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0053 FOREST HILLS ROAD - Health
53 FOREST HILLS 1; A=025-007 LOT 6 I SENDER: COMPLETE THIS SECTION COMPLETE THIS S ECTION ON DELIVERY ■ Complete Items 1,2,and 3.Also complete A. Signature ent item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return they card to you. B. Receive y(Printed Name) C. Date of Delivery ■ Attach this card to the back Of themailpiece,. or on the front if space permits. . D. Is delivery address.tlifferent from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: 0 No Mrs,B& Mrs George Kashuba 53 Fdrest Hills Road Coftht. MA 02635 3. Service Type 10 Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insure Mail Cl C.O.D. 4. Restricted Delivery?P"Fee) ❑Yes 2. Article Number ? ; 3 , _ 7006 0810" 0000 = 3525 5330 (transfer from service IabeO PS Form 38.11,February 2004 Domestic.Return Receipt r3 m ° .. u1 ru I Ln M Postage $ Nos r3 Certified Fee _-. 00stmark C3 Return Receipt Fee lie (Endorsement Required) q ?2011 ` C3 Se':Lled Delivery Fee t rq (Endorsement Required) Total'Postage'B Felsf"- pC3 A-4 t ro - :- - - r` Street Apt IVo ' or PO 8oX No. ieg3 F—A'14..- C� eiy,:state.ztP+d"JJ:t t!%t !rJ p. .ao?L..3s UNITED ST f..CW.P Paid • Sende%c Please print your name, address, ind ZIP+fin thPOx • -� cn Town of Barnstable00 rn p Public Health Division 200 Main Street Hyannis, MA 02601 Certified Mail Provides: a A mailing receipt t aooe eunr'oose uuo.4 sd a A unique identifier for your mailpiece q A record of delivery kept by the Postal Service for two years 19 rt Reminders:Certified Mail may ONLY be combined with First-Class Maile or Priority Malle. to Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registefed Mail. a For an additional fee,a Retum ReceiQt may be requested to provide proof of delivery.To obtain Return Receipt seW oe,please cemplete and attach a Return Receipt(PS Form 3811�to the article and add applicable postage to cover the fee.Endorse mailpiece'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. • For an additional fee, delivery may be restricted to the addressee or addressee's authorized aunt.Advise the clerk or mark the mailpiece with the endorsement RestrictedDegvery° o If a postmark on the Certified Mail,receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt Is not needed,detach and affix label with postage and mail. IMPORTANT:Save this recelpt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I m x &C&- 4 F. DATA 2�26 . BIKE rO+I�, Town of Barnstable i � y ,. ' U.S.POSTAGE>y PITNEY BOWES Public Health Division 200 Main Street FOMo•e Hyannis,MA02601 ZIP 02601 4 02 1VV 005.54° 0001361475 APR 04 2011. i I 7008 3230 0002 5178 2480 NFE i Ciflt Oo '09/0S/1l NOT %Fw SENDER OF .NEAJ ADDRESSX1 i.SHUBAr .7q REFLECT IflN DR ].lO ° SANOWIC:H MA O :3S�— 24 04-a4 NIXIE 029 9E 1 OD. 04/07/i-1 RETURN TO SENDER, REFUSED UNABLE TO FORWARD BC: fls^B014OO�00 �13B4—O6712-fl4-�4> ��� ill,,,,,1�1,11,,11,,,,,,)1,1�,111,�,I ,►,►,1,111,�,11,,,,1�1,1 i _ _ i COMPLETESENDM •N 1, COMPLETE THIS SECTIONON DELIVERY ? i ■ Complete items 1,2,and 3.Also complete A. Signature Item 4 if Restricted Delivery Is desired: ' 0 Agent i 1 ■ Print your name and address on the reverse X ❑Addressee j so that we can return the card to you. . i B. Received by(Printed Name) C. Date of Delivery i ■ Attach this card to the back of the mailpiece, or on the front if space permits. I 1. Article Addressed to: D. Is delivery address different from item 1 T ❑Yes If YES,enter delivery address below: ❑No i Ms Doroth A Kashuba Y 53 Forest Hills Road i Cotuit,:MA 02635 3. Service Type ❑Certified Mail [3 Express Mall ❑Registered ❑Return Racalpt for Merchandise 13 Insured Mail ❑C.O.D. 4. Restricted Delivery?(&ft Fee) O.Yes 2."Article Number (rransfer bom service iabei 7008 3230 0002 5178 2480 p t 102585-02-W 540 i Town of Barnstable Barnstable °pSHE TAMmd �L Regulatory Services Department �"aC j + BARWS-TABLE, 9� 639: Public Health Division Arfb MAss 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f )undwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5330 May 31, 2011 Mr& Mrs George Kashuba 53 Forest Hills Road Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system 53 Forest Hills Road, Cotuit MA was last inspected on 3/21/2011 by Brian K. Tilton a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionall Passes"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Flow not reaching field due to leaking tank. