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HomeMy WebLinkAbout0025 GROVE STREET - Health 25 Grove Street, Cotuit Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - t7 26 Grove Street Property Address Jean McGa a Owner Owner's Name -n infonnation is required for every COtuit AAA 02635 90-1�12 r tom• Cttyffo n n state Zip code Date tr,spedrona Inspection results must be submitted.on this forth.Inspection forms may not be al and many way.Please see comp leteness checklist attire end of the form, Ir inj out form A General Information of tiiilin" out lames on the comp der, use only the tab 1. Inspector: I ;O� .. .OS, key to move your V G; =".-' JAMES •N = cursor-do not James D.Sears =o use the return SEARS Mme of trtspector — — key. :# Capewide Enterprises, LLC s 'cFRu `6 •o�,`� an � 153 Commercial 5t. ����i,,�rrn„rN SP1ti° `� �1 Company Address Mashpee AAA 62649 cityrrown State Vp code 50&477-8877 S1623 Telephone Number Ucense Number B. Cerfification 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 f p nspectia� was performed based on m training and experience Pe y g exile in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section IS of Tate S(318 CHAR I&IM).The system. ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Auttwity 10-18-12 ispectoer.signawre Daft The system inspector shall submit a copy of this inspection report to the Approving AtOoffty(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 sycte??ow- and copies sent to the buyer, if applicable, and the approving authority. at the time of inspection and tender the eonditk"n of use t, f� 91 r.. ♦h t,_c..r_att9tattlrne. This inspection does not srl�os_ ss3'�v Lhe syK_M� ���:: �6g-_�f:? err :.:e :��:.�r�sEi'?de.t' the same or different conditions of use. ��� ) rsne•11119 Tft 3 Fom:&Avxfa*Savage alrpcaaf Sp om-Paga 1 of 17 Oct 19 12 08:37a p.2 Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface Sewage Disposal System t=orm-Not for Voluntary Assessments 25 Grove Street Property Addrew Jean McGay it°`^ O mer's Name rtforrnation is ; sor every Cotuit MA 02635 10-18-12 page, clyfTo ne State zip Coft Date of Irm ectioe B. Certification (cont.) Inspection Summary. Check A,B,C,D or E I 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 16.304 exist Any Wure 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 foiiowing statements_If"not determined,'please explain. The septic tank is metal and over 20 years olds or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration ore txfitration or tank failure is imrninent System will pass inspection if the existing tank is replaced with a complying septic tarok as approved by the Board of Heallft. "A rmetal sepUc tank will pass inspection if it is structurally sound,not leaking and if a Ceitifcafie of Corn.pliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): ISne-1t1t0 Title 5 Otridet lnepeyiort Forth:8uDsuAeoe$ervepe[Neposat 9yatnrn•Pepe 2 of 17 Oct 1912 08:38a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispoisai System Form-Not for Voluntary Assessments 25 Grove Street Propedy Address Jean McGay Owner Owner's Name frtfomv tton is Cotuit N1A 02835 10-18-12 required€er every page. Ckfrown State Zip code Date of tnspeefim 13. Certification (coat.) B) System Conditionally Passes(coat.): ❑ 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. Systern will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced Q 'Y © N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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)ace mptac W ❑ Y ❑ N ❑ NO(E)q%-,n belawr ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Farther 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. 11. System will pass unites Board of Health determines in accordance with 310 CMR M-303(1)(b)that the system is not functioning in a manner which will protect pubtic 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 snit marsh tsins•t vto Tire 8 orulat ht4mcim FwrL euw wiece sewep D4csw syewm-pop 3 at to Oct 19 12 08:38a p.4 i Cornrnonwealth of Massachusetts Kwim Tide 5 Official Inspection Form Subsudmm Sewage Disposal System Form-Not for Voluntary Assessments 25 Grove Street Property Address Owner .lean MCGay Owners Name information equired fo is Gotuit MA 02635 10-18-12 r��forevery page. down state Zip Code Date of Inspection Be Certification (font.) 2. System will fail unless the Board of Health (and Public Water Supplier,9 any) determines that the system is functioning In a manner that protects the public healEth, 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 Zane 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 distarmw. This system passes if the well vrater analysis, performed at a DEP cerfified tabermory,for tec:al coliform bacteria indrates aunt 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. i D) Sysferrr"l=aiiturs Criteria Applrcabte to All Systems: You must Indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ 0 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 grouncl or surface waters due to an overloaded or clogged SAS or cesspool g Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool Liquid depth in del is less than T below invert of milable volume is less than Ya day flow A&4cA IA-167 t5fns•t trt0 Tilt 5 Oftical ln%ndkn Fomr Ssbamiate Se%vne Disposal System•Page 4 of 17 f i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Frnm-Not for Voluntary Assessrnents 25 Grove Street Property Rddrr s Jean[Vlctzay. oumers Name iNulme tlon i cofuit MA 02635 10-18-12 vrrY rroam S'rame Mp Code Dot--of Win. ems- _ S. Cerfifcaton (cor►o Yes No ❑ Required pumping more than 4 times in the tact year NOT due to clogged or obstructed pipe(s). Number of tunes pumped: Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ g Any portion of cesspool or privy is whin 100 feet of a surface water supply or tributary to a surface water supply. Q 0 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 weP. Q 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 soceptataie water quality analyses.