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HomeMy WebLinkAbout0027 FOREST HILLS ROAD - Health 27 FOREST IIILL RIDAP COTUIT A = 025 007 003 1 r i� /VE to Air E • E h (STl fVG L$,A9,IC-ou► UAL L- : _ Aa= 3 14' etc--R6&M CA) TT OA ��- - .%EY,cST( NG FULL FGUNb/ T16R r P Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit . MA 02635 3/16/15 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered intj` way. Please see completeness checklist at the end of the form. Important:When A. General Information f filling out forms ' on the computer,. use only the tab Rey to move your 1. Inspector: �. cursor-do not use the return Carmen E. ShayF' key. Name of Inspector - Shay Environmental Services rab Company Name P.O.,B_ox 1576 Company Address Mashpee MA 02649 CityTrown State Zip Code 508-539-7966 3080 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: x❑ Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/16/15 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 uWder the same or different conditions of use. 3�3 -) 0 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 S Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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: System consists of a 1500 gallon tank, a D-box and one 12' x 25'x 2' long Leach Trench, consisting of 2-500 gallon chambers and stone. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA . 02635 3/16/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 T T Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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. El 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 El ❑x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 'L _ Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ x❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑x Any portion of cesspool or privy is within 100 feet of a surface water supply or. tributary to a surface water supply. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑x 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.] ❑ ❑x The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? 0 ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town State Zip Code Date of Inspection D. System Information Description: Tank, D-Box and one -12' x 25' Long Leach trench present consisting of 2-500 gallon chambers and stone. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes M No Laundry system inspected? _ ❑ Yes 0 No Seasonal use? ❑ Yes 10 No Water meter readings, if available (last 2 years usage (gpd)): Detail 76,000 gal -2013 59,000 gallons 2014 Sump pump? ❑ Yes Z No Last date of occupancy:. Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203):, Gallons per day(gpd) Basis of design flow(seats/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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: ' Source of information: Board of Health Was system pumped as part of the inspection? 0 Yes ❑ No If yes, volume pumped: 'k gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) 4 Approximate age of all components, date installed (if known) and source of information: 2001 per plan on file at Barnstable Board of Health Were sewage odors detected when arriving at the site? ❑ Yes ❑x No Building Sewer(locate on site plan): 2, 6„ Depth below grade: feet Material of construction: ❑ cast iron x❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20 feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: 0 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: 5' x 5' x 10' 6" Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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 23" Scum thickness 1/2 - Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" 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 in good condition. Inlet and Outlet Tees in good condition 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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 D-box Present 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.): Two outlets present to leach trench. no evidence of backup noted or of any carryover. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑x leaching trenches number, length: 12' x 25' trench 2-Chambers ❑ 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.): Opened chamber cover and Probed stone in field and found No evidence of backup noted. 1 inch Liquid on bottom. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 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 .-w•.a Sprint 101-28 AM taW, _ba S a rFr� t b t ma iiS�. z ........ ......... ................ .......... .......... .............. ......... ......... _.._.. ._......................................................... rowrr of BARIvsTABL� LOCATION a�:.'Z ��t+e�� .t 4ta. sswAcl=tt 2ap+ r os VB.LAGF t''t.��� AssPSSbR•s i4lAP�I..or Q=�s'��m I . tNS'r.AJ 7 FR'S NANM,&PfiONE NO.. Cie. -es.-, SEpTic TAwjc CAPACrrY r' S�Cs LHA.CE.BNG.FAC'Q..; (type)) C�„r bS�-� RCS, (size) Z.'7jk_]e ;�� tVO.OF BEt?ROOMS 3 BUMMER OR OWNER. I�RMITt7A'I76: - COMp[.IIRNCE DATE: Separation Distancc'Bctween the: Maximum Adjusted Groundwater-rabic to tha Rottom of Leaching Facitity Fact Private Waxer Supply Wcll aad 1. hing Facility (If any wells exist on sit.or within 200 feet of Icaching facility) Foot Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of Leaching facility) Fad ��zrnishea ey GZR It-7 B3�37` z 3 ti i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: Over 10 feet+ feet Please indicate all methods used to determine the high ground water elevation: ❑x Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: TopoObtained records for the site and surrounding properties. ❑ Checked with local excavators, installers -(attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Obtained engineered plan from 2001. no water located at 128". Bottom of SAS is at 6 feet below grade. Hand augered to 120 inches to confirm no groundwater. at least 4' separation present. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 9 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form i' information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 27 Forest Hills Road Property Address Judith Murray Owner's Name Cotuit MA 02635 3/16/15 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x 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 a t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _ a C C i TOWN OF B:ARN5TABLE LOCATION 2a01=161 VILLAGE_ —ASSESSORS MAP & LOT INSTALLER'S NAN E 8z PHONE SEPTIC.TA NK CAPACITY /SOO i LEACHING.FACILITY: (ty Cabr� ( a, (size)� .�. X �lS NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE:. COMPLIANCE.DATE: Separation Distance Between the: Maxtmum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well Leaching Facility.(If any wells exist :,On,site or w1dun:.200;fee(:of leachin:g.facility:) Feet `Edge of Wetland and Leaching Facility.(If any wetlands exist within:39Q feet of leaching facihry) — Feet - Furnished by _. _... I _ I i f � '2 I LF -fin 1 Lh z� zjh€ :�� , 1 .Q 1 01 N IF TOWN OF BARNSTABLE 17.289 ` ` I ovo ' L'.P. cA 'r o c3, •, A PEA S 1 LOTS rnl UPL AND; 267, 713-kS. F. 5. 15-kA C. cry WETLAND; 0#S. F. O--kAC. u TOTAL; 267, 713-*S. F. 6. 15-4AC. 2.8.8 % ROADS 116, 189 =kS. F. 2. 57-4AC. 12.4% OPEN SPACE 11 . 81-&AC. UPLAND; 514, 568�5. F. — • u, WETLAND;. 32, 116-*S. F. 0. 74�AC. � , m TOTAL; 546, 684&S. F. 1 s2 5�AC. 58.8% �,�• car TO TA L: 9 3 0.,58 6$S. F. 21 . 37 l00%° �G• OPE,'V SPA CE 46 GP UPLAND=132. 818$S. f PIE TLAND=O$�. F . TOTAL=132. 