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action ER ORDER OF TH BOARD OF HEALTH —� Orr as McKean, R.S., CHO Agent of the Board of Health JA53 Forest hills,Cotuit.doc ti OftHF Tp� Town of Barnstable Barnstable Regulatory Services Department "'e'caC " BARNSTABLE, ' r "Ass. i679• Public Health Division �� m ArFO MAC A. 200 Main Street, Hyannis MA 02601 2007 Office: 568-862-4644 Thomas F.Geiler;Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED.MAIL # 1006 0810 0000 3525 5408 April 25, 2011 Ms. Dorothy M. Kashuba 24 Reflection.Drive Sandwich, MA 02563-3113 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 1301 Old Post The septic system located at53 Forest Hills, Cotuit, MA was last inspected on 3/21/2011, by Brian K. Tilton, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Flow not reaching field due to leaking tank. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification, by repairing/replacing the septic tank. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. nOF THE B ARD OF HEALTH ean, R.S., CHO Agent'of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc ` � �. • fL co OFFICIAL U—SE rl Postage $ try Ln Certified Fee ni tmark 0 Return Receipt Fee O (Endorsement Required) Restricted Delivery Fee (Endorsement Required) A M s��Y NV M Total Postage.&Fees $ S m CO Sent To 1Ut S�_ --wt----K--S 1- Nstreet,Apt NO.; orPOBoxft.�3 �OrcSZ* ffi L [ �� � �;ty State,Z,� ;t Certified Mail Provides: o A mailing receipt �� o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. a Certified Mail is not available for any class of international mail. o NO INSURANCE OVERAGE IS PROVIDED with Certified Mail. For valuables,pleas seder Insured or Registered Mail. a For an additi0n e,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS,Fomt 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece°Return Receipt Requested°.To receive a fee waiver for a duplicate return receipt,a USPSa postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for,postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present It when making an inquiry. j PS Form 3800,August 9006(Reverse)PSN 7530.02-000.9047 °p THE r° Town of Barnstable Barnstable ` Regulatory Services Department Mlftedcaci j IIARNS-rARLE, • - - b . ,�� Public Health Division $ArFD 200 Main Street Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7008 3230.0002 5178 2480 April 4, 2011, Ms Dorothy M. Kashuba 53 Forest Hills Road Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located 53 Forest Hills Road, Cotuit, MA was Iast inspected on 3/21/2011,by Brian K. Tilton, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Flows not reaching field due to leaking tank: You are ordered to repair or replace the septic system within Two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action: PER ORDER OF THE OF HEALTH as cKean, R. ., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information.is required for every Cotuit MA 02635 3/21/2011 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:When filling out forms A. General Information on the computer, 111� use only the tab 1. Inspector: key to move your cursor-do not Brian K. Tilton use the return Name of Inspector key. The Building Inspector of Cape Cod Company Name PO Box 307 Company Address Eastham MA 02642 City/Town State Zip Code 508-255-9343 S14392 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 o s to sewage disposal systems. I am a DEP approved system inspector pursuant',to Section 15.340'of Title 5(310 CMR 15.000).The system: .. . ❑ Passes ® Conditionally Passes ❑ Fails �. k ❑ Needs Further Evaluation by the Local Approving Authority i. 6� 3/21/2011 In pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewagg Disposal System•Pa a i1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 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. 