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Home My WebLink About0031 FOREST HILLS ROAD - Health 31 FOREST HILLS RVAP COTUIT A = 025 007 004 i , f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Y required for Cotuit MA 02635 May 18. 2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the n f computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name ' r� 189 Camrnett Road " Company Address Marstons Mills MA 02648 reR1 City/Town State Zip Code 508-428-1779 SI 12855 .Telephone Number License Number " B. Certification I certify that I have personally inspected the sewage,disposal system at this address and that the U_ co information reported below is true, accurate and complete as of the time of the inspection. The inspection C' 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 `A- Title 5(310 CMR 15.000). The system: no Passes L_ r.,� �_"2 ❑ Conditionally Passes ❑ Fails CD r "v ❑`,Needs Further Evaluation by the Local Approving.Authority hC, r-� f L May 18, 2011 Job# 11-81 In ector's 8Rgnature 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. v 2� Dispos t5ins•11/10 Title 5 Official Inspection Farm:Subsurface wage System• ge tlo1 1 . t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every page. Cityrrown 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. Ary failure criteria not evaluated are indicated below. Comments.- Recommend pumping tank. Leaching chambers were found at 50% capacity with no high stains 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): 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for Y every page. Cityrrown 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 Y q P P 9 Y st ucted 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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Y required for Cotuit MA 02635 May 18. 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments *� 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every 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 CM 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 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Y required for Cotuit MA 02635 May 18. 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: Tank pumped three years 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): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC (explain): other ❑ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1'feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for Y every page. Cityfrown 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 28" Scum thickness 3 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? 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.): Liquid level was found at bottom of outlet invert and tees were intact. Observed a trace of solids in outlet tee indicating the need for pumping. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every 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: 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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for Y every 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.): Observed_a trace of solids, no high stains present. Liquid level was found at bottom of outlet pipes. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: Two 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternatives stem Ely Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level was found at 50% capacity with no high stains. Cesspools (cesspool must be;'lumped 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 EUSUNM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every page. Cityfrown 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.): 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is required for Cotuit MA 02635 May 18. 