HomeMy WebLinkAbout0081 HIGH STREET - Health 81 High Street ` a)
otuit ° P
• I
TOWN OF BARNSTAKE
LOCATION V SEWAGE# 3-r5j 31 j 3 Sl y
VILLAGE (2n=u i y ASSESSOR'S MAP&PARCEL ` ® \-
INSTALLER'S NAME&-PHONE NO. c� aA-t. 2)_, 19Q'T C.S. 6'cP-a g-Y u
SEPTIC TANK CAPACITY l c50n
LEACHING FACILITY:(type) Ur- L e, C kar,; -g(size) 3 �l
NO.OF BEDROOMS 5 .
OWNER '25rA C C`� �ON.
PERMIT DATE: .(p'pZ COMPLIANCE DATE: (0 - R,,
Separation Distance Between the: _
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility `J 4' Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) . '4 A Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) ] n A)I A` Feet
FURNISHED BY C
R¢�r aF
� �
R ---_.� �� /Sa c�
. d�� � ) r
�� .5�b E �� ^ 1
�� � ��� -�
�� �
R,� �rjs a� �``�
No �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co puteih r:
PUBLIC HEALTH DIVISION ' TOWN OF BARNSTABLE, MASSACHUSETTS Yes
1
01ppYication for``lltsposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair O Upgrade X Abandon( ) Complete System ❑Individual Componetits'
Location Address or Lot No. I i-�i `� f &miu •7- Owner's Name,Address,and Tel.No. ,
Assessor's Map/Parcel 35 ,3J 3a
srkGC S� ,
Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size I +) of$® sq.ft. Garbage Grinder(AJ
Other Type of Building M Orw- No.of Persons R Showers( Vf-Cafeteria( 11
Other Fixtures
Design Flow(min.required) gpd Design flow provided a gpd
Plan Date Number of sheets a Revision Date
Title
Size of Septic Tank i �� l Type of S.A.S. (�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of tYHeh!
nm de d not to place the system in operation until a Certificate of
Compliance has been issued by this Board of
S' ne Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
M Permit No. `� Date Issued �j
4 Noy. - Fee
THE COMMONWEALTH OF MASSACHUSETTS T Entered;ncomputer: 1/
PUBLIC HEALTH DIVISION TOWN'-OF BARNSTABLE, MASSACHUSETTS Yes _
litafion for is `oral stern Construction j3prutit -�
Application for a Permit to Construct( ) Repair( ) UpgradeX Abandon( ) Complete.System ❑Individual Components,,
a
Location Address or Lot No. N 5 �-� 1 a T Owner's Name,Address,and Tel.No.
,r
` Assessor's Map/Parcel 35 131 1 3A
Installer's Name Address,and Tel.No. 5 -.Designer's Name,Address,and Tel No. `
tLV V, k-,c,'J"
Type of Building: :J tl�uv
r
Dwelling No.of Bedrooms Lot Size c�$O sq.ft. Garbage Grinder(N yA
Other Type of Building tJ Or w No.of Persons Showers( KCafeteria( ► )
Other Fixtures
Design Flow(min.required) ; J Z) gpd Design flow provided,., L4-4" gpd
Plan Date `\�' !, \ Number of sheets Revision Date "'
�1t �2�C� G� ter' �'xiS-�e lJ[�C,cGP
Title
Size of Septic Tank y Sl. j Ct C� (_ Type of S.A.S. x�,Cl fit' '(��ct
Description of Soil _
r
Nature of Repairs or.Alterations(Answer when applicable)
:y
D"ate last inspected: Ai 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 Envi' o71 ,1de d not to place the system in operation until a Certificate of Compliance has beenissued by this Board of He .th., y
t Sig ha Date
.Application Approved by �• t Date
`'Application Disapproved by• Date
is _for the following reasons
Y•Y 'r yY
Permit No Date Issued / t A -
r�,�„a - -
�' THE COMMONWEALTH ORMASSACHUSETTS
.; BARNSTABLE,MASSACHUSETTS,,,
Certifitate of.6alp lance', w
THIS IS TO CERTIFY,that
`the On-site
QSewage Disposal system Constructed'( ) R111epaired( ) Upgraded(��)
Abandoned( )bye ,• �
1. `. _ • . r _ _ - � _ , ._,
at , t� _ has been constructed in accordance
with the provisions of Title 5 and 1he for Disposal System Construction Permit NoN / dated
Installer ) c PnV� S1;;?.V CS. Designer �CC
#bedrooms Approved design flow f� d
i � PP g gP
The issuance of this permit shall no be construed as a guarantee that the system will fimptio2-as designe
ffd.
r. t
Date )( " (o " ( Inspector G✓�-�( r
No Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal **stem Construction 3Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( )
�, System located at
� r
ra.
. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. l'
Provided:Construction must be completed within•three years of the date of this pe" rmit.