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 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 ill Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. CitylTown 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 be'dow): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): t ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 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. ❑ 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: Leak in tank causin fluid to be one foot below invert needs to be sealed. 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 1/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 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): 355 actual t5ins-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 �,M s 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 Gal septic tank, D-Box and two 500 gal concrete drywell chambers in series With stone. Number of current residents: Vacant 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 ears usage d '10= 134gpd. 9 ( Y g (gpd)): '09=90 gpd. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons uons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other describe below): N/A General Information Pumping Records: Source of information: BOH and Treatment Facility records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks or clogs Septic Tank(locate on site plan): Depth below grade: 5 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: 68"x 10'6"x 5'8" Sludge depth: 6" 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 �M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. CityTrown 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 27" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 1.5' due to leak in tank Distance from bottom of scum to bottom of outlet tee or baffle 2°due to leak in tank How were dimensions determined? Accusludge, Baffle stick and tape measure. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): System should be pumped and leak located and repaired. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. CityTTown 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A - Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. Cityrrown 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 of, 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.): Liquid level 1" below outlet due to lack of flows from leaking tank. 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.): N/A 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ❑ 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.): Lawn and small shrubs nearby, no evidence of leaks, break out or hydraulic failure, excavated with no evidence of pond ing;:.flows not reaching field-due to ieaking'tank;SAS looks good. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/201.1 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.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I I > Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 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 W GARAGE DWELLING A B All=40.5'BI=18' rj A2=461 B2=24' l A3=.52' B3=31' O A4=57' 134=29' 2 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. Citylrown 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: 11'+ no water encountered 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: 8/27/1998Date ❑ 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: .System design plans on file with BOH, corrected to estimated high water table using Frimpter method 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 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 53 Forest Hills Road Property Address Dorothy M. Kashuba Owner Owner's Name information is required for every Cotuit MA 02635 3/21/2011 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 d ��• I ' r 53 ;%rest.H Its Rd,.Cotuft M?A 02635 •t • ,1 a 00 44 '),2091 Europa Technologies _ �, N I i ,I i � I � I 1 I' _.I Barnstable I 1 X Cl;3. I�;Y ....:r!V4✓l.dtC"..L fit,; ri lS COMAL E'TE PRIOR r PERCOL A TION RA TE. 