Loading...
HomeMy WebLinkAbout0130 FOREST HILLS ROAD - Health 130 FOREST HILLS DR. COTUIT A = 025 007 016 r i i I Commonwealth of Massachusetts Da �� -b(�O Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 'r 130 Forest Hills Rd. �* Property Address _ Barbara Simmons Owner Owner's Name information is required for every Cotuit Y MA 02635 "-- page. City/Town State 0 Code 6/6/2017 p 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 A. General Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not Paul Martin use the return key. Name of Inspector Cape Cod Septic Services Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State 508-775-2825 5016 Zip Code Telephone Number SI 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/8/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 loeva Vs 1 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t r 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 130 Forest Hills Rd. Property Address Barbara Simmons Owner information is Owner's Name required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. 6) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. 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•3/13 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 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and'SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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-3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Forest Hills Rd. Property Address Barbara Simmons Owner information is Owner's Name required for every Cotuit MA 02635 6/6/2017 page. Citylrown 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. ❑ Z 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ED 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): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): '16-145 GPD Detail: '15-216 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: !Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Forest Hills Rd. Property Address Barbara Simmons Owner information is Owner's Name required for every Cotuit MA 02635 6/6/2017 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: No 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °f 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 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: 2001 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 15" feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 6" feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Gal Sludge depth: 6-8" t5ins-3/13 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 vy. 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) . Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2-3" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers 6" below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page to of 1z Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Forest Hills Rd. Property Address Barbara Simmons Owner information is Owner's Name required for every Cotuit MA 02635 6/6/2017 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 ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form $ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'f 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 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 Oil 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.