(This syst om passes if the wolf water analysis,performed at a DEP certHW laboratory,for fecal coliform Bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or toss than 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and Chain of eustody must be attached to thft form.} The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g1d The system falls.i have determined that one or mars of the above Panora criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determhe what aria be necessary to correct the failure. E) .large Systems: To be coristdared a large system the system must serve a facility with a design flow of 10,000 gpd to 45,00 gpd. For large systems, you most indicate either"yes"or"no"to each of the fallowing,in addition to the- questions in Sec*on D. Yes No ❑ the system is within 40.0 feet of a surface drinking water supply 11 Q 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 Prptection Area-IWPA)or a mapped Zone li of a public water supply well If you have answered'yee to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has fafled.The owner or operator of any iangg.e system considered a signihcalnt threat under motion E or Wed under SeMon D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department 150.11110 TNe 5 OMOW k%PB M FQ=SUb=1 ce Sewage 04MOl System•Page 5 0l 17 Commormeaith of Massachmefs Title 5 Official inspection Form Srrbsut►t W SMW 018posal Systern Fsrm-Not for Vokwi ary Assessments 25 Glove Street Property Address Jean McGay Owner Owner's Name f isrequirred br ev ryCout MA 02635 10-18-12 Paw. cAyyrrafm stage Zip Cade Date of In4"m C. Checklist Check if the following have been done.You must indicate"yes"or"now as to each of the fdUowing: Yes No ® ❑ Pumping information was b the owner, or Board f P n5 provided Y .ocoupant, a Health 0 Were any,of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal Rows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recer y or as part of this inspection? ® ❑ Were as built plans of the system obb**d and examined?(lf they were not available note as N/A) ❑ Was the facility or dwelling inspected for slgn3 of sewage back up? ® ❑ Was the site inspected for signs of break out? Were all system Components,excluding the SAS, located on site? ® L Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the batt4es or gees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ❑ Was the facility owner(and o=pants if different from owirrw)provided with inforrnattoet on the proper rnairt"ance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® Q Existing information. For example.a plan at the Board of Health. ❑ 0 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)1 D. System information Residential Flow Conditions: Dumber of bedrooms(design): 4 Number of bedrooms(actual): 3440 . DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms), tSLa•11H0 Tile 5 OMCIM 103POC MForm:SUDsAUM Se*sgen SY31em•Fepe6or37 Commonwealth of Massachusetts CAP Title 5 Official Inspection form_ Subsurface Sewage Disposal System Form-Not for Voluntary tents 25 Grove Street Property Address .lean McGTt owner Owner's Name required for is Cotuit UA 02M6 10-18-12 regain_d for every page- Cdylrwm state Zip Cade Date Of hupection D. System Information Description: The system is a 1500 Gat Precast Tank D Box and five 3050 in or chambers Number of current residents: 2 Does residence have a garbage grinder? 0 Yes No Is laundry on a separate sewage system?[if yes separate inspection requited] 0 Yes.t@ No Laundry system inspected? 0 Yes 0 No Seasonal use? Yes 0 No Wafer meter readings, if available(last 2 years usage(gpd)): 201"1,00CGa€ 2012-128,9OOtial Detaff: - Sum pump? _SUMP P 0 Yes IR Na Last date of occupancy: P nt owe Commerclatltrndustdat Flow 4onditiarrs: Type of Establishment Design Row(based on 310 CMR 15,203): Gallons Per deb►(g Basis of design flow(seaWpersonslsq.ft, etc.): Grease trap present? 0 Yes 0 No. Industrial waste holding tank present? 0 Yes 0 Nc Non-sanitary waste discharged to the 11tie 5 system? 0 Yes ❑ No Water meter readings, if avandabte: Wutg-111t0 Tke 5 ON"5tspedM rant 8L6xafaoe Beweige fl6aposal System•page 7 of!l Commonwealth of Mawachusetts Title 5 Official Inspection Form Sul�u� Sewage Mposal System Form-Not for Voluntary Assessments 25 GmV@.SVW Property Address Jean McGay Cyr OwnWs Nerve requation is k cotuit MA 02M 10-18-12 ��for every page.. Cfty/TOVM state Zip code Date of Inspection Q. System Information (cunt.) Last date of occupancy/use: DM Other(describe below): General lnfornsation Pumping Records: Source of information: 51281138"t>f29111 Was system pump as part of the inspection? ❑ yes 0 No If yes,volume pumped: _-- _ gallons Hoye was quantPty pumped determined? Reason for pumping: Type of System: Septic tank,distribution t*x, soil absorption systern Single cesspool ❑ Overflow cesspool Privy ❑ Shared system(yes oc no)(if yes. allach previous inspection records,if