'rr S PLAN MUST BE APPROVED <5 MIN./IN. AL TH AND CAPE 9 ISLANDS WITNESSED BY: ' GERRY DUNNING A LA TION SHALL BE IN BARNSTABLF$RO. OF HEAL TH DESIGN DA TA E...STA TE SANITARY AUG. 11. 199E ND LOCAL APPLICABLE DA TE.' ONS 3 M RECORD PLANS AND o �,.s)NUMBER OF BEDROOMS G ' .� `'m' 2�'` a GARBAGE DISPOSAL NO FOR SOLAR PURPOSES a .-, ... C (NON-HAZARD) LAMr„y .Sgnd �oYM s/y DAIL Y FL ON rowN wA TER y2 a~ SEPTIC TANK REG 'D. 1_ 1500 GAL, SEPTIC TANK PROVIDED LEACHING REGUIRED 330 M C.cl a V MCI Sd SIDENAL L AREA 152 S. F. S.F.X 0. 74G/S.F. - 112 GPD. BOTTOM AREA - 329 S.F. 329 S.F.X 0. 74 G/S.F. = 243 GPO LEACHING PROVIDED a 355 GPD ED ELEVATION C`e's, NG CONTOUR SINGL E FA MIL Y RESIDENCE C A TION PIT BUTION BOX o►'"" ' PROPOSED SEl✓A GE DISPOSA L S YS TEM I HARD JAMES U ee2 4N° PREPARED FOR r O rANK Ay°��s�G'STE�`�"��'� McSHANE CONS TRUC TION L O T 6 (HSE. 53)- FORES T HIL L S RD. E AREA - ��.��H OF CO TUI T-BA RNS TA BL E—MA SS. NVERT EL EVA TION � DAVID CHAR S SAM l h DA TE.'.A��. ..� �, 1,99e CAPE 6 ISLANDS ENGINEERING s SCALE AS NOTED 1.3.9 F'.4/_M.Call T!-! Ptl4 n - Sly T TF PF HIGH GROUND-WATER LEVEL COMPUTATION Date: 3/21/11 Site Location: tv7 !g�L�+ltl(5 �� �oz,; Permit: Owner: Dort Ll K-t5 Phone: Contractor: AVW1!4 X"- Podd & Gve Co Phone: 5)$-25f-J3 Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ` (depth is in feet below land surface) Date: 5111 t' J 4- 0 mm/dd/yy feet below Is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: I A) Appropriate index well c.5a B) Water-level range zone STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water level for index well. mm/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level /z 7 adjustment. 0 STEP 5 Estimate depth to high water by subtracting the �a� water-level adjustment (STEP 4) from 0 measured depth to water level at site (STEP 1). NOTE* Tables 1-9 "Potential Water-Level Rise" are attached as worksheets to this file. monthly index well data: www.capecodcommissionorg/wells.html Cape Cod Commission: USGS Well Data- February 2011 Page 1 of 1 N, February 2011 USGS Site Water Record Record Departure from Average** Number****Location Well No. Level* High* Low* Monthly Overall (links to USGS national water- level database) 20.88 (provisional adjusted value) Thanksto NOT NOT A1W Horsley AVAILABLE AVAILABLE Barnstable 230 Witten Inc. 19.5 26.6 AT THIS AT THIS 41395b0701.64301 for assistance TIME TIME in providing substitute data until a new well can be drilled. Barnstable 24W 22.8 20.6 28.6 1.6 1.6 414154070165001 Brewster BMW 21 8.9 6.9 13.61 1.4 J1 1.2 14145180700203011 Chatham CGW 138 23.3 20.9 26.61 0.4 11 0.5 IF414160070011,1011 Mashpee MIW 29 7.7 5.6 10.0 0.6 0.7 413525070291.904 Sandwich SDZ 47.0 45.6 48.2 0.3 0.3 414418070241601 Sandwich SDW 47.8 45.8 55.1 2.3 2.2 414124070265901 Truro TSW 89 11.3 10.2 13.0 0.7 0.8 IF420206070045901 Wellfleet W 7W 10.1 7.3 12.8 0.3 0.3 415353069585401 f BOLD New Monthly High Pink background New Record High Measurements are in feet below land surface. ** Measurements are in feet above mean sea level. ** USGS national water-level database provides historic data,hydrographs, and site maps. http://www.capecodcommission.org/wells.htm 3/23/2011 �� II No. V I 1 J 2 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for M .5 ont *p11em Construction Permit rp,4i�'' LE�4 Application for a Permit to Construct( ) Repair(c+ Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. s3 arl= Owner's Name,Address,and Tel.No. corer nn OoraTGly �, !<�.3G�c�ba Assessor's Map/Parcel 0077 0 U 14 Ao-e_ 8'd- 9152 Ins aller's Name,Addre s,and Tel.No.Seg 2 Designer's Name,Address and Tel.No. �os_elVh �t ( Krrros / /2 0 r5 rvys /I/jl Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 15/O`4!d' L/514GG In pj 0 r F' j ycl� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed G ,EJ Date _ Application Approved by Date tz /( Application Disapproved by: Date for the following reasons Permit No. 7-0 1)— 132. Date Issued .5 I I No. `' ) 3 2 _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l Yes r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Mi opal *pftem Construction Permit Application for a Permit to Construct( ) Repair(c-)- Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. S or/s S 1 / S 3 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0 006 �w� ✓Ins aller's Name,Address,and Tel.No.