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure Cover 18" 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 chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •' 130 Forest Hills Rd. Property Address Barbara.Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500Gal ❑ 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.): 2-500Gal chambers with 4'of stone. 13'x25'x2'. No standing effluent in chambers at time of inspection. No sign of overloading or hydraulic failure Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Forest Hills Rd. Property Address Barbara Simmons Owner information is Owner's Name required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,-signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10, 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: 2001 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 130 Forest Hills Rd. Property Address Barbara Simmons Owner Owner's Name information is required for every Cotuit MA 02635 6/6/2017 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 3 ' TOWN OF BARNSTABLE LOCATION IZC3 SEWAGE # 01— C;6 VILLAG ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE N0.-fR,C -77C `i'OSy SEPTIC TANK CAPACITY 15*00 // \ LEACHING FACILITY: (type) C navN\,teqs ( Z 1 (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: Z 9-o I COMPLIANCE DATE: /J--0/ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Y Facil•t Feet t 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 Dec C1=Z2 ( t B' QZ_ lb ' .---- t CZ '29'�zt y 3 83 _ZS A Y 33 I , `ems .:k� �`Z^s. '`^ c .. ,f r .;.. .,'• ,. --= ._.-. Iva. k'� - `TQ1 OF B'ARNSTABLE �� - LOCATON SEWAGE # G I C'n VILLAGE C6i►T ASS-ES 0 R'Sr LOT. 7=/6 INSTALLER'S NAME.&,PHONE No::, 7C- SEPTIC TANK CAPACITY _/SoC) LEACHING FACILITY: (type) C a y�loe,i� ) (size) i �c S� .. -VO. OF BEDROOMS BUILDER OR OWNER, en PERMITDATE: COMPLIANCE DATE: /! O/ Separation Distance Between the:. Maximum Adjusted Groundwater Table to the:Bottom.of Leaching'Fac►Irty Feet Private Water Supply Well and Leaching Facility (If any wells exist on site of within200,feet of leachjn.g facility) Feet ..Edge of Weiland and Leaching Facility.(If any.wetlands exist within 300.feet of leaching facility).:: Feet Furnished by ,' ► i Z i. CL Y r TOWN OF BARNSTABLEC/ LOCATION ��O �oceC� ���� SEWAGE CS(o VILLAGE ASSESSOR'S MAP & LOT © 7-16 INSTALLER'S NAME&PHONE NO. y SEPTIC TANK CAPACITY I5'0G // \ LEACHING FACILITY: (type) C\NawsNcketS ( 21 (size) NO.OF BEDROOMS 3 BUILDER OR OWNER N\c PERMTrDATE: COMPLIANCE DATE: ,F—/--D/ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility .. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Q = 16 Z CZ =207 y 3 Q3 :23 A Y 35 �y qd .7 r - - I� '� � 2 ,O� ,. f � . .�.