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HomeMy WebLinkAbout0039 FOREST HILLS ROAD - Health 39 FOREST HILLS DR.V?C-- COTUIT - - - A = 025 007 005 ii I Commonwealth of Massachusetts Title 5 Official Inspection Form COPY Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 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 the r /� �/ computer, r,use 1. Inspector: '�/n J< only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-6055 SI 12843 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 1_5.34�§f Title 5(310 CMR 16.000).The system: =� ® Passes ' ❑ Conditionally Passes ❑ �Fas a �; � c ❑ Needs Further Evaluation by the Local Approving Authority — X ? November 2, 2010 r Inspector's Signature y" Date I The system inspector shall submit a copy of this inspection report to the Approving Authority(Board Qf 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•09/� Title 5 Official Inspection Form:Subsurtace Sewage isposaI System•PaD,of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28 2010 every 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: 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 determine ' (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years d*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial i iltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is eplaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass insp tion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is less than 20 years old is available. ❑ Y ❑ N ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 2 f Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break otit or high static water level in the distribution box due to broken or obstructed pipe (s) 'a broken, settled or uneven distribution box. System will pass inspection if(with app of Health): ❑ broken pipe(s)are ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remo ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is laced ❑ 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 the Board of Health: ❑ Conditions exist which require f her evaluation by the Board of Health in order to determine if the system is failing to protect ublic health, safety or the environment. 1. System will pass unle Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sys m is not functioning in a manner which will protect public health, safety and the environ ent: Cesspool or ivy 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Jr 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 every 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 oil absorption system (SAS)and the SAS is within 100 feet of a surface water supp or tributary to a surface water supply. ❑ The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic to and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water suppl well". Method used to determine dist nce: This system passes if the w I water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent an he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t t no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..'< 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 every page. Cityrrown 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. ❑ ® An portion of a cesspool or privy is within a Zone 1 of a public well. YP P P Y ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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" "no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 0 feet of a surface drinking water supply ❑ ❑ the system is wit n 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is I Gated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWP or a mapped Zone II of a public water supply well If you have answered"yes"to a question in Section E the system is considered a significant threat, or answered"yes" in Section D bove the large system has failed. The owner or operator of any large system considered a significa t threat under Section E or failed under Section D shall upgrade the system in accordance with 3 0 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ment. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28 2010 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): 1355 GPD t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28 2010 every page. City/Town 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 Seasonaluse? ❑ Yes JZ No Water meter readings, if available(last 2 years usage(gpd)): 2009=263 GPD2010=271 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 1/system? Gallons per day(gpd) Basis of design flow(seats/person Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No Non-sanitary waste discharged to t ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 ial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter records: Pumped Aug 2009 Was system pumped as part of the inspection? ❑ Yes 0 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is Cotuit MA 02635 October 28 2010 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed Jan. 5, 2001. As-built and Certificate of Compliance on file at Health Department. