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HomeMy WebLinkAbout0015 GERALDINE ROAD - Health 15 GeraldineRoad �GOtUlt Commonwealth of Massachusetts + '�r ® /- " Title 5 Official ,Inspection Form Subsurface Sewage Disposal System Form - Not for:Voluntary Assessments 15 Geraldine rd _ Property Address -- --- ----------- -- --: ' -- r Jill Beaumont_ _ Owner Owner's Name r . information is required for every Cotuit _Ma Q2536 6/18/15 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, _i6t j j �j % 1p use only the tab 1. Inspector:, / L' / key to move your cursor-do not Michael DiSuoriio use the return - — -- ---- - - —--- - - ---Name of Inspector — --------- _----------- key. DiBuono Sewer and Drain raa Company Name 8 Johns path. L Company Address S Yarmouth _ _ _ _MA 02664 CitylTown — — --- State ----- - ' Zip Code ---- -- 508-364-9587 S113522 --------Telephone Number + --' —�--- -- P License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Lo I-approving Authority ----------------- - 6/19/2015 ector'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. Y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 15 Geraldine rd Property Address Jill Beaumont _ Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A;B,C,D or E /always complete all of Section D A) System Passes: ❑ 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: The system contains two original Cesspools. The first Cesspool is unsafe and no longer leaching. The pipe to the second cesspool is under water. Exact location of second cesspool is unknown. I was not able to force a locator down the line between the two because the pipe is so corroded. Recommend replacing the system. B) System Conditionally Passes: ❑ One or mores stem components as described in the "Conditional Pass" section Y p need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C�M , 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 — — page. Cityrrown 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. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken.o.r obstructed pipe(s) or due to a broken, settled or ineven_c_iistribyt on box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of. Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of (Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont _ Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 . 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. Fi 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 '/2 day flow l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd _ Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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•3/13 Title 5 Official-Inspection For Subsurface Sewage Disposal System•Page 5 of 17 .t ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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 ❑ Z Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth'of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of,the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a,plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd _ Property Address Jill Beaumont _ Owner Owner's Name information is Cotuit Ma 02536 6/18/15 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains two original Cesspools. The first Cesspool is unsafe and no longer leaching. The pipe to the second cesspool is under water. Exact location of second cesspool is unknown. I was not able to force a locator down the line between the two because the pipe is so corroded. Recommend replacing the system. Number of current residents: 2 � Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 9 d10 -- 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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: — — -- 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 ot.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd _ Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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: — 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 ❑C 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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: 65years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 24"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.