� -- , i No. AQ24__JeTHE COMMONWEALTH OF MASSACHUSET"'S {°` 4FEE d� BOAR OF HEALTH OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (V) ►repair ( ) Upgradc ( ) Abandon ( ) - [?eomplctc System ❑Individual Components ocalion Owner's Name MCI, c r7 G� a Q�� �� Map/Parcel# Address Loi# h Icphone Installers Name Designers Name Address Address `Zij-j_ Telephone# Telephone# - Type of Building: Lot Size VZ- Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 5 �� gpd Calculated design flow ,3:�b gpd Design flow provided 3� d Plan-.. Date - •100 Number,of sheets Re Date Date _I itle LJ Q-c ,!1n Descriptio f Soil(s) aL,-,, SCx-._,L1 a,tJ44- Soil Evaluator Form No. Name of Soil Date of Evaluation (50 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the ab ve described In l�idual Sewage Disposal System in accordance with the provisions of TITLES and further agrees of to p!l!!�p the s tem in olIera6 until a C ate Compliance has been issued by the Board of Health. � q Signed DhI14 4 FORM I - APPLICATION FOR DSCP DEP APPROVED FORM.5/96 j/ 4No THE COMMONWEALTH OF MASSACHUSET' S `FEE .; 1. y -� lI BOARD OF HEALTH . �Ql a• �( APPLICATION,FOR DILSPfOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to COiistru ( IZ�Iil ,(°�) 4tJj�gradc ( ) Abandon 'O - :ompletc System ❑Individual Components Localiun Owncr's Name aPl S Oct OCSl 01to Map/Parcel H Address Lot q I'cicphonc Inslalla's Namc Designer's Namc l ! y •� i, ;"\ Address - Address G �� '�v r Telephone 11 Telephone N Type of Building: Lot Size 2 (0 Sq.feet Dwelling_No.of Bedrooms Q3 "" Garbage Grinder ( ) l Other•=Type of Building No.of persons b Showers ( ), Cafeteria ( ) • Other fixtures Design Flow min. required) 5 S d Calculated design flow - d Design flow rpvidedr..,' , d g ( q ) gP g gP g P. g•F Plan- Date e - V-00 r-%----N-,umber of sheets Revision Date tle-V 1 1C�a; a e r Descriptio ofSoil(s)�• — u u '—Soil Evaluator Form No. Name of Soil Evaluator l:7.SGl.aiJL cW Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLES and further agrees not to plc 0 the stem in operotioduritl a C ' ate Compliance has been issued by the Board of Health. Signed Da 5--'� ;I �' 1 �� Inspectoo T - .; - FORM I - APPLICATION FOR DSCP DER APPROVED FORT—9i96 P— ' NO- - THE OMMOJJNWEALT°H OF MASSACHUSETTS FEE I �w�Lr✓,G� BOARD OF' HEALTH:_ CERTIFICATE OF COMPLIANCE `�� ` Description of Work: ❑ Individual Component(s) ,;Complete System The undersigned hereby certify that tX eew,a/ge`Dii^sposal System;/Cons'tructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: rG (/r �J ILfI�'�5 has been installed,in accordance with the provisions of 31' C 15.00 (Title 5) and the approved design plans/as-built plans relatingjoj applicatio NO. I-Owl�dated Z Approved Design Flow rgpd) Installer Designer: /Inspector Date The issuance of this certificate shall not be construed as a guarantee that a system will function as designed. f. FORM 3 - CERTIFICATE OF COMPLIANCE DER APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSA'CHUSETTS FEe ;f1.°, •`'f . , '��' BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT r•' Permission is hereby granted to Construct ), ep rit ( Upgrade ( ) Abandon ( ) an individual sewage disposal system at � d�� � y '// ,/ as described in the application for Disposal System Construction Permit No.2,00 Z-' x-4 g dated 2 t .