arry) innovative/Altemative technology.Attach a copy of the current operation and maintenanoe contract(to be obtained from system,owner)and a copy of latest inspeCbM of the MA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): tSL�s•11Jr0 Tole 5 Ohl W kzMm*n r-wm-3ubwzkm 8ftWe Wapmal System•pop 8 of 17 Commonwealth of Massachusefts Title 5 Official Inspection Form UVSubsurface Sewage Disxsat System Form-Not 1dr Volunilwy Assessments 25 Grove Street Property Address .lean McGay Owner Ownees Name informa"O"is cotuit MA 02835 10-18-12 required far elmfg per, C41 TaMm State zip Code Date of InsprrrWn D. System Information (cunt,) ApprixAmabe age of all components,debt installed(tf known)and source of triiormation: 2002 Permit # 2002- 494 Were sewage odors detected when araving at the site? 0 Yes O ,No Building Sewer(locate on site plan): Depth below grade: 26" !e Material of construction: cast iron 40 PVC ❑other(explain): Distance from private water supply well.or suction.line: feet Comments(on condttion of joints,venting,evidence of leakage,etc.): Pipein2 is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 18" feet Material of construction: ®concrete 0 metal 0 fiberglass ❑polyethylene 0 other(expfaln) If tank is metal, list age: years Is,age cgffwmed by a G. iR - to of Compliance?(attao a copy of cerii mate.) 13 i'8S [! No Dimensions: 15(lE}dal Precast Sludge depth: 2" t5lrm•t Uf 0 TOO oftet ktspea6oat Faces S"Meoe SOM90 MP=d 3yptens•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage ulspixig System Form-Not for Voluntary Assessnwts 25 Grove Street Property Address Jean McGay OW^W owners Name fetched tQt s won� retZuir Colon MA 02635 50-18-12 its=ry ..Pop, Cry town StaW Zip Code Date of bspeefien D. System information(conk.) Septic Tank(cant,) Distance from top of sludge to bottom of outlet tee or baffle 21r Scum thickness l„ Distance from top of scum to top of outlet tee or baffle 6n Distance from bottom of scum to bottom of outlet tee or baffle 1T' How were diizteroons determined? Asbuilt-Tape Plan Sludge .tud R ..._..__ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc,): Tank and covers at tir below grade, Tardy atwarldng favef outlet tee No sign of or aver loading Grease Trap(locate on site plan): Depth below grade: lest Material of construction: concrete ❑ meth tens fiberglass 0po ►ethy ❑other(expfaln): Dimensions: Scum thickness Distance from top of scurry to.top of outlet tee or baffle. — Distance from bottom of scum to bottom of outlet tee or baffle Date of Last "- pumping: flare t51ns•1 Lf0 TWo 5 Official Inspection Forme Subsixtam System•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage Disposal system Form-Not for VbkMtWy Assessments 25 Grove Street Property Address Jean Mc�- Owner Owner's Name Inr°rrnsfi0is ° required to every Cotuit MA 02635 10-18-12 page- Gtyrrown state Zip code Date of hnpecdoa Q. System Information (cont.j Comments(on pumping recommendations, inlet and outlet tee or baffle condiflon.struchnsl 9r:ftrity, 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: ❑cortcrete 0 mega f+s rgtass ❑p ,yl p o (expw}; f Dimensions: Capacity. gallons Design Flow- Ublon Alarm present 0 Yes .0 No Alarm level: Alarm in wo+c #V ardsr: 0 Yes Q. No Date of last pumping: Data Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required).Is copy attached? D Yes a No rsins•r 1/1C Tsft 5 Of Pda!hsPection Farm:Sibs ABM$&&no DiWOW System-Page 11 d 17 Ccwnmon wvealth of Massachusetts Tale 5 Official Inspection Form Subsurtace Sewage Dlspmd System Form-Not for Voluntary Assessments 25 Grove Street PWperty Address - Jean McGay Owner Owner's Name irrfortnatton Is Cotuit MA 02M 10-18-12 requ ml for every ems. City/Town. state Zia Code gate of han D. System Information (cunt,) DbU ibutbm Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Q Comments(note if box is level and distribubon to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D Box is 16"x 187-Zr below grade w!three lines out, Box is clean and solid no sign of over loading or solid carry over Pump Chamber(locate on site plan): Pumps in working order: 0 Yes No Alarms in mxidng order; 0 Yes No Comments(note condition of pump chamber,condition of pumps and appurtenances.etc.): Soli Absorption SystBrn(SAS)(locate on sii:r Rom,cxcavaiiart not> uired): If SAS not located, explain why: MUM-1 vto TO S 0ft d 1nFd8W n lam:&ftw bw SWAM DtRmd 3Yftn-Page 12 a117 Commonwealth of MassachuSeffs Title 5 official Inspection Fora Subsurface Sewage Disposal System Forte-Not for Voluntary Assessments 25 Grove Street Property Address .lean McGay Owner Owner's Nine informant is required for.eve:jf Cotuit MA 02635 10=18-12 page_ 0100" Stele Zip Code DMB of it an D. System Information (cant.) Type: ❑ teaching pits number. ® iewhing chambers number _ ❑ leaching galWdes number ❑ leaching trenches number,length: ❑ leaching Raids number,dimensions: overflow cesspool number: innovativelaitemadve system Typelname of technology. - Comments(note condition of soil,signs of hydraulic fait m, level of ponding,stamp sod,cDndb-%n of vegetation, etc.): Leaching is five 3060 infiltrator w 14 stone I Vx 3Er Leaching at 30"bebw grade. Camera out to leaching, Prob and T.H. above and beside chambers No sign of over loading CessPo+Qis(cesspoot most be pumped as.past of inspection)(locate on site plant' Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum Layer Dimensions of cesspool Materials of consOuction _ indication of groundwater inflow