Loading...
HomeMy WebLinkAbout0020 FOREST HILLS ROAD - Health 20'TOREST HILLS "A-t COTUIT __ A-= 025 007 001 TOWN OF B STABLE C LOCATION 0 = oyt SEWAGE # Z600—S9-A I� VILLAGE r, i ASSESSOR'S MAP &'LOT f`� r00' INSTALLER'S NAME&PHONE NO. ML e C�av► �}?�"gSOC� SEPTIC TANK CAPACITY 5-0 0 LEACHING FACII.ITY: (type) I eaneh (size) y X, f Z X NO.OF BEDROOMS BUILDER OR OWNE 'J, PERMUDATE: r 000 COMPLIANCE.DATE: Q� 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /Feet Furnished byr/— lJ } � � +�� Z�lI•Z,1 _ _ ...•. _. _ � - - - - -, � --�: � � MIDI � NO. -� > HE COMMONWEALTH OF MASSACHUSETTS "FEE BOARD ObaAwo FH ALTH OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components Location Owner's Name V Map/Percel N Address Lot N j It. aller's Namu I Designer~Name ^Address WE, 9 all Telephone it Telephone N Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures _ Design Flow(min. required) JCS gpd Calculated design flow t�5�0gpd Design flow provided �5 1Ggpd Plan: Date 5'a3-0C) Nu>nber of sheets \ Revision Date Title �j II Descriptio of Soil(s) �� " `'- " 3 1r"- Zm Soil Evaluator Form No. Name of Soil Evaluator C1 CC o Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date fins FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ,,;,,,.bra o _ � .-�. _ • 4 No.."FJ (" HE COMMON• •E=ALTH OF MASSACHUSETTS t^ 'FEE �� BOARD OF HEALTH _ �•� OF � Vw APPLICATION FOR ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (,r Repair ( ) Upgrade ( ) Abandon ( ) 1�r/cnnplete System ❑Individual Components Location - er owner's Name (�� n25 (D 1\ _W1 Map/Pacrl;#�;1 '?s. 4 Address Los# o w"I• on cl�phc n dlu,;s N un>r .5 T�r Designers Name Est 1�Jls 4). A ,` - / Address 7 \ Ad cs TeIepluiiic R, telephone# i Type of Building: Lot Size Sq.feet- Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No. of persons (O Showers ( ), Cafeteria ( ) Other fixtures �. =,.Design Flow (min. required) gpd Calculated design flow �0gpd Design flow provided 3..J� gpd Plan: Date C5_Q3�00 Nu ber of sheets Revision Date Title Lk- CA d Description of Soils) QI` Soil Evaluator Form No., Name.of Soil Evaluator , C('&An,i c(ZL Date of Evaluation 0?-CYR- t DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in opd'ration until a Certificate of Compliance has been issued by the Board of Health. * .,,max; Si ned Date r IWp cW"S - 4r ..-FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM S/96 — -- ,o.�' �• a r. -----r ---w —--,_-.-------— . { — ——---———— —,- -----•--,--I ,` y01*-S-HE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) [Complete System r The undersigned hereby certify that the Sewage Disposal System;Constructed Repaired( ) Upgraded( ),Abandoned( ) by: ° A4 Q at 14, us 1 _ has been installed in accoLdance with the provisions of 10 CMR 15.00 Title 5) and the approved design plans/as-built plans relating to appl' . ti �tlt dated / /.'� Ap. roved Design low (gpd) Install e kc� 3' Desigtie�g: Inspector Date X l/ sue;' The issuance of this certificate shall not be cony trued a`s a guarantee that th sy tem will function as designed. "+ FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED ORM 5/96 I No. 4 PW . 1,07eHE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT . Permission is hereby granted to Construct Repair ) Upgrade ( Aban n ( )ta,n_i.ndividual sewage disposal system at 2.n - uQo as described ' F, •i ' in the application for Disposal System Construction Permit No. 1 dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date Board of Health t FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSB WARREN'"' " PUBLISHERS- BOSTON Town of Barnstable P q ,J Department of Health,Safety,and Environmental Services �t►,E,q Public Health Division Date - 367 Main Street,I lyannis MA 02601 eanxareer.