✓/3 Provided: Construction shall be completed within three years of the date of this pe 1 it.All local conditions must be met. Date �-- '�/ Board of Healt ��/��� FORM 2 - DSCP DER APPROVED FORM 5/96 �* FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS;;,BOSTON w`a; D9 Do s DECK 23•-8 1/2' II'-7 3/+' 12-8' ROOF OVERHANG 22-1 1 0 7 + $ •.� IL'-O' 1'-8 1/7- 5•-1 1/2' 51-1 1/+' T-a'_ _°-- _ °'-- 7-8_ 1-8' 8-1 I/1- 6'-10• �� D 1 �a G 13 EO o 8 8110 1/2 :DW 1 I p 13-10 3/8• 21-1 5/8' c- 1 I HALF WALL W/CAP O g KITCHEN I BREAKFAST/ (OAK RAIL OPT'L) F� --= R2 nSIC I ` I _ DINING. ;. GREAT ROOM 1 3 1/2 5 4/2 in 1 I I e 1 1 I m I CATHEDRAL p I 1 •-10- 5'-1 1/2' 3•75' 1'- 3/a �• a LOW HEADROOM UNDER STAIRS e 1 I 1 TO ATTIC ABOVE F n I T h 23'-5' It 3'_,. '-10 1/ , 2 4 ON 1 1 r _' e o■q Ll/ �- I1 ;, - O o de 15 , 1 1 g• • 1 1 i 1 1 GARAGE 3' 21/2' -O ' U zqp BRMS i `l2 * n 1 ' I • ` - E l 2X8 JOISTS a IL" r(p----''���-' 2XIO RAFTERS a IL" O.C. i•_t- -c 1/ 5 cL- ° 1 �1 1 Ill -- �i _ X BEAM (TO BE SIZED) 15•-5- 3' + ' i'-o•` On C O O STANDARD 22'-0' X 22'-0' I I M E O I ` LIN. W/ I - It'-0' GAR. DR. • C m .- ALTERNATE 7+'-0' X 2+•-0' W/ 2 V-O' GAR. DRS. CONC. SLAB W/BRIG TRIM r I1 1/2' SOLID BLOCKING a (BRICK PAVERS OPTONAL) I TO FOUNDATION Q 1 15'-5- J D n 3•-1• �•-3• 3•-1• p DN ;tTASTER :B. EDROOM OIl 18p m o � I-- it y o HEADER O HEADER - I CATHEDRAL 'so ry ~ 1 U U tlI POO A A o I = c r-� v I �0 7'- I/2' 3•_t l/It' , O � 2+._0. B aboiD 6•cr LY-8 1/2' r a �] *I FIRST FLOOR ILL4 SF cc co HIGHLAND CAPE FIRST FLOOR R PLAN SECONDLIF G AREA 23 4 SSF F \\ SCALE: 1/8'-1'-0- FII F 9lPI AN CK)CF u 0 24'-2" ob 3'-8' 5-10 1/2" 10-0 1/2" 4-1" 20'-L" e �a K K I L 11 �+8 4"•' Q- I 6 C J E�n L�n LROPTIONAL) OPE ;-LG 99 ROWtn cm \ BEDROOM uagg�o , O HALAOD CAP S a K Oi BALUSTER e o .� JJ 9 C DOORO LIPPOLL S 75 N DN S!I CEILING LINE JJJ 0 N O 34 .4uoODWAA K I 1 ©L ( EN BAWS R Ati BED DROOM #2, RAr OPTiO L) ATTIC o I I I I fr 9'-3' 14'-1' 2' I I ��I^� 11/2 IS'-5' — 30- KNEEWALL - OPE TO *� n FOYER BEL Woj L, v v � � 3 I N In m n K K �r, ABOVE OPEN O hl TER ><S BEDRO ELOW L3 3� �v cn=m 3' L l/IL" 3'-L l IC 8'-O' 8'-0" 9'-10" IL'-0' 6-6- SECOND FLOOR FLAN SCALE: 1/8' = 1'-0' 00 6- II'-2 3/4' 12,-a" 22'-1 1/4" a ab / - - - &T� O m — — 2-2XI0 — — — — — — — e �S P o. 1 I P a- BASEMENT 12' THICK I �� CONC. FIREPLACE O I L SLAB CONCRETE .P FOOTING P I In oP''I 2O X 10 JOISTS •0 9 O.C. 9/IL" C- 9/L L'- 9/L L'- 9/L L'-4 9/IL" G'-4 9/G 4 9/L TOW FF I'-O" L 4 I I PJF — CKEfT­ M. I I 0r =a`sPoe u cli — I v1]- 2x10 GIRT 4 20 N WAL POCKET I IT W LL jg L P I— - O OOgE3NI/2- DA LALLY CO U Zancu _ O 30•x7)o'A2' CONC, FOOTING (TYP) UNEXCAVATED W REIN EDP mup R h O GARAE PITCH TOWARD DOOR TO DRAIN) t1 2 X 10 JOISTS,* IV O.C. '4 I/2" 4 -10 ° 8' V N POL ET 6 IRT_ 3 - 2x10 I_ _ J WALL �Ir— WALL _J WALL I IV M POCKET I I POCKET POC ET I 7 X 10 JOISTS • I O.C. I NNN99BIO.C.F. PROVIDE 6 of R RODS • 1'- I a I O.C. TO TIE IN C NC. �� I ENTRY SLAB IF OVIDEI 2 X 10 JOISTS • IL' D.C. I � dd •lO 6- CONC. FOUNDATION WALL 1 O U — LINE OF CA TIABOVE P ON IC•x8' CONC. FOOTING :r I I (TYP) I I d s N- CONC. APRON TOW= FF - I'-O_ I- I I J �5` 2'- DOOR DROP FOR 2 DOORS 20'-0" 2•_ 21'-O• 15'-8 1/2• 14-0• I?.'