2011 every page. Cityrrown 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 42 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ , \ ♦ ♦ ♦ \ \ \ \ , \ \ \ \ ♦ \ \ \ 29 . .... ........ ...... Front of House m r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 May 18. 2011 required for y every page. Cityrrown 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: 20+ 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: Low areas of abutting properties with no surface water are lower in elevation than bottom of SAS. 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•Pa 1 f g po y Page 6 0 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Forest Hills Road Property Address Dave Griffith Owner Owner's Name information is Cotuit MA 02635 Ma 18. 2011 required for y every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 o1 17 s.:;r-:y� 'it 3 a•�fia,x.}�� i.�° tea, x.: �� x�SI` b�''.�sr� 2.u+'•�.t n; �� &'�'l�"z,-t«�"4x• x+y .e '. .s- .-.yS. „2. 3 ... F. •zt � -r -.� 'tom' �•� r ,a '+ ,� yes�ik� TOWN OF BARNSTABLE LOCATION SEWAGE # 20 a9�t I t i VILLAGE__Ca", ASSESSOR'S MAP & LOT INSTALLERS NAME&PHONE N0. lf'Ri .. 7 76 `�45 C SEPTIC TANK CAPACITY /, '6Q LEACHING FACILITY:,(type) (size) i j- r . ..:NO. OF BEDROOMS BUILDER OR OWNER_ PERMIT DATE: -X 6 1COMPLIANCE DATE: • Separation Distance Between the: ..: - Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leachin Facili PP y g Facility (If any wells east =; on site'or within200 feet of leacEung facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300:feet of leaching facility) Feet Furnished by j C t a �=1 .. z c3,v01 , TOWN OF;- n BARNSTABLE LOCATION3( f"o(`��t' 0,MS 2 �E#`��1SP 'fit"d / '1 VILLAGE do-Wit-t- ASSESSOR'S MAP&PARCEL .I S NAME&PHONE NO. `r r1`L �C_.Q h I L/ -177 SEPTIC TANK CAPACITY S C LEACHING FACILITY:(type) I,CV., 4 L(,� (size) Jco QA A' q NO.OF BED OOMS OWNER PERMIT DATE: C0M=;A;=F-DAT9n I 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 tlands exist within 300 feet of leaching facility) Feet FURNISHED BY e f f f f f �r,\ \f\ kf\fh f♦f i .. '. - st. f F f f f f f f f f f f f F f 42 ff f f i f i f f i f f F f f f f J ••••................ \ 1 1 \ \ \ \ \ 1 \ \ \ \ \ -- f i ^^ xY� k \ \ \ \ \ \ \ \ \ \ \ '2 VU vf;JfJ;F;f Front of House 1 1 TOWN OF BARNSTABLE LOCATION 1c �q SEWAGE # 2()0-439'1 VILLAGE ASSESSOR'S MAP& LOT 25-7-y INSTALLER'S NAME&PHONE NO. �R�t✓mo w,` 7�"`�4�C,' SEPTIC TANK CAPACITY P;6Q LEACHING FACILITY: (type) t_m*,wt .. (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: --X 1241<S I COMPLIANCE DATE: `7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C Aj� t j I ?j7-, Ll No. ?'&vj THE COMMONWEALTH OF MASSACHUSETTS FEE 01'—r BOARD OF HEALTH (}/ O F � �rJ I PPLICATION FOR DISPOSAL SYSTEM CON . TRUCTION PERMIT Application for a Permit to Construct (V) Repair ( ) Upgrade ( ) Ahandon ( ) - Complete System ❑Individual Components Location Owner's Name 1� 1fJ oZ ocG c>oi-UO�4 ' Map/Parcel H Address Lol q I'Icphunc Co-OL Lot Installer's Nantr Designer's Name Address A Id,[t Telephone H Telephone H Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow( in. required)_G= gpd Calculated design flow 3 Qgpd Design flow provided 26�pd Plan: tiooil Number of sheets Re ision Date Title (( �� a� Descriptio (s) (�°' l `' tD"- 3(o rt � lAl3e�t �Jl�"" (�.C�" � � Soil Evaluator Form No. Name of Soil Evaluator t�SCLvu6CA., Date of Evaluation