Ye, Np •r tyro ref s 0Md* Foal&b=fw* Did 2ydem-Pegs to nr 17 Commonwealth of Manachusetts Title 5 Official Inspection Form Subswbce Sewage Dull SyM m Fw m-W W votary Assessments 25 Grove Street Property Address Jean McGay owner Owners Name requb db is Cctuit MA 0263a 10-18-12 pam•age, foreYery Cky/Fown State zip code 0M of hopecrian D. System Information (coat.) Comments(note condition of soil,signs of hydraulic fame,level of pending,con.dif on of vegetation, etc.): Privy(locate on site plan): Wtetials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5irts•f fH0 rate 6 Otedar trssyecaton Fans s�acfeae se.,�t Seam•t�to at 17 Gomnl< mealttll of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System pom-Not for l Voluntary Assess wts 25 Grove Street Property Address Jean McGay Qwmrs Norte Enformaeon is regdrred far eeerg Cotuit MA 02635 10-18-12 page, C YITOM state Zp Code Late of Inspeerm D. System Information (cone.) Sketch Of sewage Disposal system:Provide a vier of the sewage dis�system►inchrethg sea to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 Let. Locate where public water supply enters the building.Check one of the boxes below: hand-sketch in the area Wswlr. ❑ drawing attached sgwatety 8 A ,? EPA 13 G t I { -,_ �a= � fig• B-3 _ � Q� t5fns•11H0 Tft S 0McW.knspet*m Foms.&t=jzw Sewage 0hpc&W System-page 15 o!17 f Commonwealth of Massachusetts Title 5 Official Inspection Form ftbsurtace Sewage Disposal ftstm 1FW-Not for VoWntwy Rssesm*nM 25 Grove Street Property Address .lean McGay Owner Owner's Name (rltorrrlaI is Cotuit MA U635 10-18-12 Iegwred for es�ry pap, city/To" state Zip Code Date of MVecfim D. System Information (cone.) Site team: ❑ Check Slope ❑ Surface war Check cellar ❑ Shallow wells Estimated depth to high ground water: 14;1 feet Please indicate all methods used iD determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: 10-16-2002 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with k I Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USES database-wgft rt; You crust describe holm you established the high ground water elevation_ T.H.on Design plan 10-16-2002, No G.W.at 14' Before filing this Inspection Report,please`ses Report Completeness Checidist on next page. 15aa•1111 o Title 5 official kwPeclon Font wMeace 36wage Dlapnsw Sys am•Page 16 or 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurtam Sewage Disposal System Form-Not for voluntz ►Assessmw% 25 Grove Street PmpertyAddtess Jean McGay Owner Owner's Name requ*r�t4reveryr Cotuit MA 02835 10-18-12 pap, Citylrow n state Zlp Code Date 01 kqvcbw E. Report Completeness Checklist 0 Inspect m Summary:A, B,C.D,or£checked 0 Inspection Summary D (System Failure Criteria Applicable to Ail Systems)completed System Wbrmation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached In separate file t�iu•t vt 0 Title 5 0ftW kuyertian Form S1hufflOw&WSP Di 03W Syzam•page t 7 of 17 FEE COMMONWEALTH OFMASSACHUSETTS Board of Health, � MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for (Permit to Construct( ) Repair Upgrade( ) Abandon( ) XComplete System ❑Individual Components Location C i T Owner's Name Map/Parcel# MAP aO Address p Lot# $� Telephone# _ u 8 _S Installer's Name g Designer's Name d Address Address 1••�A Telephone# _ �S Telephone# Type of Building \ Lot Size MO♦-sq.ft. Dwelling-No.of Bedrooms Q. Garbage grinder Other-Type of Building one C No.of persons�_Showers ( ,Cafeteria ({� Other Fixtures L:A\j K- JQ`��k� t�A�. LCtS Rt u Design Flow (min.required) �14D gpd Calculated design flow -440 Design flow provided gpd Plan: Date �(�11�� Number of sheets Revision Date Title O V qk � Description of Soil(s) Ie Soil Evaluator Form No. Name of Soil Evaluator ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS { Co Qc)ka&)Q:� The unde signed agrees to instaUthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es to 't to place a ration until a Certificate ofI(,- omp'ance has been issued by the Board of Health. Signed Date Inspections . d )2 n i Board of Health, MA. APPLICATION V FOP DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT � Application for Permit to Construct( RepairX Upgrade( Abandon( Complete System ❑Individual Components r, Location �'-cave'. 1�- Owner's Name 7 e. M Map/Parcel# p ao E as Address �'�� 1 n Lot# Telephone# _ Installer's Name kS.' ; �\ Designer's Name U,�. A` &CS Address '* S Address M +,. Telephone# _ L �-s Telephone# Type of BuildingO ��e�n � Lot Size L-;)n. obO+—sq.ft. Dwelling-No.of Bedrooms F-4�1�� Garbage grinder (IV114 Other-Type of Building NOR P No.of persons 4 Showers (►/j Cafeteria (V< Other Fixtures v�1AT�� Design Flow (min.required) "t4' o gpd Calculated design flow 4a Design flow provided ���•3 gpd Plan: Date Number of sheets Revision Date Title " f O 'FQ �C Description of Soil(s) Ci. J Soil Evaluator Form No. Name of Soil Evaluator . &tJ �R i�Date of Evaluation 0 DESCRIPTION OF REPAIRS OR ALTERATIONS Ara ,w t -•i The u ersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrrees to /tt to place thg syst�e(m ration until a Certificate of Coom • yp ante has been issued by the Board of Health. Signed ! �� / 1 i`(/� Date �U tYx Inspections No. � % FEE COMMON U'V' H �OF /A' AC14USETTS Board of Health, _ (,1 f / �� MA. CERTIFICATE OF COMPLIANCE Description of Work: 0 Individual Component(s) Y-Complete SystemThe undersigned hereby certify thatrtthe Sewage Dis Disposal System; Constructed ( ),Repaired fjV),Upgraded ( ),Abandoned ( ) by ! (�{J 