& t639 ` Date Scheduled Q� Time �b,(� Fee Pd. rfn +�dC �� � I Soil Suitability Assessment for Sewage Disposal Performed By.. t �� Witnessed By: /�o>T sa �"r LOCATION& GI NEE RAL INFORMATION * . Location Address Fd�`p Owner's Name Mn 1kWA_p�,, s�y-&0+, � Address `-� 'I Assessor's Map/Parcel: ZF� Y(—eF Q (�0� 7-00� Engineer's Name a YJ, S Q• ", u NEW CONSTRUCTION V REPAIR Telephone# Land Use wo ve-( - ( Ld^ Slopes(%) Surface Stones Distances from: Open Water Body It Possible Wet Area R Drinking Water Well ft Drainage Way R Property Line R Other R SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) t Q" 1 b� Parent material(geologic) o� w�s Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater . DETERMINATION FOIL SEASONAL,HIGH'VVATEn<TAI3LE Method Used: --- - Dep(h Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION:TEST Date t't8 me:::,LZ Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time® of Time(9"-6") End Pre-soak Rate Min./inch Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back Copy: Applicant DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,©oulderes. % 4W /0yA� L/Z DEEP OBSERVATION HOLE, LOG Hole# z Depth from Soil I lorizon ( Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones,Doulderes. Consistency,° �4,,v Gv ioji? %y ' 3 - �6 •, Lot... /O iL 6 1 DEEP OBSERVATION HOLE'LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Bouldcres. ° el • DEEP.OBSERVATION HOLE 11 OG Htile Depth front Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° T Flood Insurance Rate Mp.a" :Above.`.•00 year flood bouoda:y No_ Yes v Within 500 year boundary No 4" Yes Within 100 year flood boundary No L Yes Depth of Naturally Occurring'✓Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y, J If not,what is the depth of naturally occurring pervious material? Certification I certify that on J _ (date)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,expertise and experience described in 310 CMR 15.017. Signature Date g 17-9 VT -o- 7r� yr ,]•..P ]r-)• IC-'1• ---- ------ -- -- -- , - - - -- - - --- L I - -- - --------------- --- ----- - --11 ! I I I I yr f-,yr Y I 210o JOMTa • O.C. •IN.,OL I 1 I )Vr Du. LALLY COWL■ 1 I rOOT71G I rYn - -I PO +' I -- - - - --- --- ------ IN r ---- J - - -------- -- ------ I -� I I I i I I !c-t t' I'-I X -,)/f{•-1 r r CONIC.P"DA tAu I al 14• x r CONIC. Df/'MIN a I I Ina�xr�,,�y ,� ANY Y , I Nnrwll 1 b l I f��f��ppNNyIN� .p�fClo�aC,OBI` ^t I I 1 I p I! I ,OtAlD DOOM 70 OI4WU I I 2100 JOM/� ■ IP C. rl! T-0 1/•]- 1 {' !��'-10• 7 VT l'-0.)/P ♦-T C-O!��• 7-,VP ►-T - , L_J L_J I L_J L_J L_J L_J L_ I I G7 I I i I VW JOMY).•r• OZ. NILI ' a I I I L yrI W-W c-IO• .-0 I I I - - ------------ - _ f-. -____- __- _ I-- d i—� -- ------- ------- -- L J rah 1 1 11 C ~ ' 1 I I -2111 1 I I - _J KIO-JOM» ■ or_ I i 67 I 1 y 9' r� Jos»• r•oL. r - - ------ - -- - -- 000+l Dleo� oo•A-r I , Mpe .t AYIr. 1 I p• 3 -------- --- i►ROVIDaD ■rr■ 4 J ,7-J 1/r 0 FOUMDATIONPLAN BF-ACON public Health Division Town of Barnstable PO Box 534 Hy annis Massachu setts efts 02601 Fax(508)775-3344 r� " Phone(508)790 6265 tl - �: Tr-t In• Ly-0• _ _ as-o• � >a•.t yr - - -- ---- �•-�- FT-4 v71 n'-a• <'-r -•Lir r-1 1' lO-t• r-+ ---------------- TH `�� r:An•.ate V t ' TRAY CLQ • �-o- � w.n•r�rr � �� -------- ----- b t11 C 4 o«i ZenJ WA wr o !!8Dl�OGIi t1 4 Y gal v P ►AY CL,G • r-tr ■ 4 ■ k -00 •� < T L 0 r g F w-•w* Ctq. T 7T M K rs ••v♦ e �•� r-r S CLG. Ll{LJI 1 I � O