�p6 U- 7�S Designer's Name,Address and Tel.No. kV 1,0114`5 r0A>S Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ) Nature of Repairs or Alterations(Answer when applicable) _ Rl;)y14 yy l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed r�i���2�1j 1�! �,� Date Application Approved by �4 �- Date 9 /( li Application Disapproved by: %i •• Date `l for the following reasons 5 , _ f Permit No. ZO 1) - 132 Date Issued ��9/!1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired ( ) Upgraded ( ) Abandoned'( )by at 'j � C'1 tvy as been constructed in accordance with the provisions of Title w�//5 and the for nDisposal System Construction Permit No. 20/1 - 32 dated 1 9 /I Installer I�/;����� )O5t I/e���'��S Designer #bedrodms j Approved design flow gpd The issuance of this permit shall not rbe construed as a guarantee that the system willfuncti n'as destgned. Date r�! >� i Inspector , - . . . - No. Z0 6� � I J Z Fee �tN THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwigoml *pfstem Cori.5tructiou Permit Permission is hereby granted to Construct ( Z—)-- Repair (. ) Upgrade ( ) Abandon ( ) System located at T yik 14T- 5-3 T /ii/ls X0,46 �c 1"v/•T and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit 4= Date .M I I Approved by , - `�� � TOWN OF BARNSTABLE p � ff tt / 11 '^' Q LOCATION LET{{ L��ce�t ,IISci SEWAGE # 1 a79 - VILLAGE (alum ASSESSOR' MAP & LOT 2" INSTALLER'S NAME&PHONE NO. ►L2KS� Aki l ayrS . yZ� SEPTIC TANK CAPACITY I�Go LEACHING FACILITY: (type) / _Zd IetAN kZ (size) NO.OF BEDROOMS ff BUILDER OR OWNER , t 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 '. govz _ 63 = 3ii �I J, -00 THE COMMONWEALTH OF MASSACHUSETTS FEE BOARP OF HEALTH OF \ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) andon ( ) - Vmplete System []Individual Components all r -�tlA kr t Lo •lio wer n 's Name _m �S A �-� Map/Parcel# Address Lot# Tele hone# ^ Installer's Name Designer's Name Address Telephone# Telephoone[## Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms e� Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow in.re ui d) gpd Calculated de i�gn flow y�3C�gpd Design flow providedsgpd Plan• ate Number of sheets —II--- Revision Date Titl - I Description of Soil(s) D'LO" ® "' 2t, �- �t- Y14-J- S �-� Soil Evaluator Form No. Name of Soil Evaluator --S �a Date of Evaluation - DESCRIPTION OF REPAIRS OR ALTERATIONS r. The undersigned agrees to install the a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ag snot to pla th srp6_o�unfilSa Certificate of Compliance has been issued by the Board of Health. /I vim. /�, c 4 i"'" 1. Signed AA-11 G f , ate 3 ID 71 0a lok 711, W V V I FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 r I E� O. , • '� THE COMMONWEALTH`OF MASSACHUSETTS�k z ��w,.,,�yf'FEE w� / BOAR OF H EA'LTH'{ ' s ' ` OF \. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) bandon ( ) [_Complete System E]Individual Coinponents. /W� Lor uoq f 1 wner's Name IlU" !/ Map/Parcel# c` - /1 Address Lot# Or} Tele hone q i CCk pg-v f A—1t !kQ/l 4Y�J T�/L�III (JJ1�l�t { : Inst�dtler's Name ' ''/ Designer's Name ` Add s ITclep` ne s �; t/ Telephone# ' f r Type of Builditl t t ti ,Lot Size Sq.feet Dwelling—No.of Bedrooms t t' 3 ,Garbage Grinder ( ) Other—Type of-Buildifi No.of-,ersons� LO Showers Cafeteria YP g P ) ( ) ""''Other fixtures { ' Design Flow' in.re ui d) Calculated deign flow _330 gpd !''Design flow provided��gpd I. Plan• ate / a"1 SST ber of sheets� Revision Date __ - Title,- wr... t. { �� �fl b'" Description of Soil(s) d'-�,;.. �; �� �,! ^ . 