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0042 GUIMQUISSETT ROAD - Health
42 Guinlq%:i§sett-Road COWlt A= O19 - 112 r td No. � 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9pphration for BispoSal Opstrin Construction Permit Application for a Permit to Construct( ) Repair( ) `Upgrade'( ) Abandon( ) ❑Complete System ❑Individual Components. Location Address or Lot No. G'�,j � $�, hod& Owner's Name,Address,and Tel.No. L Assessor's Map/Parcel iDP ea C'u'i wt �cA�� Installer's-Name,Address,and Tel.No. Designer's Name,Address,anI Tel.No. A+�au.cc `7"Au�ttlr� meev .t two Type of Building: Dwelling No.of Bedrooms ?j Lot Size '26) sq.ft. Garbage Grinder(i7p) Other Type of Building ReS No.of Persons 5 Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -3 3 O gpd Design flow provided gpd Plan Date gb (Q Number of sheets 19 Revision Date Title 3 i I'S 5?q- / Size of Septic Tank /tj�p v Type of S.A.S. 406 O r� G tint ur PCYi. f/Sfctl�' Description of Soil ft/ed, 4,+u& Nature of Repairs or Alterations(Answer when applicable) E/1 VA�c Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar th. Signed Date /6, , (Q Application Approved by Date 5 25�-( Application Disapproved by Date for the following reasons Permit No. `� Date Issued �� a- No. ` i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitatiow for Disp aY 6pstrm Construction i3Prmit Application for a Permit to Construct( ) Repair( ')`AJPgradw( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ''G'v i M QVi SF rati 6 Owner's Name,Address,and Tel.No. 1 Assessor'sMap/Parcel b!q Cb rl Cu i wlc2-cs5 «i�it /031 Installer's Name,Address,and Tel.No. Designer's Name,Address,ant Tel.No. �l cui-(t 7d E 'S��'dC/( Type of Building: Dwelling No.of Bedrooms ?j Lot Size �13,� '/)o sq.ft. Garbage Grinder(hp) ^K Other Type of Building s No.of Persons ^S Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided 3 y`rs,7 gpd Plan Date 9/2 ltq Number of sheets 2 Revision Date Title r Size of Septic Tank /! D U Type of S.A.S. 6 b a ,/ /i el /5�n��? Description of Soil iu pd. -:!2A q 4, Nature of Repairs or Alterations(Answer when applicable) L'/,2 � t, Date last inspected: Agreement: 0 The �j (unders �j ( _t igned agrees to ensure the construction and mainte6fied of t%afore(de cribed on-'site_sewage disposal system in ` accordance with the provisions of Title 5 of the Environmental Code and not to place the systeznn.irroperation until a Certificate of Compliance has been issued by this Board th. f Signed �� � Date �il, ,Q Application Approved by � 990 Date Application Disapproved by Date for the following reasons Permit No. d©/9 1 Date Issued -=------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance ~THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at D CL, (w, 'V i s Sr rc,Q has been constructed in accordance with the provisions of title 5 and the for Disposal System Construction Permit No. 2011 dated Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wi nc'o as designed. Date Inspector y r J r V ------------------------------- -- - --------- -- ------------------------------------- ---------------- ----------------------- No. ;-o/9 — 60 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction joPrmit Permission.is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at e f, d A aJ It 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. Provided:Construction must be completed within three years of the date of this permit.,--, � Date roved A � f PP b y TOWN OF BARNSTABLE f jam/ LOCATIONr.-'�jv°I? e/%/h ���;fSP� / SEWAGE# d;�O ICI— VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY. (type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: �-�%''`J 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 Faci ity(If any wetlands exist within 300 feet of leaching fac' ' Feet FURNISHED BY 2=y3'6" a al' 3_a „ House- 3-3�'�" Li-�3 �( 4 - ►3,�., � � � a e _ I 'own of Barnstable �Pyo�zt+e ro�� / o Recyulatory Services 4 S Richard V. Scati,Interim Director �* BARNsrABLE, MASS. A pro 0 Public Health Division aTfc I'homas,McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4044 [7a:�: 508-790-6304 Installer-& Designer Certification F orin Date: �f�r 1 Ck