O' ' • � y �s` OT e 000a - OOrT'L DO"LQ ZMw n K�f CLG•Ip"-L-i I © b d K ± •lwf Cl6• Wti"i !f ��Is � g I � Y IV I � n• L I ir-01 r-o ' 7i-O- r-a yr -P T-o- •-o- �•J"�•" 7r-4 v7- r-o- Lt1 PiR61 FLOOR PLAN BEACpK ,,,,,,,,,po.,�..,.,.,,k-,,,,■. Public HeL'--: 9at.I�i4�81 Town of Barnstable o 0 PO Box 534 Hyannis,Massachusetts 02601 Fax(508)775-3344 f)mne (508)700-6265 . T . TOWN OF BARNSTABLE i LOCATION ZO Q SEWAGE # 2XG—S5-A - VILLAGE G ASSESSOR'S MAP & LOT - INSTALLER'S NAME&PHONE NO.Y_YIC��{�V"p cah - SEPTIC TANK CAPACITY /,5�O O LEACHING FACILITY: (type) (size) /fix NO. OF BEDROOMS l BUILDER OR OWNERZ - PERMITDATE: 000 COMPLIANCE DATE: woo ` Separation Distance Between the: Maximum adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and-'Leaching Facility wells exist . any on site or within 200 feet of leaching:facility) Feet Edge of Wetland and Leaching:FacILty(If;any wetlands exist z , within 300 feet of leaching facility) Feet Furnished by • 1. h2r, h lh9 - - - - - �9h t � • � i U J _w l �- IZ NIF TOWN OF BARNS TA B L E ` . 01.40 ` L'.P. wo e 44-7 A p S UMMA R Y LOTS UPLAND; 267, 713�S. F. 6. 15�AC. z-� c WETLAND; 0#S. F. O�AC. cs� TOTAL; 267, 713�5. F. 6. 15=&AC. 28.8 % N ,' ROADS 116, 189 -4S. F. 2. 67-4A C. 12.4% OPEN SPACE UPLAND, 514, 568-+S. F. 11 . Ln WETLAND;. 32. ?16-*5. F_. 0. 74 CUN . TOTAL; 546, 684-*S. F. 58.8% % TN In TO TA L 9 3 0,,58 6&S. F 2? . 37 /00% y , \Fi OPEN SPA CE UPLAND=132. 818�S, f WETLAND=O# . r"• TOTAL=.132. B'p L-�,. F ' Y i 594.7. fT N/F NIF RAYMOND R. 8 /RENE AN TONE 1 RODGERS 1 SOUZA 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Forest Hills Road Property Address f Harold McInnis Owner Owner's Name -0 information is ar, required for every Cotuit Ma 02635 5-25-18 page. City/Town State Zip Code Date of Inspection " >�YA Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI13747 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 5-25-18 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 Official 5 Title_ _ 0 a Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 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: ® 1 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: The system was in working order at the time of inspection. 13) 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 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. CityrFown 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•Page 3 of 17 I . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18_ 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 El ® 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•3/13 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 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of_a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. CitylTown 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? El ® 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): 336/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: 2016- 137,000gallons 2017-66,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 f Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. Cityfrown 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- last pumped 1 year ago 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 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): 1'6" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6 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: 1500gallons Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is Cotuit Ma 02635 5-25-18 required for every 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 34" Scum thickness 1 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 15" 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 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 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 working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type.