8 R 4.711 S;3o 88' 17LI N/F N/.F RAYMOND R. & I RENE AN TONE f 1 RODGERS ' SOUZA 1 Town of Barnstable P# Abil %,// Department of Health,Safety,and Environmental Services �t Public Health; Division Date 2-.3—b0 367 Main Street,I lyannis MA 02601 eeruvareerE. �rtnrud� Date Scheduled Z ' Z 8' c7 � Time Fee Pd. ly(D Soil Suitability Assessment for Sewage Disposal Performed By: .Z)OLL) t �Q - i� _ Witnessed By: P o s,.e.c i4-4 i o r + e, �r LOCATION & GENERAL INFOIZMATION Location Address 7 1drF�,� 1�``� Owner's Name ��� �, .}— v Address 1 Assessor's Map/Parcel: (�j� ZG� (�Q� (�U�-t�3 Engineer's Name L f.- �10.� NEW CONSTRUCTION REPAIR, Telephone# 1 Land Use r`°u a <f t aI 4V; Slopes(%) Surface Stones Distances from: Open Water Body R Possible Wet Area R Drinking Water Well R 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) �l �L —0— 1 Kb Q I Parent material(geologic) �`��r'Oir 4 Depth to Bedrock Depth to Groundwater: Standing Water in Ilole: Weeping from Pit Face Estimated Seasonal High Groundwater DTCRMINATIOlV 1♦~OIZ SEASONAL HIGII WA'TEI2'1'AI3YE Method Used: Depth 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 ... P ...ERCOLATION:TEST: Dale Time t _ _ Observation tole# Time at 9 Depth of Perc fG Time at 6" Start Pre-soak Time© Time(9"-6") y� End Pre-soak Rate Min./Inch L'L Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public I lealth Division Observation Hole Data To Be Completed on Back Copy: Applicant DEEI'.OBSERVATION HOLE LOG Mole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % I( ' /0 l ,36 i zo' C "✓' �0 2 616 DEEP OBSERVATION HOLE LOG Hole# 2; Depth from Soil I lorizon Soil"fexlure Soil Color Soil Other Surface(in.) (USDA) (Munscll) Mottling (Structure.Stones,Doulderes. 0 G ,-36 $ Lo» Y �o J2 r/4 DEEP OBSERVATION HOLE LOG Hoe#'. ' Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Douldcres. Calislaigncy.0 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil I lorizon Soil•fexlure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. Consistency.%Gravel) Flood Insurance Rate Man: Above 500 ycar flood bcunda:y No_ Yes W ilhin 500 year boundary No V Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at leastff u'r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? 17_e .s If not, what is the depth of naturally occurring pervious material? Certification 1 certify that on `�s� (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 z .— Z�—`� C� TOWN OF BARNSTABLE y LOCATION W`\,,�, U� SEWAGE # Ay-.01 �S VILLAGE zV,"T ASSESSOR'S MAP & LOT O(�-JCS. INSTALLER'S NAME&PHONE NO. Q�C ih SEPTIC TANK CAPACITY /SOO LEACHING FACILITY: (type) C t3w§ ia-'-!, a, (size),c3a�• NO. OF BEDROOMS 3 \\ BUILDER OR-OWNER MC AN. cov 7 PERMITDATE: COMPLIANCE DATE: D Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet r . Furnished by i cZ. 97' I C-s 3y =N�y2 No. THE COMMONWEALTH OF MASSACHUSETTS FEE p6i ( BOARP OF HEALTH UAPPLICATION OF (j FOR DISPOSAL SYSTEM CON TRUCTION PERMIT Application for a Permit to Construct ( V/Rcpair ( ) Upgrade ( ) Ahandon ( ) - /ompletc System ❑Individual Components Lko (M4-1 �Vo��V� � Owner's Namc Mapwarcel H Address Lot k I'cicphonc k Installer's Name —����— Designer's Nam Address ddress Telephone it Telephone Z Type of Building: Lot Size) 4 Sq.feet Dwelling—No.of Bedrooms L;P 3 Garbage Grinder ( ) _4 Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures _ Design Flow(min.required) T99 gpd Calculated design flow gpd Design flow provided —3e6gpd Plan: Date - -©C7 Number of sheets Revision Date Title Description of Soil(s) `. t t " milSLR Soil Evaluator Form No. Name of Soil Evaluator ' Date of Evaluation ,1 �( DV 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 un'I a Certificate of Compliance has been issued by the Board of Health. Signed Date. I i FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO. W / THE COMMONVI%E:ALTH"OF MASSACHUSETTS Fee `av/ (' BOARD OF HEALTH " - O F &MW : _ ' APPLICATION FOR DISPOSAL SYSTEM CON TRUCTION PERMIT Application for a Permit to Construct-( VRcpnir ( ) Upgnide ( ) Abandon ( ) omplcte Systtfii'- 'Individual Components Location _ - Owner's Name -. M-CL P/0'e; nc 1 0o"1-06 3 I MaIlWarcel# ,�Y Address Lot H `tcicphonc h t A at-,f u �.