Sewage Permit#Zo I q - /5-Assessor's Map\Parcel 4 i 9 -it_Z' Designer: 1 '-_' r n �' _- t�_s�_ka IV-1 Installer: F,-a6tC;(S_c0_Jcw�t�es �y C Address: 12 In1. Cr s;C�IC.i � address: 6 q d lot tef-le, hc r r �G..r r--L M A Oil , etas issued a hermit to install a (d,ate) (installer) septic system at +z G- 'wi ass e ft I- based on a design drawn by (address) e5n r1c J dated (designer) - N I ccrtlf3, that the septic system referenced above was installed substantially according to the design, wrhich may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out: (if iI-quired) was inspected and the soils were found satisfactory. _ -- I certify that the septic System referenced above- „pis installed with nin.or c1lanccs (i. . grca.ter'than 10' lateral relocation of the S,-�ti or any vertical relocation of any component of the septic system) but in accordance with State cC Local Regulations: Plan revision, or certified as-built sat by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. _ I certify that the system c rented above was constructed in _ ,�rith the terms off ie appr r.,,ai -ers(if applicable) tqrEgT ins[all rFs Sig nature) CNIL / To.35109 O _6� �9c�,RFQiS�ER�C�� (Desig�er's Signature} (Aff.s io. LE ere) i PLEASE RETURN TO BARNSTaBLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE «-ILL NOT BE ISSUED UNTIL BOTH THIS F6_04 AND :kS- BUIL I'CARD RE RE.CIj I!%t,D I3v'TIII:: 13�1IZNS'I'kBLE PC,'3LIC HLALTI-I .DIN'ISI*36�- THANK YQUi.-_ tl:`:Septic ,Uesi_rcr Certification Form Rev 5-14-13.doc Engineers note:This certification is limited to an as-built inspection of system components as installed prior to backtill.The engineer did not supervise consimcti",o`the system.The installer assumes respansibility for all materials,workmanship,backtilling to specified grades e.,ith proper compaction and setting:iserslcovers as stios.n on the design plan. I TNE1 ToWn of Barnstable Ft O ,s " Department of Inspectional Set-vices MRNSlA13l.E, ;=z �0� Public Health Division ArFp MP�� 200 Main Street.fivannis MA 02601 Office:,508. 2-4644 Date Scheduled 5 ( _Time / ,'G L A t"1 (,� {Soil Suitability Assessment,fogr S'e:wage�Disposal � Performed By F�'� TV~ 1 L—:5V-\. t— tnessed By: 1J LOCATION &GENERAL INFORMATION Location Address: Owner's Name: '. cSA -C 1 Owner's Address: 44 C.c`S -E'W o v LC-5-t( Assessor's Map/Parcel: G — ]t Z Certified Soil Evaluators Name: Certified Soil Evaluators Email -qi� New Construction or Repair: P�Q(DG' ,'i Certified Soil Evaluatorsfielephoric 0 50Fy73.7--ct76, f Land Use 1z \ o ' � �rt�C �Cy Slopes( �) Surface Stones 1�.'t Distances from Open Water Body.7- O ft Possible Wet Area N/A it Drinlune Seater Well 15,0 ft Drainage Way, iUA ft Property Line 7� is ft Other ft Parent material(geologic) l �—CS+1 S Depth to Bedrock; t _ � Depth to Groundwater: Siandi.ng Water m ifole: #\tit 6rck,) °Weeping from Pit Face (\1�z'Alk Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: /Je W Deptli {)'sewed standing in obs.hole. _in Depth to soil mottles _ in Depth to weeping from side of obs,hole: in, Groundwaier Adjustment_ it Index Well 4 Reading Date. Index Well level Adl factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation �� Hole fi � 'rime at 4" T Depth of Pere Time at 6" __A Start Pre-soak.Time',ii; \ S Time(9"-6") Fnd Pre-soak Rate Min.Anch Site Suitability Assessment: Site Passed y Site Failed: Additional'resting Needed(Y/N) Deep Observation Hole Log' Hole#: l Depth from Surface Soil horizon Soil Texture Soil Color Soil`:hairttling Other ('n) (USDA) (10unsell) (Structure,Stones;Boulders, Consistency,°n Gravel _ 12 t No °tC,C, . 'S-�'tj -tC, Ad- Deep Observation Hole Log Hole#: ~Z Depth from Surface ` Soil horizon Soil Texture Soil Color Soil 'lottlinb Other (in) I (USDA) (Munsell) (Structurc.Stones,Boulders, 1 Consistenc- %Gravel) I j s I 5 f Deep Observation Hole Log Hole#: Depth from Surface ' Soil Plorizon Soil Texture Soil Color Soil N•tottling Other i � (n) (USDA) (Tvlunsell) (Structure,Stones,Boulders, Consistency—% l l i Deep Observation Hole Log Hole #: Depth from Surface Soil Horizon Spil Texture Soil Color Soil Mottling Other- (in) (USDA) (Munsell) (SvUCtLIIC,Stones,BOUI&I5, Consistency %Gravel) E I --- t Flood insurance Rate.Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No �� Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed:"throughout the.area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? . Certification I certify that on_ i( 111�{��.�'(date)`['have passed the soil evaluatpr examination approved by the Department of Frivimnmental Protection and that the above analysis was performed by me consistent with the required Lrainino,expertise and experience described in 310 CMR 15.0.17, i 7 Signature Date �I SKETCH: (.Or you can attach a separate sheet) (Street iutme,dimensions of lot;exmt locations of test holes&nerc,tcks,IQ"Ite�vti utt4s in Froium ty to hulesj PARCEL ID: 019-112 r iFORMER HOUSE' LOCATION #42 ? o y TP-1 TP-2 W o 40�0 GUIMQUISSETT ROAD 40 No.JJDSqa Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou ff or Yell Cou5truction Permit Application is hereby made for a permit to Construct , Alter( ), or Repair( ) an individual well at: . �- �� !`7 — //2, nn Location&d7ess I Assessors Map and Parcel U 1�a�C., `�/ -4! v ��5 L1 1 Jd l GL� Owner Address 1A T0— -BQ-� 17(- -R Installer) riller Address Type of Building Dwelling Other-Type of Building No. of Persons /i Type of Well .7j,(rI a , � � Pye— Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the n well in operation until a Certificate of Co p 'an a as b issued"by the Board of Health. Signed Dah Application Approved B / Date Application Disapproved for the following reasons: IDate Permit No. k,)oxo)l © Issued / ( � Date ------- — -------------------------------------------- -------- �I BOARD OF HEALTH 1v�1 J� TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual we Constructed(' , Altered( ), or Repaired( ) by A I Y Installer at has been installed in accordance with t provisions of the Town of Barnstable Board of Health Private Weli Projection Regulation as described in the application for Well Construction Permit No. �"�� --O l 7 Dated Z THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector -13 No: Fee — q BOARD.OF HEALTH TOWN OF BARNSTABLE T[ppricatiou ff or Yell Construction Permit Application is hereby made for a permit to Construct(� Alter( ), or Repair( ) an individual well at: dd V Location Oddress ff n AssessorsfMap and Parcel Ut DID/5S-C GG�.i�' �.d�t✓ L/a (3141M/Oytf.4Set 6iarr 10 Owner V Address I Installer jbriller a Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Sy y i A 041 r, j,% ��� /�V L Capacity / Purpose of Well -I o a,t 1 r, V1 Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of CCoorppliiannccee)ha-s�/een issssued'by the Board of Health. a Signed y Date Application Approved By F �� Date Application Disapproved for the following reasons: ii Date Permit No. Q r? Issued / 1 Date --------_--�--------------------------------- --------------------p__-----___----------- BOARD OF HEALTH s SYv'� TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual weV Constructed(V, Altered( ), or Repaired( ) by All ('&a,_ A//.�. 11 / ,Installler has been installed in accordance with thk provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ` s 91 "`0 1 7 Dated $ 1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector ----------------- 1 I U BOARD OF HEALTH TOWN OF BARNSTABLE Q Verr Con.5truction Permit �1 No. ��� / Fee Permission is hereby granted to f 1 C ►v L Installer to Construct(J) A/lter( ), or Repair( ) an individual well at: ' No. "`� 2- oStreet` as shown on the application for a Well Construction Permit No. � �/ Dated Date I /' 1 Approved By iKE Town of Barnstable Barnstable �~ A®-fte icaC" Inspectional Services BAEWSTABLE, 9� bg Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 7756 May 13, 2019 GUIMQUISSETT REALTY LLC . 44 COLUMBINE RD NEWTON, MA 02459-3444 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 42 Guimquissett Road, Cotuit,MA was inspected on 04/01/2019 by John P Graci Sr., certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed'that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The cesspool,is full of roots. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action: i RDER OF BOARD OF HEALTH as McKean, R.S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\42 Guimquissett Road Cotuit.doc Town of Barnstable s a a s 9�A 6 9 ,�� Regulatory Services Department rfn Ma's" Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. . ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10'components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: r- Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc r� c Commonwealth of Massachusetts Q/g_ ��oZ Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD t Property Address e F ` Owner Owner's Name information is COTUIT MA 02635 04/01/2019 ` required for every page. City/Town State Zip Code Date of Inspection u� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information S(-' (37-4-(a3 filling out forms on the computer, JR use only the tab OHN P GRACI S key to move your Name of Inspector cursor-do not GRACI SEPTIC INSPECTIONS LLC use the return Company Name key. PO BOX 2119 Company Address TEATICKET MA 02536 City/Town State Zip Code ram, 508-548-7500 S1468 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and.maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluatio by the Local Approving Authority 4. ® Fails 04/01/2019 Inspector's Signature Date The system inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 ays of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the i pector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 I •a j S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: NA 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion,of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 t i . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The Y 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): 3) 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. a. 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: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for.fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: NA 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts jn p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ® ❑ 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. 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on.the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): ND Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ND Description: Number of current residents: VACANT Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 ATTACHED 9 . ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Cityfrown State Zip Code. Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: NA I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NA Last date of occupancy/use: NA Date Other(describe below): NA 3. Pumping Records: Source of information: NOT PROVIDED Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I� Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): SINGLE CESSPOOL AND 1 - 1000 GALLON LEACH PIT Approximate age of all components, date installed (if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: liftfeet 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.): CESSPOOL AT TIME OF INSPECTION WAS FULL OF ROOTS t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: NA Sludge depth: NA Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? NA Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NAgallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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.): NS "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): SYSTEM DOES NOT HAVE A DISTRIBUTION BOX t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts x - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NA Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ry - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-1000 GALLON LEACH PIT HAS BEEN FULL. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 -6X5 Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool 6X5 Materials of construction BLOCK Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 6X5 CESSPOOL AT TIME OF INSPECTION WAS FULL OF ROOTS. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 A Fkb►r 0 �W d w .KW 2 A7 5$ �2 4a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 GUIMQUISSETT ROAD Property Address Owner Owner's Name information is required for every COTUIT MA 02635 04/01/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. . ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L_ 5EW C, _PERMIT 1JP. .1N.5TALLER-5_1J�P/lE_�_ADD.RES -- BUILDER 5 QA1 F-- AD _ DATE.-PERt Al-T-- 155UF-D -_ DATE. COMPLI-DMCE 1� < No......................... Fmc 2................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F �EL T �J v rn SS Apphratinn -for DhiVwial Works Tonstrurtinn Vrrntit Application made for a Permit to Construct PP is hereb Y.. ( ) or Repair ( } an Individual Sewage Disposal System at r .............�)................................ c n.Address - - or Lot No, \ ..E._. ... ... ... .................... .. ..... ............ . .__ W e s -- ------ °'' -= �• --------------------------- I ------ nstaller Address �. Uype of Build Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) 04 d Other fixtures -----------------------------------•----------------- W Design Flow.............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth---.------.----. x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area--------------......sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.-.---..-.---.___-sq. ft. z .Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by...... -----------------------------•-•-•.........------....-----------• Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water..-.---..-----.--.-.---- (xq Test Pit No. 2................minutes per inch Depth of Test Pit.--_-_-_--_-----__ Depth to ground water.-.--.-.-_-.---.-._----- t4 ------ ----------------------------••••--------•----••••----•...--•-•----•-•--••--•-----......................................................... 0 Description of Soil._ U ............ ---------------------------•------------------------•---------------------------------------------------------------------------------- --- -------------------------------------- ---------------------------------------- ------------------ ...... ::--------------------------------- U Nature of repairs or Alterat' ns—Answer when applicable.-_--p? -- - .-�-C�-.- -------- -- Z----------------•-------------- ----"� ---------------------------------------------------------------------- Agreement: The undersign agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ` ed by t boar Signed-- - -----� Date ApplicationApproved By----------------------------------- - ........................................................... Date Application Disapproved for the following reasons------------------------------------------------------------------- --------------------------------------- ..--------••-•-------------------•••--------------.....-------•- Date Permit No......................................................... Issued.. r S_ Date No......................... FIcu............................ THE COMMONWEALTH OF MASSACHUSETTS --- BOARD HE G� • �..... _..............OF... ....................._...-...................-......................... Appliratioo -for Bhipwial Works Tontitrurtioo Vrroiit ton is hereby ad a % 't onstruct or Repair an Individual Sewage Disposal System at ��.. Loc on.Address } r - or Lot N o. `------ ................................................ / .......... Installer Address Q pe of ilding Size Lot-...........................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building p ._ Showers ( ) — Cafeteria ( ) Pat Other fixtures -------------------------------------------------- ------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity._......._.gallons Length---------------- Width................ Diameter--.-...._..---__ Depth-----__--.-.._- x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------- ------------------------------------------------•---------------- Date------------------------------------ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water.-----.-_.---.-.--.-___. �rA Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ,ground water--._.--.--__----..--.___ a ---------------------------------------------------------•-•-----•-------------.....-••--••---------......................................................... 0 Description of Soil- LL: . x -----•---•-•---------•.................