- El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2)4'x55' ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma' 02635 5-25-18 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•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 c�M 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 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 Al-i '6" B •26' A2! t6tt 82-27' 0 A3.36' B3.481 A4.64' B4=24' 2 3 - - - - s - r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .IM 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is required for every Cotuit Ma 02635 5-25-18 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: No GW @ 132" 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 0. 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.- Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 20 Forest Hills Road Property Address Harold McInnis Owner Owner's Name information is Cotuit Ma 02635 5-25-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to'high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file III t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable P# Department of Health,Safety,and Environmental Services �"M Public Health Division Date -, — 9& 367 Main Street,Hyannis MA 02601 BABNBPABLKKAM r lECMId� Date Scheduled IeAA-> A? // �1 Time % %aim�1 Fee Pd. a r • � � f Soil Suitability_Assessment for Sewage-Disposal{" Performed By: '/�Y � � 6� Witnessed By: LOCATION & GENERAL INFORMATION Location Address Owner's Name < ��i .V E' �Aj$ , • —,`p�v/ Address Assessor's Map%Parcel:"f�ti/ Z S 0 0z, ! NEW CONSTRUCTION REPAIR Telephone# 2 5''U 3S p , �/� r f Land Use Slopes(%) 1' D f Surface Stones_ •r'T ; Distances from: Open Water Body ft f'�(Possible Wet Area It Drinking Water Well =R Drainage Way _ft ' Property Line • ft Other rw. fti SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) q f .>r �. a c V% Parent material(geologic) V" Depth to Bedrock ZDV Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DE �'YtMINA'TtON F R S �ASONAL 14IGH VV"FR:.I'ABLE i � ,ter ��j� ,. Method Used: �1 '> OQU`{11EP-4ild Depth Observed standing in obs.hole: w in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well#_ Reading Date:_ Index Well level_ Adj.factor Adj.Groundwater Level PERCOLATtON'TEST Date 1D. Time Observation h Hole# ' Time at 9" .a y 15U� Depth of Pere �— Time atA� 6" 1 Start Pre-soak Time @ lr, Time(9"-6") D� Vol End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--� Copy: Applicant rU J , , f �:'::DEER OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % 0 0 I V j6 R vin `I DEEP OBSERVATION HOLE.LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. IJ� ( Consistency.° Gravel) 1 . Pi EP OBSERVATION HOLE LOG Ho DE le. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistencv.° Gravel) DEEP OBSERVATIM HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency. ra el t Flood Insurance hate Map_ , Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100.year flood boundary No�Yes ,a Depth of Naturally Occurring Pervious Material r feet of natural] occurring erviou erial exist in all areas observed throughout the Does at least fou y g p g area proposed for the soil absorption system? ' If not,what is the depth of iaturally occurring pervious material? ' Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environin r tal Protection and that the above analysis was performed by me consistent with the required tr ' g,exp ise ex ri nce described in 310 CMR 15.OI'* 44I� Signature Date SYSTEM PROFILE NOT TO SCALE TOP FDN. FINISH GRADE �� ; o FINISH GRADE OVER EL . �9 �' FINISH GRADE OVER 'o' DIST. BOX 7�-s" FINISH GRADE OVER 0..9 ' SEPTIC TANK LEACHING TRENCH D9 9 O 9 e 4..e RISERS TO 12" BELOW BRADE 4.0 •Q: �• •y :Q•b. .,. ..a.. b,•,a. p; •v o: .;a :p::o q.:o•o v,. 