� r. Installer's Name T Designers Nam } Address ntdress t �-�-� f "telephone A� -telephone N Type of Building: Lot SizeD 1 1,A IOd Sq.feet ' i Dwelling---No.of Bedrooms IbF - Garbage Grinder-,( Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) 4 !"4 Other fixtures t d Calculated design flow d Desi n flow provided d Design Flow(min. required)�gp g _��gp g r p ��,gp • ;l Plan: Date -DO Number of sheets Revision Date f. v how ;'Description of Soil(s) th Soil Evaluator Form No. Vame of Soil Evaluator �' Date of-E-valuation O� aDESCRIPTION OF REPAIRS OR•,ALTERATIONS i F Th undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of F TITLE 5 and-furthelr agrees not to place the system in operation un it a Certificate of Compliance has been issued by the Board of Health. .. Signed G .ram Date . , --�. . . - 115pecti®ns I 6c 3 Ila I. FORM t - APPLICATION',FOR DSCP- DEP APPROVED FORM 5/96 . 'No.� , c ,THE COMMONWEALTH F MASSACHUSETTS - --.FEE / .. r r OARD OF HEALTH f CERTIFICATE OF CO LIANCE Description of Work:( ❑ Indiv(idual'Component(s) omplete,System - -,The undersigned hereby certify that thee -Sewage Disposal Systeem� `Constructed(,t/);Repaired( ),Upgraded( ),Abandoned( ) •- by: C. �. /�� ter_ 5 f at O V U'G p 1- s R �� y7,, AAA- has been,installed in accordance with the provisions of 310 . MR 5.00 (Tit 5) and the approved design Tans as-built t plans relating- .,applicatio No:( f�( l dated Approved Design Flow �.� (gpd) Installer Designer: Inspector G L 1 A ate zo io I The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 fNO -&,V THE COMMONWEALTH OF MASSACHUSETTS FEE 40,WnJ 4-k4 BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT r _ Permission is herebyred to Construct )*"Repair Upgrade Abandon an inidual sewage granted� ( ✓) P ( ) Pg div e( ) ( ) g I disposal system at ��✓GS �.1 /�� �� �� A� as described f in the application for Disposal System Construction Permit No. /��' ��,dated W? Mel Provided: Construction shall be completed within three years of the date of this pe . it.All locale itions !t be�net. Date T/ C/o/ Board of Health!A*,( / FORM 2 - DSCP DEP APPROVED FORM 5/96 Y FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON f -._ ._.. __ _..1... --..... - r �+ d r - s I � -. Vr r-r r-4 wr W-4 Vr r-d yr _r T-0- 11� •rZ� � � .- I rp1 ai . T TT D•-r OPTIONAL 7- g� r •` � 8�l room \ __ _ / � 006 csocef E H 4 BEDROOM 12 /ICTIYd/f . I MMAD. / it r x -s' F 3 .fi L• � NAI, Wll �` r-r KUSIALL ATW O O LOFT D� aj u -- r-s v oo►naw War) i rA alAAd .TTfC ATTIC --- -- ---H----------- fa. > • Cl Aa a s I � i • ► m —r TIC4x 1 I GARAGE ROOF ` / I #`3 r� N o II Ugt $ECOkD FLOOR PLAN cu aF (oFT-L Lori zn sF) SCAiIL yr - r-o- t ■ 00 O\ -a tr rr I II 1 J K � 13) A W 1 ) K b0 ! � PLAT r-r 1 10•-r ] 1 h ancz R T�+q OR G 4 fa ■orf• s&c ♦, ' f0-4 CfAa116 I O [�' � I MRIA r 1T�1/?• 111u-311 t I � II C 11 1 f --ff11 T y A I VLL r sr 1Z/qXi Ir+'tideawr O' 1 C y ral 1 vr- . Q b � -�--,--� ►OCRfT Ow ± w �!! , �'_D• I R® OIL o I V C • wove fnu sewn • Pa _ f � IfLA11D � �.1 i n 7-P POST • 6 X 1 Y1 e two to A 434 t� 1 � Yr I-p I *Art o G �- G 0 • 6 W l A `G �' 1 C 3 COW. A►Rp .. -�yr A, ?•Y-1 VT I-f fiT r r V N-0 t8§T FLOOR PLAN ell I'r To- FAMIL FLOOR IL/ 1382 s✓s n ' sacoNo°OOR a'G ®1V►S!