•--------•---......._....--•--•-------•---••----......------------------------------------ V --- ----- - --- --- •------••-•-- -•-•- -- U Nature of Repairs or Alterati ns—Answer when applicable.....ji .____ '+ , , . �!' ''�'� 1 - """' - -- - fit`-- • -----c- �- -------------------- ------------------------- ----------------------------------------------- Agreement: (r' The undersigns agrees to install the aforedescribed .Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' d by th boardf he�alt Signed..._... -.....1_:.......A/ . ------ -------- --- Date ApplicationApproved By-------------------------------------------------------------------------------------------------- ---------------------------------------- Date Application'•Disapproved for the following reasons:................................................................................................................ -------------------------------------•---------------------•-------------•----------------•-•-------------•---•----------------------------------------------•------------------------•---•------------- t Date PermitNo......................................................... Issued.....................--................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD VHEALTH ......... ..... ........OF........................ :......................................... Qrrtifirate of MUNIMP aurr ISliT TIFY, hat t e Individual Sewage Disposal System constructed ( ) or Repaired by...ZfZl�,, ------_------- w I�s aller has been installed in accordance with the provisions e XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. __._ _._..,, ------------ dated._../,D___jX:-... ....__.....••. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTF.......RUED AS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. C7 DATE `. 1�1.. .Z`� Inspector ------- THE COMMONWEALTH OF MASSACHUSETTS / BOARD F HEA TH ..........OF...... .................. ....... ..................... j— Bispwia _yk15;�&,Taowtrjtrti 1n/Vrrotlr Per ' sion is hereby gra to .� �--.li.'�' f' �... �y ��' to Co S r R yam (�)�t In 'vidu ewage Disposal Syste / at No..•--•-• -->f.... cif%......_- � G(j - - ----9- A_,_%f!•1 l , t1 Street as shown on the application for Disposal Works Construction Per o........ .... ..... --71.......... i -------------- - --- . . . r_ - H - --ea - .�,�{c-��f ---------- Board of tU / DATE...--------------------------------------------------------------------------•-• (// FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS C '66- -100-- EXISTING CONTOUR x 100.98 EXISTING SPOT GRADE N 34 PROPOSED CONTOUR 32.2 PROPOSED SPOT GRADE CB/DISC FOUND N/ PROPOSED WATER SERVICE �a ' R) (a TEST PIT Rosh ee rleok Rd J Crockers w BENCHMARK N `tt X h / poPonesse q�s LEGEND SPff -p o 'Qa o � -o • ClJ� a LOCUS o goyberry Ln v n� LOCUS MAP NOT TO SCALE IC X�A nO \\ Z EXISTING SHED TO \\ BE REMOVED �\\ 27 L— — ,p• 30,0 NEW 10'xl2' �? LOT 154A SHED �\ N x U' 29,7 20,420f S.F. \\ rn \ N \ C v PROPOSED \ � BOARD FENCE ,gyp. LOCATION OF FORMER \ 3 BEDROOM HOUSE \\ - 30 28.8 x (REMOVED) - \ x 6' GATE o PETER T. \ o MCENTEE 30,2 �,� 31.3 p �r� S CIVIL PROP. _ _ PROP. , �� �. No. 35109 DECK -. PORCH- -- ----- INS °j BOARD FENCE , , 18' O \ PROP. Fq�, 30,9SEPTI------ --- 1 TANK PROPOSED BH ti� �Z- HOUSE(#42) T.O.F. EL.=32.17 Cli OLD DRIVEWAY m QI LOCATION �\ . :Go / 31.3 PORCH 6,a 3L5� - ------ -- 31:3 PROPOSED12.g+" II II 12' I a u \ I " TP-1 TP-2! i ; EXISTING CESSPOOL q\\ u 3 0� TO BE PUMPED, FILLED I N { T I N W/SAND & ABANDONE01 !U p it cZ O r) OR REMOVED lP ij ii !L CB �1 0 FOUND,1UUNVi 27.7. _ 32.8 �� 32.511 S37.07 30 E .� 135.�5 — 1r o o—�. 0 QP POST AND RAIL FENCE x cp- 30,6 OF EDGE BENCHMARK: GUIMQUISSETT ROAD ,(�0 NAIL & CAP �( EL. 32.62 0 y OWNER OF RECORD GUIMQUISSETT REALTY LLC 44 COLUMBINE ROAD PARCEL ID. 01 9-1 q I Z NEWTON, MA 02459-3444 Engineering by: SCALE DRAWN JOB. No. PROPOSED SEPTIC SYSTEM DESIGN 'PLAN Engineering Works, Inc. 1"=20' P.T.M. 173-19 42 GUIMQUISSETT ROAD, COTUIT, MA 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 5/2/19 P.T.M. 1 Of 2 Prepared for: Guimquissett Realty, LLC, 44 Columbine Rd, Newton, MA 02459 r€� NOTE: TO PREVENT BREAKOUT, FINAL GRADE . SHALL NOT BE AT, OR BELOW, EL.