-0- TOW- FF - I' O• C-Cr I/2" 6'CF FOUNDATION PLAN cc00 SCALE: 1/4- = I'-O" N" m� ' � j �.� , ,• Town of Barnstable Department of Health,Safety,and Environmental Services �,HE1t7M Public Health Division Date 2-,3-vt> 367 Main Street,l lyannis MA 02601 eAnriereerJ& . rteraa+►�� Date Scheduled Z Z ` `� Time Fee Pd. wo / Soil Suitability Assessment for Sewage Disposal Performed Ba�aw ► �a Witnessed By: e30evl r+4 /�i`�v-r K e< LOCATION & GENERAL'INFORMATION Location Address For��r Owner's Name McShaA-_R_. .+ , Address Assessor's Map/Parcel: ()U'7_O1b Engineer's Name Cafe- NEW CONSTRUCTION REPAIRI Telephone Land Use wet,, ,(, 11`" Slopes(%) -4-' T° Surface Stones Distances from: Open Water Body R Possible Wet Area R Drinking Water Well It Drainage Way R Property Line R Other R SKETCH:(Street name,di ensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) U' v� cb m Parent material(geologic) O '�t W 4 S (+ Depth to Bedrock Depth to Groundwater: Standing Water in Ilole: Weeping from Pit Face Estimated Seasonal High Groundwater DCTEIt1VIINATION' 'Olt SEASONAL ID ' VAmER TAME Method Used. Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment n. Index Well N Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST 'Uale . Time Observation Hole N Time at 9" Depth of Perc rla r� Time at 6" / b Start Pre-soak Time© Z Time(9"-6") 2v End Pre-soak Z Rate Min./Inch Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public health Division Observation Hole Data To Be Completed on Back Copy: Applicant > DEEP.OBSERVATION HOLE LOG Ilole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Uoulderes. o + oQ f ot'.Q L zV-i2Ur, c ioVA 6� 67r �I' DEEP OBSERVATION HOLE LOG Hole # 2 Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. L o+ fd yD2 Z/Z �/ JG .3 Lo•r ..., Ivy2 S� JG -/2d C f to 2 /t'Jo Gi rN- �✓�Y DEEP OBSERVATION.11OLK LOG '' hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,I)ouldcres. % DEEP'OBSERVATION HOLE LOG Hole# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consislena.%Gravel) R + , •t Flood Insurance Rate Man: • Above 500 year flood boundary No_ Yes ' Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material • Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? yt.1 If not, what is the depth of naturally occurring pervious material? Certification I certify that on Y -7 s' (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. r� t Signature Date 2 i I SYSTEM PROFILE FINISH GRADE OVER NOT TO SCALE TOP FNDN FINISH GRADE SEPTIC TANK EL. 78.2 FINISH GRADE OVER FINISH GRADE OVER DIST. BOX EL. 78.2 EL. 79.5 EL. 7$.6 TRENCH EL. 78.2 RISERS TO 6"OF FINISH GRADE IE4!171 - RISEF TO 61° OR l� FIND GRADE I TRENCH SECTIONS MIN. SLOPE 1% OUTLET IPE LEVEL 3„ FOR 2 FT. MIN. (MIN. M MIN. SLOPE I% _ I -d 1% SLOP BEYOND) TOAL LENGTH OF TRENCH = 25' 81 -611 76.50 76.28 611 -if f "T --]I I\-./ - 1 -� -1 -- 76.03 75 95 75.7 o c� o 0 0 o a o 0 C.I. OR PVC TEES 75.00 o a o 0 E= o r� GAS BAFFLE -� DISTRIBUTION BOX BSMT F.L. 1,500 GALLON a ��[ I vIUM INSIDE DIMENSION 12" PRECAST CONCRETE EL. 72.0 PRECAST CONCRETE `� 500 GALLON DRYWELLS a OUTLI ET INVERTS 2" BELOW INLET INVE T -10 REINFORCED LOADING H-10 REINFORCED a M1NIN4UM.CONCRETE WALL THICKNESS 2" H v INSTALL ON 6" COMPACTED LEVEL BASE 12" MIN. SEPTIC TANK _ 36" MAX. 3" OF 1/8" - 1/2" INSTALL ON 6" COMPACTED LEVEL BASE NOTE: 4 DIA. COVER DOUBLE-WASHED EXCAVA"': TO DESIGN ELEVATION OR LOWER TO __ __ _ PEASTONE REMOVE Al,li"IMPERVIOUS MATERIAL BENEATHA THE - - LEACHING..,AREA. REPLACE EXCAVATED MA RIAL ME N o WITH CLEA e1, CLAY FREE, SAND. 3/4" - 1- 1/2" o EL. 74.2' ?2 �0 DOUBLE-WASHED L_j4' 5' -2" 4' T CRUSHED STONE GENERA� , NOTES 13' -2" BENCH MARK 1. ALL ELF V i.TIO,;S SHOWN ARE BASED ON B C GROUP TRENCH WIDTH FOREST HILLS ROAD RIM OF C.BASIN _ EL. 69.63' 2. ALL PIPES ."-N THE SYSTEM MUST BE CAST ON OR SCHEOULL -10 PVC. NUMBER OF TRENCHES 1 M 3. III ALTrI � T ,� �'�. , �� ;+�TT)C .�Tt; 1FT?'il�Tr �T1f TAT NUMBER OF DP.Y°��'ELI S 2 _ '---� BE NOT rL, D WHEN CONSTRUCTION IS COMPLETE PRIOR TO BACKF '�LI1NIG. OBSERVATION PIT WETLAND EL. 42.0 11 N 22°32' 10",E 4. ANY CHAT - S IN THIS PLAN MUST BE APPROVED BY P-9676 96.00' THE BOAR T'1 OF HEALTH AND CAPE& ISLA S PERCOLATION RATE: <5 MINAN. (b U ,y. N E. GINEERa LTG. WITNESSED BY: D. MIORANDI v ^ ~ n 5. MATERIALS AND INSTALLATION SHALL BE IN BARNSTABLE BOARD OF HEALTH DESIGN DATA COMPLIAh C'E WITH THE STATE SANITARY CODE DATE: FEB. 28, 2000 `^ w (TITLE V) AND LOCAL APPLICABLE RULES AND PIT #I PIT #2 REGULATI,,, NUMBER OF BEDROOMS 3 �NS. I 0,� -A- 0�� - 6. NORTH ARPOW IS FROM RECORD PLANS AND IS NOT LOAM GARBAGE DISPOSAL _NO IOYR ail DAILY FLOW _330 GAL. TO BE USED FOR SOLAR PURPOSES. 411 _B_ 411 SEPTIC TANK REQUIRED _1,500 GAL. 7. WATER SUPPLY: TOWN WATER LOAMY .SAND SEPTIC TANK PROVIDED 1,500 GAL. #1® � 15° 8. FLOOD HAZARD ZONE: C (NON -HAZARD) 10YR 5/4 - FLOOD PA'.'EL 250001 0021D, REVISED: JULY 2, 1992 2411 _C_ 36" LEACHING REQUIRED _330 GPD 2T-8%z' 22' 10.5' 9. THIS PROJECT DOES NOT INVOLVE ANY PHYSICAL L�J SIDEWALL AREA =_152 S.F. ~ GROUND DISTURBANCE OR VEGETATION REMOVAL ^� N MEDIUM 152 S:F. x 0.74 G/S.F. = 112 GPD 20„ GARAGE N WITHIN 100' OF WETLANDS, INLAND OR COASTAL z w BOTTOM AREA = 329 S.F. BANKS OF.FLOOD HAZARD ZONES. SAND _ PROPOSED _ IOYR 6i6 329 S.F. X 0.74 G/S.F. = 243 GPD N 3 BDRM HOUSE 211 8/z,° M LEACHING PROVIDED = _355 GPD b 28" d FULL BSMT N �* LEGEND NO GROUNDWATER 120 120 10.5' 43 LOT 16 74 PROPOSED CONTOUR #2 iz,476+ S.F. SINGLE FAMILY RESIDENCE DECK 74 EXISTING CONTOUR 1 O 16 O r PROPOSED SEWAGE DISPOSAL SYSTEM 11.2' O OBSERVATION PIT , 11 N _, o o Ff,s PREPARED FOR jo ❑ DISTRIBUTION BOX 4; } McSHANE CONSTRUCTION {� '' ;r ^y. LOT 16 FOREST HILLS DRIVE ^� w o o SEPTIC TANK L nJ` p r BARNSTABLE COTUIT MASS. ( LEACHING TRENCH 0 - 19.1 /�� .. -. PLAN NO.i S06260.0 SCALD; A 1NOTED �� __ _._�._ � _,_ _ _ a_ ,..:...z . N _ I r i;srlrz l i RESERVE AREA `a �� r6�s�i� FILE NAME.: McSbane-Lot Septic DATEt JUNK 26, 2000 81.82' PIPE INVERT ELEVATION a c1�9r;p: , y , b15K NO.: DRAWN BY: E.L.Y. S 22°32' 10" W 76.50 Z Z Z : SX"'�CKI Gn , �035 Cape & Islands Engineering PLOT PLAN o - - {,' _03T -- ,r � 800 Falmouth Road, Suite 301 C 025: 007-16 16 > > '`�a� arao SCALE: 1" = 20' Mashpee, MA 02649 (508) 477-7272 361 Bi_,, MAP SEC PCL LOT HSE � » s - 68 r°