Date /6W� Approved by _ -
1 Town of Barnstable
111F`"E' .o Inspectional Services
Public Health Division
• JLUWSTABLFE
MAC' Thomas McKean,Director
200 Maim Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: Sewage Permit# ' C Assessor's Map\Parcel 0 635 3a
Designer: Installer: -, ?',��_ :>c�•�C:
Address: 1201 \NI,AC-11_131A Address: 900 N 7VO-nn
H A
On S2,,�C�5 was issued a permit to install a
(date) (installer)
septic system at based on a design drawn by
(address)
dated '" c1 '
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision Ior
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in c i ce with the to rms of
the a o 1 letters (if applicable) 'CA oi
E
E.
(Ins -er' it ure) 1
No �
f �Isis�`
( ner's Signatur ) (Affix Des p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
WoaldeptAHEALTHISEWER connecASEPTIC\Designer Certification Form Rev&14-13.DOC
OWN OF BARNSTABLE
LOCATION r� �f SEWAGE#
VILLAGE I• AS SS�'S MAP&PARCEL 03 03
INSTALLER'S NAME&PHONE NO. 113
SEPTIC^TANK CAPACITY
LEACHING FACILITY.(type) �t�ss�a (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: —7 3® V
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
L
6,
Y�1= S�� �
p '9/J�OI
I �`� V
q � ,� � v �,
Q
I
TOWN OF BARNSTABLE
LOCATION o 1Sh SEWAGE #
VULLAGE C 6-rv,+ ASSESSOR'S MAP & LOT Q3 S . D7/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY —CvueIUI
LEACHING FACILITY: (type) CU!POO (size)
NO. OF BEDROOMS 3 d
T BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leac 'ng facility C Feet
Tn ,
Furnished by ,,,. _ p/
r
A a
i as s�
t
ta�5� Sr.
r
TOWN OF BARNSTABLE
LOCATION f SEWAGE#
VILLAGE ASSESSOR'S MAP& LOTS
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) z 5 (size)
NO.OF BEDROOMS
r
BUELDER OR OWNER
PERMUDATE: 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 1-aching facility) Feet
Furnished by ` 7�C®ewUX A , 44 ,.,ac..
1
L
No. l O`I Fee l
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[ppiicatiou for 30i.5po!5al *pgtem Con5tructiou Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System I owl Individual Components
Location Address or Lot No. ! /��j�� ner's Name,Addres„and Tel.
Assessor's Map/Parcel
Installer's Name,Address,an Tel.No- �c Designer's Name,Address and Tel.No.
/ e �L/
Type of Building:
Dwelling No.of Bedrooms s Lot Size r sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) VA gpd Design flow provided /V/A -- gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Verations(Ans er when applicable) (U
Date last inspe ed:
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 He�1 ,
Signed Date
Application Approved by - - Date 7 2-1—6 'q
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
NO.
,. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
i Yes
pp „ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Miopogar *v tem,,, Cow5truction Permit
Application for a Permit to Construct( ) Repair(,/Upgrade( ) Abandon O ❑ Complete System lk Individual Components
Location Address or Lot No. �� Owner's Name,Address,anC^I.No
Ass slsor's Map/Parcel
Installer's Name,Address,and Tel.No. �r Designer's Name,Address and Tel.No.
Type of Building: / .
Dwelling No.of Bedrooms / ► Lot Size sq. ft. Garbage Grinder ( ) ,r,
I
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(min.required) 7 1 r gpd Design flow provided A —� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Ans er when applicable)
Date last inspe ed:
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 o Health.
Signed / Date ��Z�(�"
Application Approved by Date 7 _d
Applica'tion Disapproved by: Date
for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
_ THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( V/ Upgraded ( )
Abandoned( )by ` V10111 �o�s�`
at / j'}lj �, � �/ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ,?001 —07 I dated
Installer Designer
#bedrooms 144 Approved design flo A gpd
The issuance of thi�ilt stall not be construed as a guarantee that the system wil 1)untoays desig-ed.
Date o ) Inspector V •1/v
/y� 1
—--— No. L�Z7_7 ` _i _— —_.---.= —•--—. _, —.---.— -- ------ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
I=igpogar �&pgtern Cow5truction permit
Permission is hereby granted to Construct ( /) Repair ( i-) Upgrade ( ) Abandon ( )
System located at �"--
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this it.