4� / at C C has been installed in accordalnr�/ L the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No\ / 4 "(X •at d Ap roved Design Flow (gpd)} Installer Designer: v? ���( C i I Inspector: ('��l / .v VI !' /C gate: l/ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No.n) ) �q v FEE 6 Board of Health, y� G1_ , MA. � DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to-(Constr(u t(( Re.air( Upgrade( ) Abandon( ) an individual sewage disposal system at ) C I F(� YC `f 1 V '(/� 1 as described in the application for Disposal System Construction Permit No.7r Z19Y ,dated 1 0/7Zhz Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date J 2 �� Board of Health / r/ � TOWN OF BARNSTABLE LOCATION C (5 VF-S 1'e1_.1_\ SEWAGE # G1Z� L VILLAGE C[ c�i ` ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. l- NE SEPTIC TANK-CAPACITY �co K_.) LEACHING FACILITY: (type) Q /`'TU�'1 (size) r4 NO.OF BEDROOMS BUILDER QR OWRaL,2:� tiro �C Yv PERMIT DATE:_ 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 13 II, I � I .33' i B a �� �, FORM 11 . - SOIL EVALUATOR FORN i Page 1 of No.: Date: 10/16/02 COMMONWEALTH OF MASSACHUSETTS Barnstable , Massachusetts Performed By: Carmen E. Shay Date: 10/16/02 Witnessed By: Waiver Location Address or#30 Grove Street Owners Name: Mr.Jena N. McGay Cotuit,MA Address and #30 Grove Street, Cotuit,MA Lot# (Map-20,Parcel 122) Telephone Number: New Construction : X Repair : OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: NoF_1 Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 500 Year Flood Boundary: No ❑ Yes Within 500 Year Flood Boundary: No FX__1 Yes ❑ Within 100 Year Flood Boundary: No a Yes ❑ Wetland Area: None National Wetland Inventory Map (map Unit): Wetlands Conservancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal ❑ Normal X❑ Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #30 Grove Street, Cotuit, MA On -Site Review Deep Hole Number: #1 Date: 10/16/02 Time: 10:00 AM Weather: Sunny, Cool Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From.- Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" - 12" As Loamy 10 YR 3/2 None <5% Gravel, Friable Sand Friable 12" - 28" BW Loamy 10 Y/R None <5% Gravel, Friable Sand 5/6 Friable 36" - 168" C' Medium 2.5 Y 7/4 None Medium Sand, 10% Sand gravel, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock:None encountered Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: None Estimated Seasonal High Water Table 168" Assumed — No groundwater Observed DEP APPROVED FORM 12/7/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #30 Grove Street, Cotuit, MA Determination of Seasonal High Water Table Method Used: ❑ Depth observed standing in Observation Hole: N/A inches ❑ Depth weeping from side of Observation Hole: 168 inches (assumed) ❑ Depth to Soil Mottles: None inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING PERVIOUS MATERIAL: Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system: Yes CERTIFICATION: I Certify That on September 17, 2000, (date), I have passed the soil evaluators 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. Signature: Date: /6 / Jo FORM 12 - PERCOLATION TEST Location Address or Lot No.: #30 Grove Street COMMONWEALTH OF MASSACHUSETTS Cotuit , Massachusetts Percolation Test Date: 10/16/02 Time: 10:30 AM Observation Hole #: #1 Depth of Perc 30" — 48" Start Pre-soak 10:28 AM End Pre-soak 10:38 AM Time at 12" Would Not Hold 24 Gallon Presoak Time at 9 Time at 6" Time (9-6") Rate Min./inch < 2MP1 Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: Waiver Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Site Passed X Site Failed DEP APPROVED FORM 12/7/95 Sep,- 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 � • 0� SiZ:;01 II ' NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. Pl✓RCOL,'kTION "PEST AND SOIL EVALUATION EXEMPTION FORM C7C hereby certify that the engineered plan signed by me le;eC concerning the property located at meets all of the • This failed system is connected to a residential dwelling only. There are no _omrrttrz a.! or business uses associated with the dwellin3. • Tie soil is ciass:ied as.CLASS I and the percolation rate is less than or equal to rl:rates per rich. The applicant may use historical data to conclude this fsc. or may conduct tests at the site without a health agent present. • There :s no :ncren;e to flow and/or change in use proposed There a:-e ;to va-tantes requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen l') 'eet aoove the m?ximum adjusted groundwater table elevation. fAdiust the ;raundwater table using the Fnmptor method when applicab[e] Pease complete the following: -fop of Groune Surface Elevation (using GIS information) —A_— S` C.w' Elevator, -- ad;ustment for ini,h G.W.62_,..1?.. = ._._ �•� �'FFF R�FNCF SET JJEEI4 A and B S:c�'1rE D -- — DATE: :NOTICE �asec �rc)n the above irformaUon, a reoair petTni will be issued for bedrooms _um. `, .ddttional, bedrooms are authorized to (h.- future without eng!neere. I_c^!!�: ;v;teln plans. �r_un:r,:oc+ PciccxmP Cape Cod Commission: USGS Well Data - September 2002 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information, please contact Hy_drolo ist_Gabrielle Belft at the Commission offices (508-362-3828). September 2002 * Record Record Departure from Average** C S(-.S Site Number ""' Location Well No. Water Level High* Low* Monthly Overall (links to ( SGS national water-level database) Barnstable A1W 230 (provisional)onal) 20.5 26.6 (provisional) (provisional) 413956070164301. Barnstable Al W 247 27.3 20.5 28.6 -2.3 -2.8 414154070165001. Brewster BMW 21 13.4***, !! 