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass, ❑ polyethylene ❑ other(explain) _two cesspools app 6x6 If tank is metal, list age: -- - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 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 .'' 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — ---- -- Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts N : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is Cotuit Ma 02536 6/18/15 required for every page. CityFrowri 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.): recommend pumping main cesspool Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - ---- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: - Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date - Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 17 - a Commonwealth ofWassachusetts e W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Na 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.): 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 page. CitylTown 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: 1 - ❑ 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.): No ponding at this time. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 tied together -- Depth —top of liquid to inlet invert 6 Depth of solids layer 4" Depth of scum layer 18 -- --- Dimensions of cesspool 6x6 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3113 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 °M 15 Geraldine rd Property Address Jill Beaumont _ Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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.): No signs of ponding Privy (locate on site plan): Materials of construction: Dimensions - ----- --- - - Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of'Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch-Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C f"', O i U t5ins•3113 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 15 of 17 c r ► Commonwealth of Massachusetts W Title 5 Official Inspection Fora o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ` ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting ❑ ( tt ng 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: Exact ground water to be established at time of system upgrade. 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 l— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Geraldine rd a Property Address Jill Beaumont Owner Owner's Name information is required for every Cotuit Ma 02536 6/18/15 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOQ�NTION p� ,�4tr e�' 1Z SEWAGE# Ae)11 •-Lq 7 VILLAGE ASSESSOR'S MAP&PARCEL -1.4 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 36 V_3 NO.OF BEDROOMS h=/d OWNER 2S,�uNC� PERMIT DATE: -f-�— 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 ✓ 0 0 y._ �s W � TOWN OF BARNSTTABLE LOCATION_/( ( L7)/A�� �SEWAGE# VILLkGE� � ASSESSOR'S MAP&LO -D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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)n�/ Feet Furnished by /Ii V[� -c �®wCy TrYnr�rr�r/1/ch .CfsvNJ --� o yousP �' /S e ra Er M m .Postage $ AYA ry Certified Fee �f p ReturnReceipt Fee PO st r (Endorsement Required) f HeNRO 0 Restricted Delivery Fee .i (Endorsement Required) A C3 �� fU Total Postage&Fees $ Sent' }}} sfre, a °"P William Beaumont city % Jill M. & Michelle Crocker, TRS 95 East Falmouth, MA 02536 ' Certified Mail Provides: o A mailing receipt o A unique Identifier for your mailp .. 1 e A record of delivery kept by the Posta rvice for two years " Important Reminders: u Certified Mail may ONLY be combined h First-Class Maile or Priority Maile. e.Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an addit onal fee,a Return Receipt may be requested to provide proof of delivery.Xo obtain Return Receipt service;please complete and attach a Return Receipt_(PS Form 3811)to the article and add applicable postage to cover the. fee.E dorse mailpiece"Retum Receipt Requested".To receive a fee waiver for, a dupp bate return receipt,a USPSe postmark on your Certified Mail receipt is required. e 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". r a 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. PS Fonn 3800,August 2006(Reverse)PSN 7530-02-000-9047 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse GA AU111 Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. I 'it D. I.elivery ad^ss different from item.l? ❑Yes 1. Article Addressed to: If ES,anter,�delivery address below: ❑No (.)