Z-Mz, DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE S and further agrees not ce the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ��g 4124wetkrkt s FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ® ---- ------ -- -- — i + 'No. THE COMMONWEALTH OF MASSACHUSETTS FEE1 41 �. BOARD OF 'HEALTH /►t/J�-kk, 79PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIOIIIN PERMIT Application for a Permit to Construct (�Rcpaii ( ) Upgrade (. )'Ahandun ( ) - 'ompletc System ❑Individual Components V N Location F Owner's Name Ka a Or_� c�o'i-�cs Map/Marcel# Address Lot# Installer's Name y Designer's Name Address � Ad�ss�n Telephone# Telephone# 'e Type of Building: Lot Size O Sq.feet Dwelling 'No.of Bedrooms Garbage Grinder ( ) Other—Type of-Building No.of persons C4? Showers ( ), Cafeteria ( ) Other fixtures Design Flow (pin.required) gpd Calculated design flow gpd Design flow provided 3' *d Plan: Date to` - Nvmber of sheets Revision Date Title .b T ' r Description o 1(s) "- ,P �• 3(0" - Zl." "'i " M.4. L If f Soil Evaluator Form No. Name of Soil Evaluator. 7. SGY J-C Date of Evaluation I-(2-C7Z� ,{ I 4 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. -;/a.-4 6 r.. Signed Date "4uspeetr6ns I'rYY.�.� /r✓J �i� G/ < FORM 1 - APPLICATION FOR DSCP 1 DEP APPROVED FORM 5/96 t r} i No. � THE COMMONWEALTH OF MASSACHUSETTS FEE Yr (�a,.-�,lfr"hG BOARD OF HEALTH .. 'Q CERTIFICATE OF CO PLIANCE Description of Work: ❑ Individual Component(s) Complete System, , The undersigned hereby certify that the Sewage Dis osal Syy(�,te Constructed'(,Repaired"( ),Upgraded( ),Abandoned( ) by: Of at has been installed in accordance with the visions of 310 CMR 15.00 (Title 5), and the approved design plans/as-built plans'relating to.application No.�/ dated 2 ` 4- G 1 Approved Design Flow (gpd) Installer Designer: Inspector Date 7 d .i The issuance of this certificate shall not be construed as a guarantee that th system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 I No. ' � THE COMMONWEALTH OF MASSACHUSETTS FEE -'"�� t +t ) +(A BOARD OF HEALTH DISPOSAL SYSTE/�' CONSTRUCTION PERMIT Permission is hereb ranted to Construct (✓) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at �� ►��bI' I /�� as described in the application for Disposal System Construction Permit No. Ze)e("� �,dated Q Provided: Construction shall be completed within three years of the date of this pe l it.All lop, nditfons m_u)stf a met. Date -'/2-6A Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARRENT"' PUBLISHERS- BOSTON _itt- 3 I r- - - - - - - - - - —: - I I I s� i I er-v 02 vT r•r f'�VT q•i Vr 11-4 VT - .r T-1D• a . oM s[GTWM E E E r IL 006 CMCKcr H NLIVINt4 BEDROOM 82 � arLs,MT is•-r x sr-s• I awn � .' - - - - -- - I s• ►+Av WALL A T FI w r-r ,U{s/fLLL o LOFT O � p Y LA O •-- —�y � Mau r us +'-s v borrooll." "WTI Q , ATTIC w d 4 - TiK LL � l -- -- --- ---------- rpe. _ ' f a > ZP PA I L -7« 1 ` ATTIC %x& i I GARAGE ROOF \ ► d 4r-v 632 8EC011D FLOOR PLAN W aF (OPT•L LOFT 211 SFL) F 41 o° rq � _ ;;j allalcllcwD S .r-4 Ur a c•-a yr r-r f-T r-r ram• Pt AT 1 Ra1M�O al �tlMl OR G I W ROTae sac �j ti VAIaTeD CtA✓114 1 4 To n-o- b j ZERO-CLIARA✓11Ca I I I Y raert ACe Q._,. I ri 0 I[AMA T 11 I 111 11 Q r S L I r I' Y 11y��/ �f-I I Oofta I If }I f! i �' 1 � OOl1IIRe i wI 111------I \ - _ �� I .:1 rAJIOVR ,I C1.0. e - MAO I"I sirx+ v7'IapEOIAn C T I - S&ILL roar g�� w y ON POCKET t t A VE: I R OWf- 7 I OIL t I 5 I O � L i+ b ® � loov�sreLL sewn L -r x f-�- -- - n If A-&. Pool • I ?I 1 A71 •• f-0 .