Date — 6 C Approved by ,
'r
i
TOWN OF BARNSTABLE
SEWAGE # f
LOCATION o 5
VILLAGE C 6Tv ASSESSOR'S Mtir & LET r13
INSTALLER'S NAME&PHONE NO:
E
SEPTIC TANK CAPACITY ' Cui 0a
� I
LEACHING FACILITY: (type)r CL4 (size;
NO. OF BEDROOMS 3
BUILDER OR OWNER bV/I/11G1t't`t'
PERMITDATE: COMPLIANCE DATE: i
Separation Distance Between the: 41
i Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Factlity I
Private Water Supply Well and Leaching Facility.(If any wells exist Feet
on site or within 200 feet of leaching facility) 1
Edge of Wetland and Leaching Facility (If any wetlands exist
�. Feet
within 300feet of lea+ng facility) 1
Furnished by
A a
s
l as sa -
D
ST
_ r
Town of Barnstable
� E Regulatory Services
Thomas F. Geiler,Director
MAM Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: -13-0 Sewage Permit#- ;-D Z-Assessor's Map\Parcel--
Designer: _V_C<1_ SS 0 cl q S Installer: L-)(,-_q
Address: 3-0 Gfytf 4-k.4 Address: /f `r Q4 ,ey" Lq I4�e
On .7—7 d 1 7 ' LX CtIVa:, o 0 was issued a permit to install a
(date) (installer) /�
septic system at A
3 .fV 1 based on a design drawn by
(add
UCL4-I rs dated 6 ^ 6 aq
` / (designer)
1/ I certify that the septic system referenced above was installed substantially according to
4 the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &Local Regulations. Plan revision or
e1 certified as-built by designer to follow.
N OFMgss�O
AW
O N
s VON HONE taller's Signature) v #1068zi
�j qNI T ARC P
Designer's Signatu e) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Sepdc/Designer Certification Form 3-26-04.doc
r _
No. a�0�- 020� ` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS , Yes
apphLation for Mispo8af *pstrm ConstCuttion permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ stem Complete Sy
stem y ❑Individual Components
Location Address or Lot No. 1 S9 MDI r6t Owner's Name,Address,and Tel.No.
COTV l-r Aunt AdcQ rn s
Assessor's Map/Parcel M -Pgrce 00 7$ 5+
taller's Name,Address,and Tel.No. Desi a 's Name, ddress,and Tel.No. 5D B-$3 3 ab 41
vber} C� �ifoy- B+R ExcQuct+ton Vl ssouc�tes
3 zo Co-prr tZp 5 A
Type of Building: 1 /
Dwelling No.of Bedrooms — 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) 4 4 l7 gpd Design flow provided �l 6 0 gpd
Plan Date & I I & I d oj Number of sheets Revision Date
Title 7 5 M n i n.S-f-► (p-ly I-r
Size of Septic Tank 1 c5 Co q a.1 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 77 (�
Application Approved by ( - n Date z- 7-0 °f
Application Disapproved by Date
for the following reasons
Permit No. �,00 cl Date Issued - 7—0
60 mil
Anne Adams
759 Main Street
P.O. Box 1906
Cotuit,MA 02635
anfieladams@comeast.net
774-238-0058
June 11,2009
Mr. Tom McKean
Barnstable Board of Health
200 Main Street
Hyannis,MA 02601
Dear Mr. McKean,
I am in the process of having the septic engineered at 759 Main Street. Currently the
town has my house assessed as a 3 bedroom. However,the house has four bedrooms and
has always had four bedrooms prior to our buying it in 1986.
Dave Stanton was at my house yesterday for a soil test. I mentioned that my house has
four bedrooms. It is an older house and has a unique lay out but the rooms definitely
qualify as four bedrooms. He suggested I contact you.
Amy von Hone is working on the septic engineering and I would like to have her design
the septic for the four bedrooms. I hope this meets with your approval.
Attached are pictures of the four bedrooms and the floor plan(three bedrooms on the
second floor and one on the first).:
Sincerely,
Anne Adams-
Enclosures:
Pictures
Floor plan
e
i
TRANS.NO.:
CITY/TOWN: C® Li
APPLICANT: Awe If01-5
ADDRESS: -75- il 5 e-1
DESIGN FLOW: r4A 0. 14r( gpd
REVIEWED BY: DATE:
N/A OK NO
GENERAL
Legal boundaries denoted 310 CMR 15.220(4)(a)] ✓'
Street,Lot,tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)] 1�
Locus Provided [310 CMR 15.2204(t)]
Plan proper scale? (1"=40'for plot plans, 1"=20' or fewer for
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served[310 CMR 15.405(1)(a)for
upgrades]-i not, a variance is required 310 CMR 15.412(4)]
Location of impervious surfaces(driveways,parking areas etc.)