� O �xl ti C' WilliatnBeaumont %-Jill M &Michelle Crocker, TRS 3. Service Type 95 East'Falmouth,MA 02536 ❑Certified Mail® ❑Priority Mail Express' ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ' 1 s h�� (Transfer from service label 7 014 12 0 0 0 0 0'7; 0358 4 916 PS Form 3811,July 2013 Domestic Return Receipt UNITED STATES' STAt~SfRV' iEE "' First-Class Mail 1.4Postage&Fees Paid USPS ,: •.,_�..• +: Permit No.G-10 +4 • Sender: Please print your name, address, and ZIP44®in this box• Town of Barnstable Public Health Division 200 Main Street I Hyannis, MA 02601 r i f I tt }•ii##}?}}a:?t}ii1373 ?iii iii}a i}7t•i:::•ii iiiiliei} }il iii:7t M No. " - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLatlon for Disposal *pstem (Construction permit Application for a Permit to Construct( ) Repair(>.� Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. I:T 6er;24 1 AG_I"j Owner's NNaam'e",Address,and Tel.No.sO� Assessor's Map/Parcel 4/0 «- CU'�'Le. Q Installer's Name,Address,and Tel.No., Designer's Name,Address,and Tel.No. sl� &r'4,01 Cv,-->�tyrxfian,=iv�c. ys�'.aclu�ir�y Rc� .r Cc � Cie jne ;rly, Trx• gas tl� sf, 0Ar Type of Building: Dwelling .No.of Bedrooms -3 Lot Size 010 y�3 — sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 33(. gpd Plan Date".j,4 it,Q666 Number of/sheets 4 A Revision Date Title , Size of Septic Tank Type of S.A.S. c2-HK) !00jaQ Description of Soil�6"F:4 PIC Nature of Repairs or Alterations(Answer when applicable) / du r 4 o l�a V-% -�,,vik J� Kx I a - 1416a� 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta a and t_-place the system in operation until a Certificate of Compliance has been issued by this Board of Health. n Signed -- Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 92'�-P(!!57 Date Issued 4 No. �O �� f + Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ • "PUBLIC HEALTH DIVISION - TOWN' OWN OF BARNSTABLE, MASSACHUSETTS Yes t 01pplication for Disposal 6pstem (Construction permit Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 1 S 6e.r,%J�i ne. O, ner's Name,Address,and Tel.No.jot=57_e;4-;•3'>/12 Assessor's Map/Parcel yp /;;... Installer's Name,Address,and Tel.No.-509-70")/ Designer's Name,Address,and Tel.No. '�rr 1 n low C?vr,st yiJG�;cr9 inC. y5"X,�us h? gv• 1► �cce ' l neai'ir�x, �r'� 9 35��r`•r �f lWi,es v <, il(S 14 a DaCc Type of Building: Ir F Dwelling No.of Bedrooms 3 Lot Size a O Y�3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) `:- Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3.3(, gpd Plan Date/`4._),`l! t t,aot Number of sheets I Revision Date Title s;4 Flap c� 1`i 6::aa_�Lx Ki r�, C�7�11� I&YA Size of Septic Tank ,� U Type of S.A.S. a?-H tO Stap4 � �C� a •$3�( �� . J Description of Soilp j r Nature of Repairs or Alterations(Answer when applicable) gsrt^�n� ��( �S x a - N(o x a' � Lao,, icr, �-A 16CL, s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maint�ce�of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental C do e and afto place the syst m in operation until a Certificate of fir. . Compliance has been issued by this Board of Health. Signed.y� Date `�- Application Approved by / c Date Application Disapproved by Date for the following reasons Permit No. a 01!!�—A Date Issued I -------------------------- ----------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance £ THIS IS TO CERTIFY,that the On-site Sewage Sewa a Disposal system Constructed Repaired Upgraded Abandoned Abandoned by (40iof+7 dnS�7j-jot^ --Ere- at 1� &e,Co4tnQ_ ( ) Pk-J• p E i t� �- has been constructed in accordance • T dated with the provisions of Title and the for Disposal System Construction Permit No. 0(S a9 6 Installer &401� l.bt�SfrtX�•t r ,..Zr C Designer ��j9Q ���r�(-!Yx , Tj-) ' #bedrooms -_3 Approved desig11--flow 3 ?c gpd The issuance of t'is permit shall not be construed as a guarantee that the system will funct on designe . Date ( Inspector • ry � --------------------------------------------------------------------------------------------------------------------- --------- No. 0 ( � ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *psttm Construction Permit Permission is hereby granted to Construct( ) Repair(, Upgrade( ) Abandon( ) System located at I'j f���T �,E yam_ N CIO`j-t� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. l� Provided:Construction must be completed within three years of the date of this permit. fa Date Approved by i SEP-23-2015 23:38 From: To:15087906304 Pa9e:2.2 FROM :down cape engineering inc FAX NO. :15083629880 Sep. 23 M5 10:54AT1 P1 t owu of Barnstable e qr"a story Soxvic , -efltr,DalreckDx DMsiou '1~inoa�a MCKCHD,Mmutor ' Pax: 508-79&6.10 4 Clffif;o, 548-562A44 - 6 sewage FaIln M Ad isA? Asps cues lidWIP&nceI Date: . r••yj As��res;,a �, D ,.