^�. C fGl�.e LI II l A" I roar ® e a!OU Am I I 1 - I i I Wr ' 1 / r-O' /-C 09" I I 7 � � I �d! i O a yr O W t I •+ c- • r-'r C? cDrc. Arson r-,g si;• v-a r-a air g� r••s yr M-O-621-0 VT I , BREWSTER FIRST FLOOR PLAN FIRST FLOOR W/ I302 SF FLOOR ROOM acALL Vr -r-a FAMILY I bt:COMO FLOOR ul 6F � ' 7 TOTAL LIVMG AREA 2043 SF I I Q0� � � rrr Town of Barnstable P# qlB Department of Health,Safety,and Environmental Services �TME Public Health Division Date L� - 30-UO 367 Main Street,Iiyannis MA 02601 a,►ertsrneU& nuas. rEDrnu+"�� Date Scheduled -,QOC) Time `a 00 Fee Pd. 'D0. pt� Soil Suitability Assessment for Sewage Disposal Performed By: 7�4v r eV —S9 Witnessed By: LOCATION & GENERALINFORMATIO Location Address 3 �eS�- KIy�I S R.�- Owner's Name C k A.12 _ C� Address ��11 C Assessor's Map/Parcel: Mae t72.Cj PtACAk 001—VD 4 Engineer's Nameapf: 'Qko '" G NEW CONSTRUCTION REPAIR Telephone!# Land Use Slopes(%) Surface Stones Distances from: Open Water Body n Possible Wet Area tt Drinking Water Well R Drainage Way tt Property Line ft Other It SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) 4YY 5 of 07,- Parent material(geologic) o r 74wa f 4, Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DET'ERMINA I01�1<FOTt:SEASONAL;HIGI WA;UR'Y`ABLE Method Used Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment n. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Hate ? Z me Observation Z Hole H Time at 9" Depth of Perc Time at 6" Start Pre-soak Time® /O ,3 2 Time(9"-6") End Pre-soak Rate Min./Inch G Z Site Suitability Assessment: Site Passed '� Site Failed: Additional Testing Needed(Y/N) Original: Public Ilealth Division Observation Hole Data To Be Completed on Back—� Copy: Applicant DEEP.OBSERVATION HOLE LOG Hole# � Depth from Soil I loiizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel) 6 —(e /o Y A Sa..oe 7 G —J 4 40 re ,, '('0 r 3c-i-rp C d 6B y 2 DEEP OBSERVATION HOLE LOG Hole# Z Dcpth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell). Mottling (Structure.Stones,Boulderes. Consistency, Gravel) jt:-fY C, Sa roYAf �2 E'/� �✓/ca 6rr3 Yz{� 8y CL DEEP OBSERVATION HOLE LOG... Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° el DEEP OBSERVATION HOLE LOG Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Gravel) Flood Insurance Rate Map: Above 500 year flood bounda: No_ Yes Within 500 year boundary No Y Yes Within 100 year flood boundary No 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? `/ts If not,what is the depth of naturally occurring pervious material? Certification 1 certify that on �l�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 1.5.017. Signature � � Date 7—/Z CY-0 03 Lc)` N/F TOWN OF 5ARN3TABLE vI\jl u, P 0.X . cA `—d'"sLIV w -A Poavl A PEA SLU MM.A R Y LOTS ' --kAC. UPLAND, 267, 713- F. 6. 15 WETLAND; 0#5. F. OAC. up �Q TOTAL; 2671 713--'S. F. 6. 15=&A17. 2.8.8 % N\b*) ROADS 116, 189 -LS. F. 2. 67-4A C. 12.4%OPEN SPA CEUPLAND; 514, 568�WETLAND; 32, 116**S. F. . 0. 74�AC. ��,TOTAL; 546, 684$S. F. 1 5 'AC. 58.8% ,;� � TO TA L. 9 3 0., 58 6*S. F. 21 . 37 l00% y� OPEN SPACE P UPLAND=132. B18�S. f WETLAN0=0$�. F. ' TOTAL=132. 8''8 5. F 594.711 % Jo 58` /T N/F N/.F RAYMOND R. B /REIVE ANTONE 1 RODGERS t SOUZA 1 SYSTEM PROFILE TOP OF NOT TO SCALE FOUNDATION FINISH GRADE FINISH GRADE OVER EL. 76.0 EL. 75.0 SEPTIC TANFINISH K 74 8 VER DISTRIBUTION BOX 74.0 FINISH GRADE 'ro OVER TRENCHES 74.8 A RISERS TO 6" o %,o ° —OF FINISH GRADE - _ ° e' PRECAST CONCRETE r 500 GALLON DRYWELLS �O it '1 .i ��•.•.1 O ^c ! , I° r �i r r•o .§t'J' ;. -_.