1 Soil Evaluator Form No. Name,.of Soil Evaluator Date of Evaluation — I ?' i I � DESCRIPTION OF REPAhRS OR ALTERATIONS The undersigned agrees to instdll the ! u Sewage Disposal System in accordance with the provisions of c&( described Individual .TITLE 5 and further agrees not to pla 4 th syd ''i0peratio�until a Certificate of Compliance has been issued by the Board of Health. :t Signed ^ /�/i)t14v1� iu I ' EDate 3 /10 Al FORM 1 APPLICATION FOR DSCP DEP APPROVED FORM 5/96 i No. �+ T tj E COM O W A H OF MASSACHUSETTS — FEErlf/ �.` BOARD OP-HEALTH •y CERTIFICATE OF COMPLIANCE Description''of Work: ❑ Individual Cotriponent(s) ❑Complete System The undersigned hereby certify that the S`ewa�geD sp al/�ystem;Con4ructed( Re aired( ),Upgraded ),A andoned( ) by: I 1 I I �( Al vc��i at � 1� has been installed in accordance with t e riv, sions a 34,0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application: ated �` Approved Design Flow (gpd) Installer 1 w ) f? ^ ` r I Designer: I pector '!rt/t v �i��{I`i/ ate �! �I � s The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. i FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 f ---—_.--- ——— ----- ————— ---- _—.__--_—__—_— —---------- -- �d e� dolb No. THE COMMO WEALT OF MASSACHUSETTS FEE D� &BAI ABOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage i disposal system at as described in the application for Disposal System,Construction Permit No. ..� dated I Provided: Construction shall be completed within three years of the date of this pert it.All local conditions must be met. { Date Board of Health I FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBsB WARREN Tm PUBLISHERS- BOSTON .,It I I � � 1 I � 1 I � 1 I I � A � • � I � --: � I � I � ! � I I � � I � I 1 � 1 � � � ���``"� ���� � \� �� � I 1 � I � � I I � � I � r � I � I � � I I � � ' y I I - _ � ' -- 1 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ea �' ASSESSOR' MAP& LOT INSTALLER'S NAME&PHONE NO. a yZ� SEPTIC TANK CAPACITY A6- c LEACHING FACILITY: (type) //Mc��e z�J,l k 2 (size) NO. OF BEDROOMS BUILDER OR OWNER ft7rS')I AA, PERMIT DATE: /�/, r 1 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 i f LS= �� lI-s = £� a �5 i N/F �2 TOWN OF BARNSTABLE `\\ `\\� LOT 17.28! U.P. 0.40 � _ LT �gyp, • AREA SUMMA R Y LOTS Z UPLAND; 267, 713�S. F. 6. 15-*AC. cq -C WETLAND; O-*S. F. O-*AC. l TOTAL; 2671 713-'S. F. 6. 15-4AC. 28.8 % N , ROADS 116, 189 -'S. F. 2. 67-4AC. 12.4% OPEN SPACE UPLAND; 514, 568-•S. F. 11 . 81-4AC. WETLAND; 32, 116tS.F. 0. 74-*AC. �' iG�P�� rn TOTAL; 546, 684�S. F. 12. 55-kAC. 58.8% tr cs TOTAL 93 0•,586 tS. F. 21 . 37-*AC. l00 % ' 2 OPEN SPACE P UPLAND=132. 818�S. . WETLAND=OAS. F. TOTAL=132. 818-*S. f 594.71' S36-58' l7` N/F N/F RAYMOND R. 8 IRENE I ANTONE i RODGERS 1 SOUZA 1 — �, _ �► _ � �' �,._ �� _.. ,. _ �� — .., ,• .�: _� '�.� i�_ ,:_. �- .,.a_.. Town of Barnstable I'# • Department of Health,Safety,and Environmental Services tM,"`'� Public Health Division Date " ^4 367 Main Street,Hyannis MA 02601 BARNBTABU& ` Date Scheduled 1�i X Time I II�Q Fee Pd. 0O. O Q Soil Suitability Assessment for Sewage Disposal Performed By: I OAAAb ELai AsWitnessed By: �5 LOCATION& 6ENERAL INFORMATION Location Address. Owner's Name �y J 3Y�� �V �O Address Assessor's Map/Parcel: ��Cv �^� Engineer's UUU NEW CONSTRUCTION REPAIR N� Telephone# �� Land Use Lo o©d S Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area R Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of t st holes&p rc tests,locate wetlands in proximity to holes) or es1, A 0 Parent material(geologic) e�7�`r'4-t 4 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINA`I'tON FOR SEASONAL.Hl(Y tl WATER TABLL 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 Date : Time Observation Hole# Time at 9" Depth of Pere 4; re Time at 6" Start Pre-soak Time c@i Time(9"-6") End Pre-soak Rate Min./Inch Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Ilealth Division Observation Hole Data To Be Completed on Back—� Copy: Applicant DEEP OBSERVATION HOLE LOG Hole# / Depth liom Soil I lorizon Soil Texture Soil Color • Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. 