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 119"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: 11'X 5.5'X 4.5' 1500 gallons Sludge depth: 1" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 every page. CitylTown 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 39" Scum thickness 1.5" 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 13" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fibe glass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top o/et r baffle Distance from bottom of scum to bet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 20110 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiber lass El polyethylene El 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 d float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .' 39 Forest Hills Road_ Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 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.): One inlet, two outlets w/speed levelers in place. No solids carryover. No high water staining over outlet inverts. D-Box is H-10 and at edge of stone driveway. No sign of leakage into or out of D-Box. 3 feet below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump//amber, ndition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i lug 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ea.w/4'of stone. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to locate and inspect chambers. Liquid level 1"from base of system. 17" below invert. No sign of past hydraulic failure. Cesspools(cesspool must be pumped as part of"nspection) (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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28 2010 every page. Cityrrown 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, sign of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is Cotuit MA 02635 October 28, 2010 required for C'ItylTown State Zip Code Date of Inspection every page. 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 �l Qs'� �� O O C `� J 3 33 N � f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 t5ins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28, 2010 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: 24.5 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: July 12, 2000Date ❑ 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: No ground water found during test hole for install. Engineered plans show adjusted ground water level 24.5' below base of SAS. Base of SAS elv=66.50 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 39 Forest Hills Road Property Address Laura Nickerson Owner Owner's Name information is required for Cotuit MA 02635 October 28 2010 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 c� TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE ASSESSOR''S- MAP&PARCEL Oa,,�-o07-<7-s®5- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �.�oc�,� �Ch..w��z t5(size) w/ 5/ NO.OF BEDROOMS 3 OWNER �ac�,-.A �►e�Y„t-SOS, PERMIT DATE: a, `l pc-) COMPLIANCE DATE: 6 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 �bc�.q p,.%I - 0 O O c 1l Aa � a7 c Y .n p. U+ TOWN OF BARNS ABLE G LOCATION 3� r�si �Ii�IS �6 S SEWAGE # 260 O- 43L/ VILLAGE L IA— ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. S %A_ V 79' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) )P f'S �2 \ (size) Sf00 NO.OF BEDROOMS BUILDER OR OWNER g �° PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist , ' within 300 feet of leaching facility) Feet Furnished by k_. A �3z ' } Az k �37 ' A3=30 B3 ^yv. lay : ' } No. J n06,9 - L1,3 y THE COMMONWEALTH OF MASSACHUSETTS FEE (go � BOARD O,F�, (,H E A LT H - a ' Lt APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct j Rcpair ( ) Upgrade ( ) Abandon ( ) DComplete System ❑Individual Components Vl> ib(Py i Cyr► . Location Owner's Name OC� Map/Parcel q Address v Lot H � fcicph nc t! , Installer's Name �� Designer's Nam Address Ad'ress Telephone P - Telephone# Type of Building: Lot Size 50 Cl' 0 Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder ( ) Other—Type of Building No.of persons (,5:1 Showers ( ), Cafeteria ( ) Other fixtures Design Flow in. required) S gpd Calculated design flow J�!)Ogpd Design flow provided_5ss gpd lan: t P ate - 00 Number of sheets I Revision Date Title TT�� Description f Soil(s) O,- " G'l/titi