®A q ���1ih J i�TOTAL LIVING AREA 2043 sF': - )s �, C G ofi B ;own u e 0260� a oa 0 Box 534 r tlyVRWS,M75 3344 z(Z 0 � Fax�50a50a,194-6265 t hone ------.---- _.. SYSTEM PROFILE TOP OF NOT TO SCALE FOUNDATION FINISH GRADE FINISH GRADE OVER EL. 70.8 EL. 69.3 � FINISH GRADE OVER DISTRIBUTION BOX 66.0 0 SEPTIC TANK 66.2 FINISH GRADE OVER TRENCHES 65.5 _RISERS TO 6„ _o''o' yo { OF FINISH GRADE yo v PRECAST CONCRETE {° ; -..,� .'� ;''0, •b b 500 GALLON DRYWELLS 3"MIN. RISERS TO 6" b' H=10 REINFORCED LOADING ° OF FINISH GRADE ;, OUTLET PIPE(S) LEVEL < \ _;o MIN.SLOPE l% - 3 FOR 2'( MIN.1% SLOPE TRENCH LENGTH 25-0" 6" .° MIN.SLOPE 1% ° Q BEYOND MIN. FO i DRYWELL_ LENGTH = 8'-6" r o 13"MIN. 14" L ,` L, 64.22 64.00 61,SUMP MIN. ° 9,v , OG — '�' PVC OR CAST IRON TEES <;� 63.30 �kzx, : '°: od��'°�, ;: '.�'T '°:'0 007'& 0 '' .0,� .gib bi���: '•'' , '•r �''bp'` ' ' �`` � �6_ DISTRIBUTION BOX 61.90 ; � �' ':, ►:; : ';:_ d GAS �0 1500 GALLON o BAFFLE MINIMUM INSIDE DIMENSION 12" 3/4" - 1-1/2" DOUBLE 3/4"- 1-1 2"DOUBLE , ��' OUTLET INVERTS 2 BELOW INLET INVERT 4' WASHED CRUSHED WASHED CRUSHED 4 ° PRECAST CONCRETE MINIMUM CONCRETE WALL THICKNESS 2" STONE STONE INSTALL ON COMPACTED LEVEL BASE H-10 REINFORCED BSMT.FLR. � _ � :,, ELEV. 63.3 oJo _ 16- TRENCH SECTION SEPTIC TANK INSTALL ON COMPACTED LEVEL BASE 9" MIN. 3" OF 1/8"- 1/2" FOR 4" DIAM. 36" MAX. DOUBLE WASHED EST HALLS R� _ PEASTONE • _ - 6... 6 � `^° • ,� . �,�.:, o o;o.(.,o 0 3/4"- 1-1/2" DOUBLE 1108, WASHED CRUSHED STONE 48" 5'-2" j TRENCH WIDTH 13'-2" — ' GENERAL NOTES: NUMBER OF TRENCHES 1 17.9' NUMBER OF DRYWELLS 2 1. ELEVATIONS SHOWN ARE BASED ON ASSUMED 2 ALL PIPES IN THE SYSTEM MUST BE CAST IRON OBSERVATION PIT M OR SCHEDULE 40:PVC. Cj 3. HEALTH AGENT/GAPE & ISLANDS ENGINEERING WETLAND EL.42.0 i T- MUST BE NOTIFIED WHEN CONSTRUCTION IS P-9676 COMPLETE PRIOR TO BAv FILLING. PERCOLATION RATE: < 5 MIN./IN. 4. ANY CHANGES IN Th115 PLAN MUST BE APPROVED WITNESSED BY: D.MIORANDI \ BY CAPE &ISLANDS ENGINEERING AND THE BOARD BARNSTABLE BOARD OF HEALTH co \ of HEALTH. DESIGN DATA I 5. MATERIALS AND(IINSTALLATION SHALL BE IN „ PIT#1 DATE: FEB..28,2000 PIT#2 0„ COMPLIANCE WI1�H THE STATE SANITARY CODE 0 _ _ =AW= LOAM \ [TITLE V]AND LO AL APPLICABLE RULES'AND =AW LOAM — II / \ REGULATIONS. 10 YR 2/2 10 YR 2/2 NUMBER OF BEDROOMS 3 \ 6. NORTH ARROWS FROM RECORD PLANS AND IS 3" _ _ 6" GARBAGE DISPOSAL NO LOT 3 co NOT INTENDED FOR SOLAR ENERGY PURPOSES. _B_ LOAMY SAND =B=SANDY LOAM DAILY FLOW 330 GPD. yuw 21,96�8 SF. 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. 10YR 5/6 10YR 514 SEPTIC TANK REQUIRED 1500 GAL. I �% \ ' 8. FLOOD ZONE C [NON-HAZARD] 36 SEPTIC TANK PROVIDED 1500 GAL. 9. THIS PROJECT DOES NOT INVOLVE ANY PHYSICAL 36 LEACHING REQUIRED 330 GPD. ��, GROUND DISTURBANCE OR VEGETATION REMOVAL ' \ WITHIN 100' OF WETLANDS,INLAND OR COASTAL a 1 I BANKS OR FLOOD HAZARD ZONES. 66 =C= MEDIUM SAND =C= MEDIUM SAND SIDEWALL AREA — 152 SF. 1oYR 6/6 10YR 6/6 96 152 SF. X .74 G/SF. = 112 GPD. BOTTOM AREA = 329 SF. p I �� I 329 SF. X 0.74 G/SF. = 243 GPD. I ' I LEGEND NO GROUNDWATER LEACHING PROVIDED = 355 GPD. 120" NO GROUNDWATER 120 11�00 I 1 52 PROPOSED CONTOUR CC? 110I I SINGLE FAMILY RESIDENCE co ; 52 EXISTING CONTOUR I � � r PROPOSED SEWAGE DISPOSAL SYSTEM OBSERVATION PIT PREPARED FOR DISTRIBUTION BOX MCSHANE CONSTRUCTION LOTS FOREST HILLS ROAD Fo__o__ol SEPTIC TANK BAR NSTABLE-COTU IT,MASS. SOIL ABSORPTION SYSTEM l PLAN NO. 040601 SCALE:AS NOTED ��\ RESERVE RESERVE AREA ,,, �� FILE NO. 361 DATE: APR.6,2001 �, �s�� \ V7 SEPTIC FILE NO. 69 PCS FILE: FORESTHILLS 22.26 PIPE INVERT ELEVATION ' sw 0.18' �. CAPE & ISLANDS ENGINEERING 0 0 0 , 800 FALMOUTH ROAD SUITE 301C PLOT PLAN 25 7-03 3 > > > MASHPEE , r • ,MA 02649 (508)477-7272 SCALE: 1" = 30' MAP SEC PCL LOT HSE L + ,