2K, ni n ° Gravel) O fo Y /e 4 Lo4 wt /0 rp— 40ari S., -( ZO y 2 s- DEEP OBSERVATION HOLE Hole # Z Depth from Soil Horizon Soil Texture I Soil Color Soil Other Surface(in.) i (USDA) I (Munscll). Mottling (Structure,Stones,Doulderes. I I Consistency,% r • I V G ;fe /a R S_ 2 C �N e c� Stitt t° y tZ 6/y- JEEP OBSERVATION HOLE LOG Hole#.. Depth from Soil Horizon Soil Texture Soil Coior Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. Consistency.° Gravel) I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Doulderes. Consistency.°° ravel Flood Insurance Rate Mao: .Above 500 year Iloou hcundary rdo_ Yes t/ 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? ` -e S If not, what is the depth of naturally occurring pervious material? Certification r I certify that on (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 CM 15.017. Signature Date %�a t�. S ♦•is rJ O Co It'-O C LLJ �S'-e Tn• a _ 23••0 IIT o i tus I o tffilr t3 _ H I t�T4 F.XSSTTry U) r- 0 1 TO R 1.4T-n/ STb2ff ovp Y V a Al ------------------------- I ( UKEXCA.VATED u Ran,ro�cfo t I I O � .O■Y.RRr �lT.l Il IIOVI. 1 � , Gl-nTCN TOIARD ,D OI.Yq L �" . OFFICE I I — — _ _ IOT�r—,•��,CR laxly I IRQM,•aoc�. I _ I jKOL.To .% i G*43 I V O fr I IL•O. � I I I � n STONYBROOK . ,5•CnIE: 3/37- 1•-p• rR. ttl31�RGR1 �x S n VI-A PIr it N B EXIST HOUSE L O C K W O O D ` Al U 4� '1 ONSET. MA. 02556 'ASPH110 MPH ALT SHINGLES EX SKYLITE PVC PANEL .fAONE .(SOB) 273-0111 (508) 273-0114 Al 6 c p E-MAIL LOCKWOODARCHOCOMCAST•.NET- 'lo SCR�ED PORCH ' A - - PVC PANEL A1' I 7 - _ r - O��PVC-CORNER. At NEI �:.. ..�:. ,... .:�-a � .: :-.-t.=. SCREEN PA'(�'1ELS�'��1 �' -, �*. SCREEN PANEL f CONT PVC SILL T V, PVC.PANELS- _ RECESSED.PVC,PANELS:' w PVC TRIM - 4•- 2•-�� 3.-2. 2•-�- 4^- � - 7 8 PVC'SKIRT BD s4 s! 1 3111 `' STEEL HANDRAIL T l99- EX ISTING STIRG WEST ELEVATION SOUTH ELEVATION. 1xaPr,sKntT.eoxtos. FLOOR PLAN SCALE: .SALE:3/16-- 1--0' - SCALE:3/16"=t•-o- LOT DATA MAP 025/BLOCK 007/LOT 006 53 FOREST HILLS RD. 110 MPH'ASPHALT ROOF SHINGLES COTUIF,.MA FELT PAPER 3 110.MPH.ASPHALT ROOF.SH,NGIES .9fi-PLYWD SHEATHING - -- . ., GROUNDWATER IAL RF PROTECTION DISTRICT(GP) FELT PAPER 2.6 RAFTERS-016"x ZOGROMIESIDEHf1AL TE .. 9f1YLYWD SHEATHING 2.6 CLG JOISTS 016'- 5 USE CtroELU/FAD PROTECTION DISTRICT(WP) 1.6 TA:G BOARDING. . 1010 12 2.6 RAFTERS 016"a Al LOT SIZE.- .40 ACRES . 4 10p - 2.6 CLG JOISTS 016'6c - '- 1'W MPH A 1.6 T&G BOARDING ASPHALT SHINGLES - SETBACKS FRONTSOS::NA_ (2)2z12 BEAM - - . NA 1. ��9 POST DOWN REAR:REQUIRED -10 FT. -... - .. EXISTING - _ r (� PROPOSED- n _ ,� .t.' PUBUC WATER '� ON SITE SEPTIC SYSTEM REMOVE EXIST CORNINCEGAS ¢ CONFIRM(2)2xt0 HEADER SCREEN PANELS it IX Z;x6. ixiO PVC CORNER PT.DECKING.. � SCREEN PANEL I EX 2x8 016-.FLOOR JDZM CONT PVC SILL m NEW INSECT SCREEN PANELS __..... .®/PVC TRIM II. 1 FILL II 11 N II 11 I. II I I 1.8-PVC SKIRT BD- LOAD DATA . - EXIST Pr 2x8 LEDGER' - ' - BASIC SNOW LOAD- 30 PSF.. ..� -" ATTIC LIVE LOAD -NA SECTION A EX 9-0 CONC PIERS /CO HANGER FA Jo,sr EAST..ELEVATION FL / � (EX) 'GC TO VERIFY 4•DEPTH SCALE 3/IV=1'-0' SCALE. 3/16"=T-0" _ WIND SPEED SECOND) - 110 MPH SECTfON'B VIEW OF PROJECT AREA WAND=SPEED(FASTEST MILE) - 90 MPH EXPOSURE 8 SCALE:3/I6'=1'-0" EXPOSURE ADJUSTMENT COEFFICIENT- 1.0 .DESIGN'WIND LOADS 12 WALL- NA 41 ROOF UPLIFT- 30 PST®EDGES 8- . 20 PSf O CENTER 36"ICE Q WATER SEISMIC CATEGORY- B ALUM GRIP EDGE _ _ aT. WEATHERING SEVERE - li8EXO -FASCIA 2x6 C2 TIE(1/RAFTER) "�$ - ASSUMED SOIL BEARING VALUEO MIN (- 3000 PSF AUGN w/EX CAP"SHNGLES"' .SCREEN'PANEL - lx6 TdIG HEAD BD RIDGE STRAP Cl1x2 STOP SCREWED ON �_A-� SET IN MASTIC CELLULAR IN MASTIC SCREENED PORCH IC 1.6 .. LINE OF-SILL 2xe'RIDGE-(HOLD'DOWN-17:. LI for Sam MOLD .711E ING Ix6 ALIGN w/EXIsr ,_ .I _ .... !i i I - 'PAUL BISCEGLIA Ir SCREEN PANEL _ OLOWEIR ORNICE 6 TYP.'CORNER-"POST SCALE: ,-=,•-o- � for . 1,2.STOP SCREWED ON ,.RIDGE SCREEN„PANEl- �� a PAUL& ALICE CELONA ix5 SILL.W/lx3 APRON SCALE,--1-0 - 1.2 STOP SCREWED ON 3'*LOWER RANT. COTUIT, MA 53 FOREST HILL.RD_. tTEAD PLYwO C7032'oc .,6- (4)2.-BLOCKING 1x4 AZ�K PLLym 5 p� ALUM ORO�EDGE - ALUM'.DMP.EDGE �� r ••////���,ii Pr P •; ,x4 BAD .RAFTERS®18"oc I SCREEN ODOt-tV 1.2 PVC `PICy(�{�,� IX PT DECKING 1.5 PVC .