'v'3: p ..O C •.a •p•.q •O • O,',.0. V, <• .e:.0,6; .e:.9.'A:O. A.* e:•d.e o 3/" L O✓�✓ TOTAL TRENCH LENGTH - X o OUTLET PIPE LEVEL Z -� �% ' s" OF 1/8"-1/2" .v o' 4 FOR 2 FT. MIN. DOUBLE WAShW PEAS70NE o.A:o:po q. may, 7 CAP END rXETS CAP EN . o•.a.• C. L OR PVC TEES �'�'.�' c� . A•D• �o °oCj sir �,�,.G,!/.e __ "'Z.a.. ,4: 7y,o 0 24' 7h! 7�f 7•y. C o �•o. a0. MID- . 3/4" - .1-1/2" DOUBLE WASHED BSMT T. FLR. o'.'A:. o: 150 D GALLON CRUSHED STONE EL �,. �- DIS TRIBUTION BOX a , 00 0' u 4' INSTALL ON LEVEL BASE 4 PRECAST CONCRETE . TRENCH SIDE SECTION a _H . REINFORCED A' :R :p q. O.i a. o•d,.o : .0 •q•,d q:0 4 C dl a•Cl:A•a''0:•,V•:0,'4'.'o.' o•• p•.•v. Q'A .0.,A: p. :.•O A o' Q c •o » b.:a' o:.a' TRENCH END SECTION SEPTIC TANK INSTALL ON LEVEL BASE NOTE• EXCA VA TE TO ELEV. A11-4 OR LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEA TH THE LEACHING AREA / �" MrN.DIAM. 3 4" TO 1-1 2" 3" OF 1/8" REPLACE EXCA VA TED MA TERIAL WI TH DOUBLE WASHED `' " •r�,.. "''' A��'' f DOUBLE MASHED CLEAN, CLA Y FREE SAND CRUSHED TONE ASTONE 24" TRENCH WID TH GENERA L NO TES 1. ALL ELEVA TIONS SHOWN ARE BASED ON BSC TOPO 1'. ALL PIPES IN 7.,qE SYSTEM MUST BE CAST IRON ._ OR SCHEDULE 46 PVC. ,�--- � 0"�SER VA TION PIT THE BOARD OF HEAL TH MUST BE NOTIFIED WHEN CONSTRUCTION IS COMPLETE PRIOR P-9669 TO BACKFILL ING PERCOLA TION RATE: 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <2 MIN./IN. BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WITNESSED BY' ENGINEERING DONNA MIDRANDI . 5. MA TERIALS AND INS.TALLA TION SHALL BE IN BARNS. BRO. OF HEAL TH DESIGN . DA TA COMPLIANCE WITH THE S TA TE SANI TAR Y CODE TITLE V - AND LOCAL APPLICABLE DATE.' FEB._28s 2000 r \ RULES AND REGU�LA TIONS qy. � i �� ` T<�.� y ,*' ls . NUMBER OF BEDROOMS 3 • � 6. NORTH ARROW IS FROM RECORD PLANS AND --- IS NOT TO BE USED FOR SOLAR PURPOSES _ GARBAGE DISPOSAL NO 7. FLOOD HAZARD ZONE C (NON-HAZARD) ,�" B w L m a,,, ,a r rr DAILY FL ON 330 GAL . B. WA TER SUPPL Y TOWN WA TER p7 2 SEPTIC TANK REO 'D. 1500 GAL . 2 3Z. ,,,• SEPTIC TANK PROVIDED.. 1500 GAL . LEACHING REQUIRED 330 GPD. N \ b` 19 3 r o �' a N h - A4 m c� v ram► .S a "e4 �+ `D '3' ,3'� N \ \ y _ _ 11/ SIDEWALL AREA 236 S.F. r c y 2 G- 236S.F.X 0. 74 G/S.F. = 174 GPD. b o ro 1 BOTTOM AREA = 220 S.F. Z 3 a 2 LEGEND 220 S.F.X 0. 74 G/S.F. - 162 GPD --- --- _ _ _ 1 _ ,•o _ - y. ., - LEACHING PROVIDED = 336 GPD PROPOSED EL EVA TION EXISTING CONTOUR - 7e N� �: =tya�- SINGLE FA MIL Y RESIDENCE C `-`------- S OSSERVA TION PI T ❑ DISTRIBUTION BOX • '''' PROPOSED SEWAGE DISPOSAL SYSTEM PL A N Llee- E�4 CHING TRENCH ` PREPARED FOR o� SEPTIC TANK McSHANE CONSTRUCTION CD. .INC. Loverc� s� __. t; LOT 1 FOREST HILLS ROAD i n�in an �ePo .—_ __! RESERVE AREA Pad o 4A . COTUI T — BARNSTABLE •- MASS. Lochs 2S a 9AJHHG £$a ^e l�r►.,�._g. M.. .k �� DAVID c- Act � -�. �� l.. was.., .: T,5',/o PIPE INVERT ELEVATION � �a �'3 _2�00 8.4 . fop p.5 p`pe. .. . -.. , Q"o 3avinelle Q F f 1 ANI KI N CAPE 6 ISLANDS ENGINEERING PLOT PLAN , A S NO TED 800 FALMOUTH ROAD SU?TE 30.i SCALE: 1 "_ .�a' �s - �-i � ,.��:�� si� ��� ��g . ,: SCALE.' _ G� T Arlos O. ,xosZ„z��'cD NASHPEE, MASS. PLAN N