6.9 13.4 !! 11 -3.0 -3.2 414518070020301 Chatham CGW138 25.6 20.9 26.6 11 -1.1 -1.7 414100070011101 Mashpee MI W 29 9.9*** 5.6 11 10.0 -0.8 -1.4 413 525070291904 Sandwich SDW 47.9 45.9 48.2 -0.4 -0.6 414418070241601 http://www.capecodcommission.org/wells.litm 10/21/2002 Cape Cod Commission: USGS Well Data - September 2002 Page 2 of 2. SDW Sandwich 253 54.6*** 45.8 55.1 -4.3 -4.5 414.12407026590.1 Truro TS W 89 12.5 10.2 13.0 -0.1 -0.5 420206070045901 Wellfleet WNW 17 12.3 7.3 j 12.8 11 -1.5 -1.8IF 415353069585401 * Measurements are in feet below land surface. ** Measurements are in feet above mean sea level. *** New monthly low. H New record low. USGS national-water-level database provides historic data, hydrographs, and site maps. The USGS compiles the above data and other water levels into a monthly, online Water.Resources Current_Conditions Report that covers all of Massachusetts. Return to CCC Fre went,U dates page � —P p g Go to Cape Cod Commission Water Resources_Office page I I i I k http://www.capecodcommission.org/wells.htm 10/21/2002 CARMEN E. SHAY (508)-548-0796 ENVIRONMENTAL SERVICES,INC. P.O.Box 627,East Falmouth,MA 02536 October 18, 2002 RE: Certification of Title V Septic System Installation: ~ Residential Property—25 Grove Street, Cotuit, MA Dear Sir or Madam: On October 21, 2002, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at �510 Grove Street, Cotuit, MA, based on a design drawn by Shay Environmental Services, Inc, dated, 60ctober 18, 2002. XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions,please do not hesitate to call the undersigned at (508)-548-0796. Sincerely, CARMEN E. SHAY ENVIRONMENTAL SERVICES,INC. 1,t CsF 1.jtA G�L vS. c%row CAR1,E E. SHAY C 0. 1181 m Carmen E. Shay, R.S., C.S. Fo/STER�� President 84A'iTAR\F�' I ! Permit Number: Date: I Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: )0 �1� . �O 1�s Lot No. Owner: �-4a N, Address: GC6 L St ►,J �' ' Contractor: + t(8c�scrv/r� Address: t Notes: I I i STEP 1 Measure depth to water table `r J to nearest 1/10 h. .............................................................................. Date iD W.102i mont /dsy/ve•r I STEP 2 Using Water-Level Range Zone and Index Well Map locate j site and determine: M� OA Appropriate index well................ O Water level range zone..................................................... I i i STEP 3 Using monthly report "Current i Water Resources Conditions" determine current depth to water level for index well ........................... mo h/y••r i STEP 4 Using Table of Water level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2f3) determine water-level adjustment ......................................................................................... STEP 5 Estimate depth to high water I 1 by subtracting the water, j level adjustment (STEP 4) i i from measured depth to water levelat site (STEP 1) ............................................................................................................. I I i ip Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection e WQcior.iam mor F.Weld Trudy.Cox e Arr Paul Celluccl OavW B:Struhs LL Cgmmhsbrt.r nnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION 25 Grove St Proper Address: CotUit Address of Owner. Margaret Natvig Date of Inspection: 8—8—9 6 (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 )7 7 5—8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails I nspectoe's Signature: W W'.j �-( )L `J Date: 'F— g— Qf 4 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] PASSES: 7.1r have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)FSYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved n by the Board of Health. (revised 11/03/95) I One Wlnter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-SM iw,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address 25 Grove St Cotuit Owner. Margaret Natvig Date of Inspection: 8—8—9 6 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution boa is levelled or replaced The system required pumping more than four 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 obstruction is removed C] FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the blic health,safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) NES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND S AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is f-se from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ten than 5 ppm. 9) (revised 11/03/95) 2 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddresa: 25 Grove St Cotuit Owner. Margaret Natvig Date of Inspection: 8—8 9.6 DI SYSTEM FAILS: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for t ' determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an 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 spool 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 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARG SYSTEM FAILS: e following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 U of a public water supply well) The owner or operator of any such system shall bring the system and facility into Hill compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Pmperl9Address: 25 Grove St Cotuit oW1er Margaret Natvig Date of Inspection: 8—8—9 6 Check if the fo have been done: ping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As t