . '••,: .o. , ..Q. , '•D:' '�' :d• b• •' • �• y.x6r �pQ.� P qq ' G FL 9, Oo pp• Vp pt' .ti• a ago ►' °AO G 8,'-S-D a a G�, .:a e:. •:b::�:a.: ,. CAP END 0 °dad: C. I. OR PVC TEES , zo EL b; 1500 GALLON DISTRIBUTION BOX BSMT FL . :o°.o° .r EL . o o v o p INSTALL ON LEVEL BASE "50O GALLON DR YWEL L S o PRECAST CONCRETE a H /_d.._._REINFORCED p. ap y o• ;�1 b�O of vb�'.a( •A�°b''O•d: 0 e'.'�.a��•p.��Pr�boo �4�'�p�P: D r SEPTIC TANK TRENCH SEC TION INSTALL ON LEVEL BASE NOTE.- EXCA VA TE TO EL EV V. �"/- OR L OWER TO REMO VE A L L IMPER VIOUS MA TERIAL BENEATH THE LEACHING AREA o• oIAM• 12" MIN. 69 \ REPLACE EXCA VA TED MA TERIAL WITH 3" OF 1/B"-1/2" G(o 70 : o d v p � •A°°qq1 CLEAN, CLA Y FREE SAND •. ° ' •z�° WASHED �PEA STONE 46) /�9, :7/4" - 1-1/2„ WASHED o �„ q �. f'RUSHED S TONE o c1 p a GENERAL NOTES TRENCH WID TH 94 1. ALL EL EVA TIONS SHOWN ARE BASED ON ASSUMED NUMBER OF TRENCHES 1 - 2. ALL PIPES IN THE S Y.3 TEH,MUS T BE CAS T IRON o " l'�UM,SER OF DRYWEL L S 2 1 36 = OR SCHEDULE40 PVC. CAB FR ION PIT ' 3. THE BOARD OF HEAD � �iUS> BE NOT1�1�Et� ' ` � �_ - —� � :� � � � ,• P-5651 -.P-5�S52 - .y,.t� _ WHEN CONSTRUCTION IS _ COMPLETE PRIOR j ' �� • _ ' y•-Z.. TO BA CKFIL L ING A PE 7COL � TION RATE: 72 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <2 MIN./IN. z s' / WI TNESSED B Y.• ' ' %� -- '^ _� '"°°f'"°'"" BY THE BOARD OF HEALTH AND CAPE G ISLANDS SURVEYING CO.. INC. — TOM MCKEAN 5. MATERIALS AND INSTALLATION SHALL BE IN COMPLIANCE WITH THE STATE SANITARY BARNS. ✓UNE 13, 19B6 HEALTH DESIGN DA TA j - - -- - CODE - TITLE V - AND LOCAL APPLICABLE DA TE. RULES AND REGULATIONS .- ,` 6. NORTH ARROW IS FROM RECORD PLANS AND _,a_.- NUMBER OF BEDROOMS 2 �' ! I y ''• M " IS NOT TO BE USED FOR SOLAR PURPOSES " -- GARBAGE DISPOSAL NO FL 000 HAZARD ZONE NON - HAZARD r s DAILY FL ON 220y GAL . g. WA TER SUPPLY TOWN WA TER s „ 66" 1500 GAL ., M SEP TIC TANK PEO D. t I 1500 GAL SEPTIC TANK PROVIDED LEACHING RECJ'UIRED 220 , GPD I . c, �� SIDEWALL AREA = 152 S. F. 152S.F. X 0. 74G/S.F. = 112 GPD. BO T TOM AREA = 329 S.F. 4 LEGEND 329S. F. X 0. 74G/S. F. = 243 GPO �o L EA CHING PRO VIDED = 355 GPO PROPOSED EL EVA TION EXISTING CONTOUR , SINGLE FA MIL Y RESIDENCE G — —- — —� -- -- OBSERVA TION PI T 0 DISTRIBUTION BOX PROPOSED SEWAGE DISPOSAL S YS TEM zi r • °�� ••"°94 � ` PREPARED FOR • .. ADRIAN LF5HTAINE O O SEPTIC TANK — RESERVE AREA - 4910 FA MOUTH RD. — R T 28 /A!G o0 �I V " °F BARNS TABL E — CO TUI T — MASS. ID ri � �,c ��„ , c8, 7 o PIPE INVERT EL EVA TION cNARls - F (�a� � .',R, /� SANOCK( DA TE* , PLOT PLAN CAPE 6 ISLANDS ENGINEERING 'zi--7 SCALE AS NOTED `crstr�� 133 FALMOUTH ROAD - SUITE 2E `SCALE: ! o ' 9 i-3 9 h✓ �!� 1 NO P/l,A n. AsJ a - f MA SHPEE, MASS. `},