-.1-Q: 3"MIN. RISERS TO 6" b' MIN.SLOPE 1% °` '° OF FINISH GRADE ;. OUTLET PIPE(S) LEVEL H-10 REINFORCED LOADING JY 6" MIN.SLOPE 1% o ;/ FOR 2'( MIN.1% SLOPE TRENCH LENGTH = 25'-0" >� :_ MIN. 9 BEYOND r o = _ O I DRYWELL LENGTH = 8'-6" i �\0 73.14 -;� 13"MIN. 14" o _ a _ 72.88 MIN. 6 SUMP p �c �� . , 72.63 EW _ _ :1 , .. PVC OR CAST IRON TEES '< L; ,: ./ o,oa o0 71.18 `0, hSoo ,oa�a�h .1� ri ` 1"� 0071��, p . � .p: / �� r. °•L—� p v 0 1. .•1 U'°:1 1 � 1 �-r 0. /,s�.y/�--�+/.'•� / •f - -� t •^Z W w \6: DISTRIBUTION BOX cl 1500 GALLON J MINIMUM INSIDE DIMENSION 12" o �: 3/4"- 1-1/2" DOUBLE OUTLET INVERTS 2" BELOW INLET INVERT WASHED CRUSHED 3/4"- 1-1 2" DOUBLE 4, PRECAST CONCRETE �_ MINIMUM CONCRETE WALL THICKNESS 2 STONE WASHED CRUSHED —,o BSMT.FLR. .o,_,o-, �' H-10 REINFORCED INSTALL ON COMPACTED LEVEL BASE STONE ELEV. 68.5 1 '• :1 O�O ..��rr "1 1 0.1 r f '1 � I I" ' I�I;...'I 1 , - f I i 11 ,, c ' •, I o TRENCH SECTION f.i `II' Is Icy :4°• `1.• pro �' �' I'^o 0/ 0 /'O s sO� s.A;10 ,O., SEPTIC TANK INSTALL ON COMPACTED LEVEL BASE 9" MIN. 3" OF 1/8"- 1/2" 4" DIAM. 36" MAX. DOUBLE WASHED PEASTONE EST HILL � .. .�,"p;o. "1' ,. •„ �,o:,"' RO +I.c=p. .1 0 0 1 ° C.BASIN ` ' 'o' 0.., ' r ., 'oro "-,,3/4"` - 1-1/2" DOUBLE RIM EL.71.75 ® I 48" 1 51-211 ." STONED CRUSHED \ TRENCH WIDTH 13'-211 - - - 76 GENERAL NOTES: NUMBER OF TRENCHES 1 �TL4,ND �L�4 _ NUMBER OF DRYWELLS 2 1. ELEVATIONS SHOWN.,,ARE BASED ON ASSUMED - - -- - - - 2.ALL PIPES IN THE SYSTEM MUST BE CAST IRON OBSERVATION PIT _ OR SCHEDULE 40 PVC. 3. HEALTH AGENT/CAPE& ISLANDS ENGINEERING D78G LO MUST BE NOTIFIEDWHEN CONSTRUCTION IS PERCOLATION RATE: < 5 MINAN COMPLETE.PRIOR TO BACKFILLING. WITNESSED BY: D.MIORANDI o 4.ANY CHANGES IN-THIS PLAN MUST BE APPROVED BARNSTABLE BOARD OF BY CAPE & ISLANDS ENGINEERING AND THE BOARD HEALTH . lc OF HEALTH. DATE: JULY 12,2000 DESIGN DATA > 5. MATERIALS AND INSTALLATION SHALL BE IN �W COMPLIANCE WITH THE STATE SANITARY CODE 011 PIT#1 PIT#2 0 lW [TITLE VI AND LOCAL APPLICABLE RULES AND =A= LOAM =A= LOAM REGULATIONS. 10 YR 2/2 10YR 2/2 NUMBER OF BEDROOMS 3 I� 6. NORTH ARROW IS FROM RECORD PLANS AND IS 6" 6" GARBAGE DISPOSAL NO NOT INTENDED FOR SOLAR ENERGY PURPOSES. =6= LOAMY SAND =B= SANDY LOAM DAILY FLOW 330 GPD. S 80°g 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. - SEPTIC TANK REQUIRED 1500 GAL. 9 E 8. FLOOD ZONE C NON-HAZARD 10YR 5/6 10YR 5/4 40.311 [ 36" SEPTIC TANK PROVIDED 1500 GAL. I 9. THIS PROJECT DOES NOT INVOLVE ANY PHYSICAL 36" LEACHING REQUIRED 330 GPD. GROUND DISTURBANCE OR VEGETATION REMOVAL =C1= MEDIUM SAND w WITHIN 1 00' OF WETLANDS,INLAND OR COASTAL W/COBBLES ��,� BANKS OR FLOOD HAZARD ZONES. 10YR 6/6 6611 °'�a I 0 =C2= MEDIUM SAND SIDEWALL AREA= 152 SF. LOT 4 =C= MEDIUM SAND 21,706 SF'. 1oYR 7/4 1oYR 6/6 96" 152 SF. X .74 G/SF. = 112 GPD. =C3= FINE SAND BOTTOM AREA = 329 SF. #1 10YR 716 329 SF. X 0.74 G/SF. = 243 GPD. #2 LEGEND 120„ NO GROUNDWATER NO GROUNDWATER 120„ LEACHING PROVIDED = 355 GPD: 6 60, 52 PROPOSED CONTOUR SINGLE FAMILY RESIDENCE i ° � �I 52 EXISTING CONTOUR zs w~ °° '`'� PROPOSED SEWAGE DISPOSAL SYSTEM 0' ' OBSERVATION PIT PREPARED FOR a. / pRo '00 ❑ if DISTRIBUTION Boxy ' ",+ McSHANE CONSTRUCTION 3 p0 2?0 , _ \ r,. eFo sFo ° 14.00' ° ° ° A . LOT 4 FOREST HILLS ROAD 0w Rpo o � SEPTIC TANK „ j -7-s_ ; 4s.o0,F<<1NG M i r t BARNSTABLE-COTU IT,MASS. �� y � � Al I SOIL ABSORPTION SYSTEM •��'. I s4±•• N68 PLAN NO. 0,3 d qp/ SCALE:AS NOTED os92�'w \ RESERVE AREA , `� RESERVE FILE N0. j , rI !� DATE: 6,6 �o ��*��H of ��`r�� SEPTIC FILE NO. 1,aq PCS FILE: 22.26 PIPE INVERT ELEVATION n °AVID SI ' c CAPE & ISLANDS ENGINEERING I z z z PLOT PLAN 25 7-04 4 v) cn � 3, �r; Ett` ., �' 800 FALMOUTH ROAD, SUITE 301C SCALE: V = 30' MAP SEC PCL LOT HSE MASHPEE,MA 02649 (508)477-7272