plans have been obtained and examined. Note if they are not available with N/A. z.facility or dwelling gwas inspected for signs of sewag e back-up. system does not receive non-sanitary or industrial waste flow site was inspected for signs of breakout. system components,excluding the Soil Absorption System, have been located on the site. septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. Zhel and location of the Soil Absorption System on the site has been determined based on existing information or app ted by non-intrusive methods. _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Grove St Cotuit Owner. Margaret Natvig Date of Inspection: 8-8-9 6 FLOW CONDITIONS RESI(DENTIAI: Design flow:-3 3 �llons Number of bedrooms: Number of current reaidents:.,04 Garbage grinder(yes or no):__,e,i O Laundry connected to system or no):� Seasonal use(yes or no):.lr Water meter readings,if available: jqqyS 20 oo O Zu-/J Last date of occupancy: 9-F~i COMMERCIALANDUSTR.IAL: Type of establishment: Design flow:_gallona/day Grease trap present: (yea or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yea or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �/ System pumped as part of inspection: (yes or no)Zi- O ,VA y If yes,volume pumped: ¢allons O Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Sin&cesspool __JLOverIIow cesspool Privy Shared system(yea or no) (if yea,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: c3 O S Sewage odors detected when arriving at the site: (yea or no) &C(J (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Grove St Cotuit Owner. Margaret Natvig Date of Inspection: 8—8—9 6 S C TANK: (locate n site plan) Depth be w grade: Material constriction:_concrete_metal_FRP—other(explain) 1GE-/d Sludge de Distance m top of sludge to bottom of outlet tee or baffle: Scum thi Distance m top of scum to top of outlet tee or baffle: Distaa from bottom of scum to bottom of outlet tee or baffle: Cowmen (rocs dation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence o leakage,etc.) G TRAF:_ (locate o site plan) Depth bel w grade: Material o construction:_concrete_metal_FRP_other(ezplain) Dimensions. Scum Disteaoe top of scum to top of outlet tee or baffle: Distance m bottom of scum to bottom of outlet tee or baffle: Comme (recomme dation for pumping,condition of inlet and outlet tees or battles,depth of liquid level is relation to outlet invert,structured integrity, evidence o leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 25 Grove St Cotuit Property Address: Margaret Natvig Owner. 8-8-96 Date of Inspection: TIGHT,,OR HOLDING TANK_ (locate site plan) Depth grade: Material of n:—concrete_metal_FltP_other(e:plaitt) Dimensions: Capacity: one Design flow: one/day Alarm level: Cowmen (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIB ON BOX: !/ (locate on plan) Depth of liqui level above outlet invert: Comments: (note if level d distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP C BER_ (locate on si plan) Pumps in rking order:(yes or no) Comments: (note oonditic of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Grove St Cotuit Owner. Margaret Natvig Date of Inspection: 8—8—9 6 / SOIL ABSORPTION SYSTEM(SAS):_V (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number:_ leeching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Cowmen : (note condition of soil,sigma of hydraulic failure, level of ponding, condition of vegetatioAetc.) o a c,/ CESSPOOLS: (locate on site plan) - 1 o � JL 9 I Number and configuration: �. � /f� I � Depth-top of liquid to inlet invert: Depth of solids layer. - 3 ' ` Depth of scum layer: 6 > > Dimensions of cesspool: 4r5 �^ Materials of construction: 1 d e .5 Indication of groundwater: i inflow(cesspool must be pumped as part of inspection) - S ,>_S- i.S / ®� (' ® ,�c� O Z• A0,0 i 7 ".17 Ceod.3 O Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) P (locate on plan) Materials construction: Dimensions Depth of lids: Comme :(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) ry 11 e( ised /03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Grove St Cotuit Owner. Margaret Natvig Date of Inspection: 8—8—9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' GOD jr- j 6 r� GB�L DEPTH TO GROUNDWATER Depth to poundwater._j.1-*feet method of determination or approximation: 6 � 0 (revised 11/03/95) 9 f i LC t 1� "c �tr y '� "R" ntr! thi+': r_'•'Y� ''t,�• s �ir2 . 3;. t -s�-. .p. 4 yC .s,m r..3Etrt`� .$ -�,. pt'4 tr.r:;r'_ :,1'�s_r.';srsk -;� -v: a Y rJY>!i.;r..t,, _� tt" ,•.,+r.; - _�" - .,,5•t?,�•-"b > -: '_!: - "•1T..'.,L>Y _' s•„_ .,a-;,e: < ^•C. %k. _ ?.r;'8 _ .".xdrt'1�,. t..lti,. 1 lx,.. _ „er:x h < r �. ; % .fL'... dv '.]ti '',�`�T :F a- "� _ _ _ _ _ ti7, .9 iw: ,L' y r "O r . +. J ' ti.rTP: rc - rr t� - - 3w.+ u� h J} - _- - -iY• x` ^7 s-_ s _: "`' ' a• M1' .i0'_ _ _ _ r7 vr, : :. , { .� •-;_ £ .,.,sue",-` i� z-. 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DtsTROJT10N BOX SHALL BE G Existing Foundation PROFILE VIES' OF LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. t2 CONCKTE COVER 7a Septic tank covert must be " L within 6 in. of finished grodt Not to Scale •.'•_•.. ywa�::.j.+, •9L //Nlode over Septic Tonle - 99.00 Grade over 0-Box - 97.00 Grade over SAS - ELEV. 97.00 r 3 - Y OUTLET 2 9 /// i t �� 3N005'OU t` of r/8• - t/t' rorA.d re.eo.,. \ 15.5• S . 0.02 3 HOtF H-10 /t" W r r/S 1►asAed LSvaAta Sto- OUTLET St 3 g 12' NEW S 0.70 GIST. BOX 3' Moxmum Cover \� / 6• SChOOt Z E,dst. PIPE r; 1.500 GAL. 35' . 