- 1z3 K K 1.2 PVC r / D A T E S lxa, INTO PVC TYP.POST EX(2)2xB BEAM-CUT FOR 1x6 PVC 7 _ FLASH.CONT 1.5 PVC SCALE. l _,•-o CONNECTOR-SCHEDULE NEW POSTS A REHAIJG - CO'MST HANGER TYP. `m 2x8'. EXIST 2.8 CUT BACK '--' C5 SOLID BLOCK PVC SHEET - SIMI SON PACING PT6.6'POST '��� - 1 32 ST 2-HAYS O -x _ �� -_-.Cl)MWECflai _ - • CONNECTOR, C.BASE ANCHOR w/ .1y6 ALIGNED WITH STUDS C5 CO..ENLISTING 2x8 JOIST HANGER ':: NEW EXIST PT1Y4 03 �b EPDXY ANCHOR BOLT .. T C4` C1' 'RAFTER'7'O'RAFTER.-.O' RIDGE :CS20-16' ALT(32'oc) IX FIN GRADE PT2Y4 7 i EXIST(2)2.8 BEAU CUT BACK ..-...y' BEAM/ 5 �TYP. RAKE C2 RAFTER TO TOP'PLATES H2.SA EA : SCALE l:=,•-0- CO C3 DBL 2x12 JOIST HANGER HUS210-2 EA .:,PROJECT DRAWING NO- CS C4 DBL 2x8/xI0 JOIST HANGER LUS28-2 EA 948 'ElI I I I I I A I I_I I F 2x6' EXIST 2XB C5 2x6/8 JOIST HANGERLU526FA I�-III-III- ,_. _ C FIR CDEPT PIER. C6,6.6 POST BASE 'ABUIiB 1/POST l CONFIRM DEPTH IN FIELD - I- UPPER CORNICE TYP.CORNER"POST c7. MASC'ANGLE A23 - ( 2 TYP_WALL SECTION SCALE: 1"=1'-0' SYSTEM PROFILE NOT TO SCALE TOP FNDN. FINISH GRADE EL . �'� • -� FINISH GRADE OVER FINISH GRADE 9• FINISH GRADE OVER OVER TRENCHES 7 SEPTIC TANK 78. 8 QIST. BOX •4•O. �oi.p•.. :o . .a� 12" MAX. � ' O o:4 Q: �p;,tFTIT a ° ;�d•;°�•� 0'::Q.e�DO�:y:OC.yia�ie'v • ! A'ti V.•,r l0 e ~ + °° OUTLET PIPE LEVEL TOTAL L ENGTH OF TRENCH 3" o FOR 2 FT. MIN. 6 nxi .Q�1 CAP END f ,0Q QO 0 • Ed 0 00• 0� v o .Q�, ti o 0$0 da:. C. I. OR PVC TEESIrk b; BSMT FL . .�°.•o;� '�' 1500 GALLON o CZ TRIBU i lON BOX rNSTALL ON L� VEL BASE 9� 500 GALLON DR YWEL L S " PRECAST CONCRETE H- P 0 REINFORCED n a• ao �•et�.7D.d,:,,o•.vp•�':n•'D.:D.b.:ta•Aa':QYp Dpp�'�'�0'0•'•°-4x►�' _ SEP TIC TANK TRENCH SECTION INSTALL ON LEVEL BASE NOTE.• EXCA VA TE TO EL EV V. OR LOWER TO REMOVE ALL IMPERVIOUS MATERIAL BENEATH THE LEACHING AREA 4" QIAM. 12" MIN. REPLACE EXCA VA TED MATERIAL WITH 3" OF 1/B"-1/2" CLEAN, CLAY FREE SAND n . o$ 'o' :d.:;0 4:o A'p b'•; ;b:;o;A •a r a1 :'n '.'• .• d WASHED PEASTONE � D:0•• o00e 3/4" - 1-1/2" WASHED CRUSHED STONE °$ o: C.7ia o , r • T~ ' � I GENE o4 NOTES �+ TRENCH WIDTH 1. AL L EL EVA TrON S SHOWN ARE LASED ON TOPO B Y O THERS NUMBER OF TRENCHES 1 / 2. AL L PIPES IN Ti,'E S YSTEM MUS T BE CAS T IRON NUMBER OF DRYWEL L S 2 � _ OR SCHEDUL E 40` �VC. °wQ, �� . '' �*" " 3. THE BOARD OF ,Hi_, .Mc�s E� NUTa'"FD ,. ..,. . 8 ,. ./ _ .. " r �.'/ ii s �• P-9204 - WHEN CONSTRUCT,,,'°ON IS COMPL ETE PRIOR TO BA CKFIL L ING PERGOLA TION RATE: _-_-_-------- _-- 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED ,z _ - 7z ----� _.._..__ _ ____ _ �--� <5 MIN./IN. may' " 7�` BY THE BOARD Ct- HEALTH AND CAPE C ISLANDS WITNESSED BY.' .4% iO3,3�� r� ` yz SURVEYING CO., . F4dc. GERRY DUNNING 5. MA TERIALS ANO ,v,.:-'TALLA TION SHALL BE IN ®I a r'y COMPLIANCE WITI- THE STATE SANITARP BARNSTABLE=$RD. OF HEAL TH DESIGN DA TA AUG. 11, 199B CODE' - TITLE V AND LOCAL APPLICABLE DA TE- _ — •- •- a',? 2 RULES AND REGUI,A TIONS 3 o �,rs � ,G•. �� � � 6. NORTH ARROW IS FROM RECORD PLANS AND �NUMBER OF BEDROOMS �r IS NOT TO BE U°"„ ���' ,aY ! NO 7. •FL 000 HAZARD ,��QED FOR SOLAR PURPOSES ` ` �� GA RB,4:GE DISPOSAL B E C (NON—HAZARD) �-�� ,y s4 n d ,a_YR S% DAILY FL ON 330 GAL . ..� +�r.•« NJt p. WA TER a7UPPL Y�-.. TOWN WA TER yz c SEPTIC TANK REQ 'D. 1500 GAL . vr' $, • SEPTIC TANK PROVIDED 1500 GAL . L EA CHING REQUIRED 330 GPD. e to .x _G/B SIDEWALL AREA = 152 S.F. 152S.F.X 0, 74G/S.F. = 112 GPD. h BOTTOM AREA = 329 S. F. L EGEND 329 S. F. X. 0. 74 G/S. F. = 243 GPD � ,-. LEACHING PROVIDED = 355 GPD !7, z e 9 s� I o - PR(;;POSED EL EVA TION �-9 9�- • -- � —� EX.rSTING CONTOUR SINGLE FAMILY RE I S DENCE & 08. ERVA TION PI T G ❑ DI.°M TRIBUTION L90X y OF PROPOSED SEWAGE DISPOSAL SYSTEM rl----, a: ll RD j i s PREPARED FOR S 2sasa e o o SEPTIC TANK 'GIs L . MC SHA NE CONSTRUCTION — — LOT 6 (HSE e 5. ) FOREST HILLS RD. RED FR I/E AREA OF CO TUI T—B RNS TA BL E—MA SS. PIS`�E INVERT EL EVA TION C2ID M C��rLEs PLOT PLAN CAPE 6 ISLANDS ENGINEERING 3 SCALE: - r J is SCALE SCALE AS NOSED 13 FALM�'UTH ROAD — SUITE 2E _ !� r'—cd, G' �': ..: —_Y :: rPLAN NO.� � MASHPEE, MASS. 5� : .' SEC PCL L O T HSE DATAPRiNT 005055