�. u +dnCto +mail a 4� �s ag:aucd p (date) (�) based Q-A a df SW dI�anby . a _ X c Ftif}r'it t th�3 sPjJti,6;aySkern ipt zed ab�rVe' i 1Xei1 s a`u ia�lpoca�t c:orrlm.g#a tb� ele►.si ,'gibicll anay iz►nliI&uut f: av c ?ei sixcb.t�,l;.la Y l relaUu ef•the dJ,4WIMton box.amAUar,;fir try. Z =6fy tl s t1a ay'aCC[C1_zefat`,xtc ed abOvz: w�i +t�¢i:a11P.d wifb 5Moi cbangrg 1 B. I.0100rid.tm of tTE�SAS a=.'Y veracrI zelomt(J� of any acrMPO-0't 't ofthe yc _ is ar.,cozdfiucr.yv kh. t tee 6s cc Rgplada mu- Plan VI;v:iEft[M nx pt,G sp ueLtlfieL1.as, • si��s to follow. � qt%OF Af4s <+ DANIELA. • .. � (S.iAI.A . civil 'A � Re) uo aBScr. Q 1 sr��� 98WNAL VTM (Drslg»a gig) , MMLYP CELL 0.1 '� r� e-A Lk Town..of 0w-,usta ble l �� ]Departianeit of Regulatory..Services * in,?LWffrABe.WPublic Health.DIVISIOU Date 200 Melia Street,Hyannis MA 02601 �... J l M. Date.Scheduled Tune Fe'a k°dl, .i:i• Soil (Suitahil ity Assessment.for ;Sew.r�kj �e IsposaZ Performed-B � 1 V y Witnessed By: ` I/V. LOCATION&�GENERA.L,W- Q A�'�®N Location Address / /1 -_ I /11 � Owner's Name /���Me /"'• Address Assessor's Map/Parcel: L � Enginoer's Name vi NEW CONSTRUCTION REPAIR � Telephone# Land Use: ().Pe~7 Slopes(96) G— Surface Stoaes Distance's from: Open Water Body>jy,G/ ft Posslblc Wct.Area 7t'�/ A Drinking Water Well >l� ft Drainage Way - > tw ft .Property Llne w ft Other ft SJOCCI TCHo(Street name,dlmenslons of lot,exact locations of test holes&peen tests,locate wetlands-in proximity.to bolos) GeKaId ine Poad ;sf • � �GG9�1 , Ex �ng a N o -' +"'R -'Parentmakerial(geologic) [� Depth tv Bedrock ,/ t Depth'to Groundwater: StandingWateHrx Hole:* Weeping from Plt Fnce /v /A i • Estimaked Seasonal Hlgh Groundwater /V//+ 3DYSERKWArflON FOR SEASONAL EACH WATER TABLE Method Used: W r "` Depth Observed standing in obs.hole: _- --In, Depth;to s,411 mgtt106:. Itl, Depth to weeping from side of obs.hole: in, ©roundwaerladjuetment fL Index Well# Rcading Datc: index Well IAYo[.�. __• AdJ,factor—.?-tdJ.,GroutidwUter Laval_,,,.,, PERCOLATION TESL' .Date ^Tjmn.._._ Observation Hole# TImv at.9" .. _ Depth of Pero. I� 71meAt6" Start Pre-soak Time @ n,• - ,rme u_(9 6„) End Pro-soak Rate MIn.(Imch A/ Site Suitability Assessment: Site Passed 5itp Filled: Additional Testing Necdcd(Y7l'I) / Original: Public Health Dlvlslou Observation Hold Data To Be Completed on Back-- ----- ***If percolatio' u test is to be conducted w tbi n 100' of wetland,you must first notify the Barnstable Cod7serVation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFO.RM-DOC LQ US �DEEPu3sFRvik rWA&rq,LOG mole# Deptli from Soil Horlmn Soil Texture Sdi1 Color Soil•. 0t'hcr Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, NTIVIftency,%-Gravel) 0- 7 I' Y A-'139 C 2<SY(ell D=-4 OIBS EIL°`4l'A:IOI.'a1.ILOL)ftO.G Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,boulders. consistmpy,co Grave (0 yI 2 ,5y 0/k, DEEP OBSERVATION ROLE LOG Role;li. Dopthfrom SoilHorizon Sall Texture Soil Color Soil Other' Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Bouldors. Co i to c Gravel) DEEP OBSERVATION]SOLE LOG Ifole'l Depth from Soil Horizon Soil Texture Sall Color 5011 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;9ouldars. Can si Eon cv.q& 9 Flood Ynmranre R- ate_1VYM. Above 500 year flood boundary No Yes "Within 500 year boundary No Yes Within 100 year flood boundary No. r Yds..;,_,,,,.• Denfh.of Ngttira*HV Or-mrring-.Pervious Matorl-aY Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption systeml .Y-�_�---- If not,what is the depth of naturally occurring pervious material's Certification 1��Z • Z certify that on (date)Y have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was potf6rmed by me consistent with . 