K t t 3ta`'- C) Soil Evaluator Form No. Name of Soil Evaluatorc-7->. Date of Evaluation `7-l Z-00 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned reel to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu :age not to a the system in operation until a Certificate of Compliance has been(issued by the Board of Health. Signed Date , Q(� Inspections FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 TOWN OF B STABLE LOCATION Las SEWAGE # ) y3c/ VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 17 OU LEACHING FACILr Y: (type) A bPrS ��� (size) SOC tyn nF nFr�u Mc � BUILDER OR OWNER hAS PERMTTDATE: COMPLIANCE DATE: �. Separation Distance Between the: 1 1 Maximum Adjusted Groundwater Table to the.Bottom of Leaching Facility Feet Private Water.Supply.Well and Leaching Facility (If*any wells exist . L. '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 We Furnished by 71 . a Fj , . No. Jd0 � L� THE COMMONWEALTH OF MASSACHUSETTS FEE, DO BOARD OF. HEALTH, _ ��3blrY:l OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (1/Repair-( ) Upgrade ( ) Ahandon ( ) - �Completc System ❑Individual Comp nests Location Owner's Name `Ih��J �� DCI• 007-00� �• Map/Parcel N - 'Address I r Lot N ff lllcph ne N r, Installer's Name Designer's Nam Address Address �. 4 -12j, - ---Telephone It Telephone N t I Type of Building: Lot Size l50 Ct 0 Sq.feet Dwelling No.of Bedrooms .J� Garbage Grinder ( ) Other—Type of Building No.of persons L!V' Showers ( ), Cafeteria -( ) Other fixtures Design'Flow in. required) r�' �. gpd Calculated•design flow 3_5Ogpd Design flow provided�s5 gpd �:.. Plan, �(7 "Number of sheets Revision Date ' Title ' I tDescription f Soil(s) .. �° CUAA t - I l Sgotl Evaluator Form No. Name of Soil I aluatorc-t--.SOLy�i[ �.t � Date of Evaluation F DESCRIPTION OF REPAIRS OR ALTERATIONS f ' r > . The undersigned es to install the above described Individual Sewage Disposal System in accordance with the provisions of = TITLE 5 and fort e>r�ogre not to ace the system in operation until a Certificate of Compliance hus been issued by the Board of Health. t +F. Signed ,Date 1610 Inspections" .. � i 1 FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 .. ---------- No. THE THE COMMONWEALTH OF MASSACHUSETTSE BOARD OF HEA-L—TH I CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete S stem The undersigned hereby certify that the Sewage Disposa System;Constructed( Repaired( ),Upgraded( ),Abandoned( ) by: R!C UE 3 C at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built '`. plans relating to application No. dated Approved Design FloXV (gpd) Installer U ( Designer: Inspector l 1N Dat'� The issuance of this certificate shall not be construed as a guarantee that thel system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 -------_---------I- �---------- ---_- -- -,_-- - I No. �LAe,!t,- 4c3y THE COMMONWEALTH OF MASSACHUSETTS FEE 1Dl.� BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct .J Repair ( ) Upgrade (. ) Abandon ( ) an individual sewage f disposal system at !__ �n"r i:' ,r i�1 £`! L`l C54- tb as described in the application for Disposal System Construction Permit No. C'�Q J7 dated { Provided: Construction shall be coppleted within three years of the date of this erntit.All local conditio s-muu be met. I c---� j Date �/t= � � �� �t� Board of Heal �'� ,, " FORM 2 - DSCP DEP APPROVED FORM 5/96 I FORM 1255 (REV 5/96) H&W HOBBSS WARREN rM PUBLISHERS- BOSTON a. I A' G i \ � N/F 3 TOWN OF SARNSTABLE 17,2t, ' U.P. 0.4C c A PEA S LUMMA P Y LOTS UPLAND; 257, 713--i-S. F. 5. 15---*AC. cq WETLAND; O-+S. F. O--.*AC. k-n TOTAL; 2671 713=L-S. F. 6. 15=1AC. 28.8 % N_ POADS 116, 189 45. F. 2. 57='AC. 12.4% OPEN SPA CE UPLAND; 514, 558-L-5. F. 11 . 81-4AC. WETLAND; 32, 116-5. F. 0. 74-AC. TOTAL; 546, 584-S. F. 12. 55-AC. 58.8010 �r TOTAL 930., 586-5. F. 21 . 37--LAC. 100 % ' ' 9 .r OPEN SPACE P UPLAND=132. 818tS. WETLAND=OAS. F. ' TOTAL=132. 818-S 594.7 S36' 58' ri-' N / F N/F RAYMOND R. 8 IRENE ANTONE RODGERS I SOUZA 1 1 Town of 11arnstable P# 6(1�0'�_ Department of Health,Safety,and Environmental Services �tH Public Health Division Date lo�3Qo b 367 Main Street,Hyannis MA 02601 aAaNereeM Date Scheduled y Time kOpo Fee Pd. `00 Soil Suitability Assessment for Sewage Disposal Performed By: �ri vi�� S4 •� /�r Witnessed By: I-)d a q /y/i r D 4 A4.01i LOCATION & G.ENERAL INFORMATION ], Location Address VisitS+ \,l It S D , Owner's Name MC-S VLC t 11✓IV-� Address /1 `_ n_ _ Assessor's Map/Parcel:1'v q a Gj PG\ OD1-�� � Engineer's Name 1 ! ►af � NEW CONSTRUCTION ✓ REPAIR Telephone Land Use Slopes(%) Surface Stones Distances from: Open Water Body R Possible Wet Area ft Drinking Water Well R Drainage Way R Property Line R Other R SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) o O [ z I i Parent material(geologic) Ou 7e u+4! Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater bv.T..... YOIV 'OTt`SLASONAL HIGI WAT"ETt TAIL ..__ 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 R. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Dater-�<z—d�rirne Observation Z Hole# Time at 9" Depth of Pere L O Time at 6" Start Pre-soak Time® /a .4"s, Time(9"-6") End Pre-soak /! D 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 Backj Copy: Applicant ^ ,}•_ail.. DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,noulderes. % Sa,&d r 36— /to �' s��( e• y2 �l /tla Cj a K /fir DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil I lorizon ( Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,noulderes. oGravel) O — G �w �04 -� /e yIZ Z/4 / DEEP OBSERVATION HOLIJ LOG' Hole# Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. oGravel) DE EP..OBSERVATION HOLE LOG Hole# Depth froin Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. .Consistency,° Gravel) Flood Insurance Rate Map: Above 300 year flood boundary No_ Yes Within 500 year boundary No Yes v 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? yes If not,what is the depth of naturally occurring pervious material? Certification I certify that on '7� `lS`_(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 tra�inm xpertise and experience described in 310 CM 15.017. Signature I Z—crcl Date S YS TEM PROFILE NOT TO SCALE TOP FNDN. FINISH GRADE EL . FINISH GRADE 72. S FINISH GRADE OVER FINISH GRADE OVER OVER TRENCHES 1Z .0 DIST. BOX_ I. D ' 'o.�'•4 o SEPTIC TANK 7 I . 9 � p..o.p0rJJll s 12" MAX. . e�f e: .ro....n ::p'. :OG•;4�.��;:ri:'::Q.of D•4'�w.a�!?p�'b��i�'v°• � •e'b•D.•.! 1 D OVOTI p TOTAL LENGTH OF TRENCH 2-S"3 a ._ -- . OUTLET PIPE LEVEL _ . . FOR 2 FT. MIN. :G _ P•,0��• 'j 00 i' .. • •e' d :b' �.pe0• 70.0oG✓. TU edobo C. I. OR PVG' TEES b ro9.53 �oJ. g° ;: 1500 GALLON DIS TRIBUTLON BOX B.SMT FL . o°o,a p EL • _Car'. O R 9� INSTALL - ON LEVEL BASE "500 GALLON DR YWEL L S P ECA S T CONCRETE e o, a O REII�fFORCED a10 ,,Q'.bp�:n '4::0Q,Q►'p''•Dpp'D'D'Nc'e''•°:C j-- d••p..p,0• .D•o•. .00, b':D.•s..a'. �'Pro,CO, _ __---- SEPTIC TANK TRENCH SE'C TION INSTALL ON LEVEL BASE NO TE.' EXCA VA TE TO EL EV._N 14__:OR 72 LOWER TO REMOVE ALL IMPERVIOUS MA TERIA L BENEATH THE LEACHING A SEA o" DIAM. 12" MIN. REPLACE EXCA VA TED MATERIAL WI Tf'' 3" OF -- 7`t- CL EAN. CL A Y FREE SAND 04 0'" A t.e WASHED PEAS TONE ILLS RD.� e. . eao 0R ST H 6 — F E _ ;.00 7 /4" i-1/2 WASHED ai Aa3 30 (`,RUSHED STONE .,575 °° GENERAL NOTES TRENCH WIDTH -'� 4 A 1. AL L EL EVA TIONS SHOWN ARE BASED ON ' ` NUMBER OF TRENCHES 1 2. AL L PIPES IN THE SYSTEM MUST BE CAST IRON NUMBER OF DRYWELL. �a OR SCHEDUL E 40 PVC. 0 5 P VA TION PIT c(! 3. THE BOARD OF HEALTH MUST BE NOTIFIED -- N t o \2 S P=97Q7` WHEN CONS TRUC TION IS COMPL ETE PRIOR - � C`t=V m TO BACKFILLING PERCOLATION RATE: 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED MIN./IN. WI TNESSE B Y.• - - • BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS 7 SURVEYING CO.. INC. DONNA MIORANDI _ L.- 4 2 N ^ N 5. MA TERIALS AND INS TALLA TION SHALL BE IN --- cal ��' COMPLIANCE WITH THE STATE SANITARY BARNS. BRD. of HEALTH DESIGN DA TA �_ JUL Y 12 2000 N CODE - TITLE V - AND LOCAL APPLICABLE DA TE.' _ " _ _ _ G o RULES AND REGULATIONS # NUMBER OF BEDROOMS 3 6. NORTH ARROW IS FROM RECORD PLANS AND 1"t � �t"f � 1�723 - - '� O GARBAGE DISPOSAL NO IS NO T TO BE USED FOR SOL AR PURPOSES "' t 0 ~ L OaM IN 7. .FLOOD HAZARD ZONE C (NON-HAZARD) G," Y4z �o" loy g DA IL Y FLOW 330 GAL B. WATER SUPPLY ! 1500 GAL . • -- 5" ___ - . satc trr �o�.Nt i : _SdNt�Y �onr•t SEPTIC TANK REO D. q 1 8= �4 • toY !/,14 SEPTIC TANK PROVIDED 1500 GAL . p ro Y'�z � , c c LEACHING REGUIRED 330 GPD. w _ m _ -Mrurt Mi_niurt o - LOT sawn ! SdNt7 SIDEWALL AREA = 152 S.F. L CST 152 S. F.X 0. 74G/S. F. = 112 GPD. i d yv_+ taY� , BOTTOM AREA = 329 S. F. l s, 090 - SF y _ � LEGEND I 329S. F. X 0. 74G/S. F. = 243 GPD LEACHING PROVIDED = 355 GPO --::PROPOSED ELEVATION 120 : NQ . t)NDWL7l:fz 1Z0 fl IGUNDWIL EXISTING CONTOUR • '�° oesERVArroN PIT SINGLE FAMIL Y RESIDENCE & I P l �� �� ❑ DISTRIBUTION BOX f PROPOSED SENA GE DISPOSA L S YS TEM g0 ,98 �'__ TRENCH , 1 h PREPARED FOR 0 o SEPTIC TANK MCSHANE CONS TRUC TION ; LOT 5 FOREST HILLS DPI VE _.! RESERVE AREA ° �' BARNS TABL E—CO TUI T-MA SS ,tip � u 7C,7OC7 PIPE _INVERT ELEVA TION 77 DA TE' J UN. 22 20 CAPE G ISLANDS ENGINEERING PLOT PLAN n - - ,� �� SCALE AS NO 800 FALMOUTH ROAD - SUITE 301 SCALF=_ 1 U 5 7-S r r y +P ' MAP .SFf- . PCL L 0T HSE PLAN NO. �to2200 MASHPEE, MASS.