=27.0 SEPTIC TANK FOR A DISTANCE OF 15' FROM THE EDGE INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX OF THE PROPOSED S.A.S. OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & WATERTIGHT PROPOSED S.A.S. COVER SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND T.O.F.=32.17 SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT F.G. EL.=31.3f F.G. EL.-29.5t F.G. EL.=29.3t F.G. EL.=29.5t MAINTAIN 2% SLOPE OVER S.A.S. L = 19' _ _ ® S=1% (MIN.) p S=1%1(MIN.) ® S=1%1(MIN.) 4'SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/8" To 1/2- ly s" DOUBLE WASHED STONE io"I as $ as (OR APPROVED FILTER FABRIC) i4" s 2' EFF. aeaaaaa INV.=27.25 4s• uoulD DEPTH BaBaaaa --3/4" TO 1-1/2" DOUBLE IEVEL 4' 4.8' 4' WASHED STONE ADD INV.=26.80 PROPOSED INV.=26.63 INV.=27.67 GAS BAFFLE INV.=27.00 D-BOX EFFECTIVE WIDTH = 12.8' INV.=26.50 PROPOSED SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-10 RATED TOP CONC. ELEV.=27.3t BREAKOUT ELEV.=27.00 NOTES: INV. ELEV.=26.50 aae00 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & aBaaaaaaBa, INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. BOTTOM ELEV.=24.50 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND 4' 2 X 8.5'=17.0' 4' TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH SIX INCH CRUSHED STONE BASE, AS SPECIFIED PERVIOUS MATERIAL IN 310 CMR 15.221(2). 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION 3) INSTALL INLET & OUTLET TEES AS REQUIRED. NO G.W., EL=19.4 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. SEPTIC SYSTEM PROFILE N.T.S. GENERAL NOTES: 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. ®®U U 0 U U U U 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS U U U U U U U U U U U OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 33" LOCAL RULES AND REGULATIONS: W ® 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR N Z ®�®®®® ®®®® TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING I-E 102" FROM-THOSE-SHOWN HEREON-SHALL-BE-REPORTED TO THE DESIGN - - - - - ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS .BASED ON NAVD88. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 4" KNOCKOUT THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 20" DIA. COVER 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. 4" KNOCKOUT / 4 KNOCKOUT 58" 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 0 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 4" KNOCKOUT 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 500 GALLON CAPACITY, H-10 LOADING IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND CHAMBERS REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. N.T.S. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. SOIL LOG DESIGN CRITERIA DATE: MAY 1, 2019 (REF. TPT#19-14) SOIL EVALUATOR: PETER McENTEE PE(SE#1542) NUMBER OF BEDROOMS: 3 BEDROOMS WITNESS: DAVID STANTON R.S. HEALTH AGENT ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) 31.4 0" 31.4 O.. DESIGN PERCOLATION RATE: <2 MIN/IN FILL FILL DAILY. FLOW: 330 30.4 Ab 12 30.6 Ab 10" DESIGN FLOW: 330 GPD LOAMY SAND LOAMY SAND GARBAGE GRINDER: NO-not allowed with design 10YR 4/2 IOYR 4/2 LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 29.9 B 18" 30.o B 17 74 GPD/SF LOAMY SAND LOAMY SAND / 10YR 5/8 10YR 5/8 PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY 28.4 C 36" 28.4 C 36" PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED a PERC USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 42"/60" SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES MED. SAND MED. SAND 2.5Y 6/6 2.5Y 6/6 SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. TOTAL AREA:.............................................................. 471.2 S.F. 19.4 144" 19.4 144" PERC RATE <2 MIN/IN: "C" HORIZON DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD NO GROUNDWATER ENCOUNTERED Engineering by: SCALE DRAWN JOB. No. PROPOSED SEPTIC SYSTEM DESIGN PLAN Engineering Works, Inc. N.T.S. P.T.M. 173-19 42 GUIMQUISSETT ROAD, COTUIT, MA 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 5/2/19 P.T.M. 2 Of 2 Prepared for: Guimquissett Realty, LLC, 44 Columbine Rd, Newton, MA 02459 I