'the required training,expertise and experience described.in�10 C IZ 15.017. Signatare Datb Q:MPTlaPB11CF0RM.D0C SYSTEM PROFILE ALL SYSTI=M COMPONENTS SHALL BE NOTES MARKED WITH MAGNETIC TAPE OR PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS ASSUMED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS EXISTING \ TOP FOUND. EL. 70.1' FILTER FABRIC OVER STONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 68'Z' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 69.0' Rd 4. DESIGN LOADING FOR ALL PROPOSED PRECAST stt PRECAST H-10 BLOCKS OR UNITS TO BE AASHO H-10 Locus RISERS (TYP.) 4"0SCH40 PVC PRECAST RISERS PIPES LEVEL 1ST 2' MORTAR S H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT. 4' (TYP.) 0' $ ENDS SIDES 66.03' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE 666.8' 10" 1500 GAL H-10 14" :y' ➢o 0 0�0�° WITH 310 CMR 15.000 (TITLE 5.) 66.34 :. . •. oao ° ° ° ' TEE SEPTIC TANK TEE 6.09' ��0� ��®� °o°oho �I]�� DODO °o°o°o° j ° O ° ° O ° ODOO D��O�DOO oo�o�o . �O�00�00�0� >a7. THIS PLAN IS FOR PROPOSED WORK ONLY AND° 000°0°0 0 °°° o GAS BAFFLE: 0000 0 0 ° ��00�00�0�� co 000000000ao 0 0 0 0 00000_ 000 ° ° ° �- � �. �i ,Oo°o°o°o 00 00 0 o NOT TO BE USED FOR LOT LINE STAKING OR ANY ce�o�o0o0o ooa00000000 o�.'000 . OTHER PURPOSE.4 LIQ73 . LEVEL (ACME OR EQUAL) 65. 65.35 0 0 0 0 0 0 ° 0 63.2 O "' •'•'' 6" MIN. SUMP 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. o� J O O O O O O O O O O O O O O O O O O O O O L L 00010000^0^0^000'0'000 00 0o00000?,o^o^ono'000000 12" MIN. INT. DIM. H-10 JO GAL. LEACHING aAMBER BY ACME PRECAST OR EQUAL. 3/4"-1-1/2" DOUBLE WASHED STONE (2, vIVITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR , axter Neck Rd CONCEALED WITHOUT INSPECTION BY BOARD OF 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30' X 9.83' HEALTH AND PERMISSION OBTAINED FROM BOARD o COMPACTION. (15.221 [21) OF HEALTH. c ui - ( Z % SLOPE MIN.) ( 1 % SLOPE) ( 1 % SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND FOUNDATION 21' SEPTIC TANK 57' D' BOX 17' FACILIiTYG VERIFYING THE LOCATION OF ALL UNDERGROUND & LOCUS MAP OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF 57.5 BOTTOM TH-1 WORK. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL NO GROUNDWATER FOUND NOT TO SCALE UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 11. ANY UNSUITABLE MATERIAL ENCOUNTERED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. ASSESSORS MAP 40 PARCEL 12 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND- SAND. 99- EXISTING CONTOUR X 991 EXIST. SPOT ELEV. GERAL DINE.ROAD -[991- PROPOSED CONTOUR (9s•4� PROPOSED SPOT EL. BENCH MARK- EXPOSED TOP OF FOUNDATION AT CHIMNEY EL. = 70.1 SYSTEM DESIGN. TEST HOLE 68 _- - - - - - - - - - GARBAGE DISPOSER IS NOT ALLOWED SLOPE OF GROUND � OO - �Q, UTILITY POLE Ot` h ' °s yF 20p 81, - - - - - - DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD 9 USE A 330 GPD DESIGN FLOW FIRE HYDRANT ° l o(�I ••� I NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING � �• O�`� � %� SEPTIC TANK: 330 GPD (2) = 660 69 Q�O I I ���' i ��o 68 _ USE A 1500 GAL. SEPTIC TANK N tiF ° °�� ° �I q I /3N 0 LEACHING: TEST HOLE LOGS 4-0 AAA' �y 69 I I � 3No ''��o SIDES: 2 (30 + 9.83) 2 (.74) = 118 GPD I BOTTOM 30 x 9.83 (.74) = 218 GPD ENGINEER: DANIEL E. GONSALVES, SE #13587 �� \ �\ J31 ��/��� I DAVID STANTON, RS OI O�� TOTAL: 454 S.F. 336 GPD WITNESS. � EXISTING /3��_ I DATE: 8/5/15 � °5� DWELLING /��� L - - - - �I USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) Ln PERC. RATE _ < 2 MIN/INCH TOF = 7C).1 Q� WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' y� <v BETWEEN UNITS CLASS I SOILS p# 14775 ELEV. ELEV. 2 O 0*0 69.0' O» `�' 69.0' 0 8 0) DECK o S S SNEQ UQ TH 1 10.8' 1OYR 3/1 1OYR 3/1 �Q °� TITLE 5 SITE PLAN 71, 8» TH2 OF B B LS LS �.g� O 15 GERALDINE ROAD 28" 1 OYR 5/6 66 7' 30» 1 OYR 5/6 66.5' �22 COTUIT, MA .:��, O PREPARED FOR C C BORTOLOTTI CONSTRUCTION PERC M CS M/cs BEAUMONT / �ZN OF M,ggs9 11 OF OF M,gSS Q�1 cy ,� q�y DATE: AUGUST 11, 2015 NIELA. DANIEL 2.5Y 6/6 2.5Y 6/6 � DA �� � CIVIL O ALA off 508-362-4541 No.46502 NO.40980„ fax 508-362-9880 P �fi �10 �`� C �P downcape.com @ 0- ('/STrc� \� FESS\o �SS/ONAI ��G �o SUR'' 'k°� down cape endiaeeh#f, iac. 138 57.5 138 57.5 civil engineers Scale: 1"= 20' -'k land surveyors NO GROUNDWATER ENCOUNTERED 113-11-2415 I 939 Main Street ( Rte 6A) LIE �/ 0 10 20 30 4o so FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 LIC # /9 5- /9 / 15-179 BORT-BEAUMONT.DWG