0.010' foots .`YaS.S' ` 4" - SCH- a0 T`> ,.7s• SITE FIiDH FOUNDATION °' SEPTIC TANK n H-10 % S 'n 1S 2' Effective Depth 5 h ----� PLAN SECTION CROSS-SECTION CONCRETE FULL FOUNDATI u 24 Effective J L Sidetoall QO t SYSTEM PROFILE 6 in.ot 3/4"-t t/2" R 4' 3 4' 5 Units a 6.25' = 31.25 3 HOLE H-10 DISTRIBUTION BOX v �' compacted stone > tT NOT TO SCALE Not to SCOIC 1' II 3 5• 31.25' 3 S, � C Effective V•dth LOCUS MAP 38' 6 in.of 3/4'-1,1/2' d Effective Length compacted stone 0 > tt�ms�vta� Leta a�� 00 SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES INFILTRATOR MODEL 3050 (H-10 LOADING)/ SUMNER & DUNBAR 1. Contractor is responsible for Digsofe notification (OR EQUIVALENT) and protection of all underground utilities and pipes. 2. The septic tank and distribution box shall be set NOTE: OVERALL HEIGHT OF INFILTRATOR IS 30' /EFFECTIVE HEIGHT IS 24" level on 6„ of 3/4"-1 1/2" stone. 3. Bockfill should be clean Sand or grovel with no LOT #40 stones over 3" in size. TYPICAL 1500 GALLON SEPTIC TANK \ 4. This system is subject to inspection during installation PL by Carmen E. Shay - Environmental-Services, Inc. NOT TO SCALE 100.00' \ 5. The Contractor shall install this system in accordance with Title V of the Mossochusetts state code, the approved pion and Local Regulations. 3-24•DIAa. ACCESS MANHOLES �3, ` SHED 6. If, during installation the contractor encounters any W. _6" ` soil conditions or site conditions that are different LOT #42 from those shown on the soil tog or in our design ! \ installation must halt & immediate notification be 20,000 S.F. +/- \ made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the IN (-1 ( - •.,i • '•'�: septic system unless noted as H-20 septic components. INLET --�' --i ✓ ou T "'`• \ 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. THE ACCESS COVERS FOR THE SEPTIC TANK, DISTRIBUTION BOX AND LEACHING COMPONENT • = 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. \ SHALL BE RAISED TO WITHIN 6" OF f---D-BOX \ 10. All solid piping, tees & fittings Shall be 4" diameter .� :.:::" .;:a :. • •. FINISHED GRADE. STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EOUALS 3 ' • !i \ \ Schedule 40 NSF PVC pipes with water tight joints. PLAN VIEW ON ALL OUTLET TEE ENDS \ 11. Municipal Water is Connected to The Residence and Abutting • \ TEST HOLE #1 \ Properties Within 150 Feet. ELEV. 97.50 ;; • / \ LOT #37 NOTE: 3-24' REUOVABLE COVERS \ \ THE PROPERTY LINES ARE APPROXIMATE AND COMPILED FROM THE SURVEY PLAN GENERATED BY E.C. BOURNE OF SANDWICH, MA 4• \ ENTITLED " PLAN OF LAND IN COTUIT, MA" 3" min. cleoronce IS' •'• rRlt 1$'-� 11 \ . 8" mi-J 2 m.t wet to outlet 6• ,. LOT #44 ,. (MAY 1, 1902) AND IS NOT INTENDED TO BE A SURVEY INLET r_- / � Lqu° '"" ,. OUTLET \ PLOT PLAN. IT SHOULD BE USED FOR NO PURPOSE OTHER THAN s' -7- - �.� L ;• s' -7" / _ j \ \\ THE SEPTIC SYSTEM INSTALLATION. sAl / 15tOv gal. E 4'-0" min • Gar r' liquid tlepdepth0 Septic Tonle ,• 0s °°""' �• ,. •.• w � � � � /\ � THERE ARE NO WETLANDS LOCATED WITHIN A 200' RADIUS t __ _ - -- O j - \ \ _ OF THE PROPERTY _. -- .. ,. . _... r 0 Failed O � O \ Cesspool \\ � \ _ CROSS SECTION END-SECTION `� r/ \ LEGEND DENOTES PERCOLATION TEST I Failed 28 / � 104X1 SPOT GRADE OPOSED I co Cesspool � 6'/ Date of Percolation Test: OCT. 16, 2002 DECx `� PROJECT BENCH MARK x 104.46 DENOTES EXISTING Test Performed By. CARMEN E. SHAY, R.S., C.S.E. #30 TOP OF FOUNDATION SPOT GRADE Results Witnessed By. WAIVER ( for Barnstable B.O.H.) / ELEV. = 100 (assumed) Excavator: Shay Environmental Services, INC. co 1 I PL Percolation Rote: Less Than 2 min./inch PROPERTY LINE `1 TOF= ELEV. 100 r 1 96P PROPOSED CONTOUR Test Hole No. 1 I EXISTING 4 97 --- 97 EXISTING CONTOUR DEPTH SOILS ELEV. I BEDROOM HOUSE I & �- D --- 9850 I I LOT #35 DEEP TEST HOLE LSa d �� I PERCOLATION TEST LOCATION t0 rR 3/2 !0 12" Ao 97.50 Sandy loom 6 FOOT STOCKADE FENCE 10 YR 6/4 LJ it2'-28' 1 S. 96.25 I Med \ GRAVEL i Sand 061 \ DRIVEWAY j 2.5 r 7/4 C� 84.50 PLOT PLAN 28"-t68 \ OF PROPOSED SEPTIC SYSTEM REPAIR Perc #1 \ _ _ / PREPARED FOR Depth to Perc: 30" to 48" ��� M C GAY Perc Rofote=<2 min./inch I • Groundwater Not Observed \ No Observed ESHWT \ AT ADJUSTED H2O Elev. = None ' �00• #,.J-QL GROVE STREET COTUIT, MA Design Calculations CB D)H. CB D.H. FN[L ��' YT �r m �► ��r FND Number of Bedrooms: 4 Equivalent to 440 Gol./Day (440 Gal./Doy Min. per Title V) / C-R CJ D' 7 A� L �L � �[ HOFA P EPA RED BY: Garbage Grinder: Now Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) (40 FOOT RIGHT OF WAY) `� CARhlNHA Septic Tank : - 2 x 440 Gol./Day - 880 USE 1.500 GAL. Septic Tank. NOTE: ANY STRIPPED OUT SOIL CONTAI04G LEACHATE E E. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch \ o v, FROM THE EXISTING CESSPOOLS TO BE DISP6SI<D 0 ENVIRONMENTAL SERVICES, INC. Bottom Area: 0.74 gat/sq. ft. x 418sq. ft. = 309.32 gallons o. 1181 Sidewoll Areo: 0.74 gal•/sq. ft. x 196 sq. ft. = 145.04 gallons OF AS PER BOARD OF HEALTH SPECIFICATIONS. 6 0 20 40 50 R E �� �` 34 THATCHERS LANE Fcl T Providing: = 454.36 gallons .� EAST FALMOUTH, MA 02536 Use: (5) HIGH CAPACITY INFILTRATOR CHAMBERS, HAVING A 2' EFFECTIVE DEPTH, EXISTING CESSPOOLS TO BE PUMPED DRY & - TAR�P� TEL,/FAX : 508-548-0796 (3' W x 6.25' L) TO BE USED WITH 3' OF WASHED STONE ON THE SIDES AND SCALE: 1 "=20' DRAWN BY: CES DATE: OCT. 18, 2002 „ 3.75' OF WASHED STONE ON THE ENDS. FILLED IN PLACE PER TITLE V. SCALE: 1 =20 PROJECT#SD351 FILENAME SD351 PP.DWG SHEET 1 OF 1