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)]
Location and dimensions of system components and reserve
areas. [310 CMR 15.220(4)(e
S stem Calculations [310 CMR 15.220(4)(f)]
daily flow
septic tank capacity (required andprovided)
soil absorption system(required andprovided)
whether system designed for garbage grindei
North arrow 310 CMR 15.220(4)(g)]
Existing and proposed contours 310 CMR 15.220(4)( )
Location and log of deep observation holes(existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h)and i
Location and date of percolation tests(performed at proper
elevation?)[310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 310 CMR 15.242
Certification statement by Soil Evaluator 310 CMR 15.220(4)0)]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3)and 310 CMR
15220(4)(n)
Address 757-7 wa-1 I 5*ei- (, t1111 Sheet 1 of 7
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220(4)(k
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply >/
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case /
of private water supply wells V
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. 310 CMR 15.220(4)0)]
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR15.220(4)(0)]
Stamp of designer 310 CMR 15.220(1) and 310 CMR 15.220(2
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate(two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405(1)(k)
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103(4)]
Test Holes adequate to confirm adequate groundwater separation? /
[310 CMR 15.103(3)]
Benchmark within 50-75'of system 310 CMR 15.220 4
Materials specifications noted? [various sections of 310 CMR
15.000]
System components not>36" deep(unless Local Upgrade
jApproval or LUA requested) [310 CMR 15.405(l(b)]
Address �� �CL14I �/; (•U�!//� Sheet 2 of 7
No. +:. ' I ` ", Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
privation.for IDisposal.*Pste tt Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 15 9 M n i n 5 t Owner's Name,Address,and Tel.No.
CUT✓IT-., ,Aare ,Acic, c,f i s
Assessor's Map/Parcel /t'1 t� („ ���<�r t C LUG, i,i i r
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 5�,i _ ,t N 1
) 6,ber{ �I it 6�1 �7B 1 I' X ((�iVG.r i I Ga it \11-1
1 1 rtt)Fr ; ., l, ct �p i,; r' 34, (e,7vr, ecc) .Sri i tejirl AAA
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) f l 9(� gpd - Design flow provided fir'(D gpd
Plan Date (< I I (r I u, Number of sheets Revision Date
Title 7 5 9 M r� �+- / �. u 1-t-
Size of Septic Tank Y j(,() q e- l Type of S.A.S.
Description of Soil
_
ti
Nature of Repairs or Alterations(Answer when applicable)
t
Date last inspected:
Agreement:,
The undersigned agrees to ensure the construction and-maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of
Health.
Signed ��7 V Date 7 7 ( �'
Application Approved by r I S Date 7- 7-0
Application Disapproved by Date
for the following reasons
Permit No. �,00 9 — Date Issued —] ' 7 0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( V/) Upgraded( )
Abandoned( )by (1 y6j !
at �5 Lj I"I CI ► 11 S1. C� ) has been constructed in accordance
C with the provisions of Title 5 jand the forDisposal System Construction Permit No.a�-1 f)X dated 7—7'0°1
Installer �Lf�C'u } (—r i i /��/ Designer \I ( I /�tj5(�/ I CA I(-- .5
#bedrooms z Approved design flow„ % d gP d
I.
The issuance of this pp/ermit shl not be construed as a guarantee that the system will function as desiAed. n
Date l 1( l tal d I Inspector �J lLJ• i`—�
No.p`�)0-1 — a U�.,, Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
Misposai Opstem Construction Permit
Permission is hereby granted to Construct( ) Repair(✓l) r Upgrade( ) Abandon( ).
System located at
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 7 _ ( '�� Approved by 6,C6-t,t
N/A OK NO
SEPTIC TANK
Size OK? 310 CMR 15.223(1)
Inlet tee located ten inches below flow line [310 CMR 15.227(6
Outlet tee 14" or 14" +5" per foot for increase ft depth[310 CMR
15.227(6)
Outlet tee with gas baffle or approved filter[310 CMR 15.227(4)]
Note regarding installation on stable compacted base [310 CMR
15.228 1
Separation between inlet and outlet tees (no less than liquid /
depth) [310 CMR 15.227(2)
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA 310 CMR 15.405 1 k
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1)and 310
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater)-
middle access at least 8" b 7/07 310 CMR 15.228(2)
Access to within 6" of grade -one port for systems<I 000gpd,
two for systems>1000 gpd 310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)]
> 10 ft from building foundation[310 CMR 15.211(1)]
Buoyancy calculation Required/Done 310 CMR 15.221(8)]
H-20 Where appropriate? 310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
Multi-Compartment Tanks
Required when other than single-family dwelling or flow>1000
d 310 CMR 15.223(1)(b)]
First compartment 200%daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2)and 3
"U" pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15.224(4)]
Address 7�/ .�/�/G�I � /, (�/ 1fA Sheet 3 of 7
N/A OK NO
BUILDING SEWER AND OTHER PIPING
Located at least ten feet from any water line? [310 CMR
15.222 2
Disposal piping at least 18" below water line(when water and /
sewer cross, see 310 CMR 15.211 1 1 ✓
Cleanouts required/provided? [310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) 310 CMR 15.251(9)and 310 CMR 15.252(2)(c
Siphonproblem/(leachfield below pump chamber)
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310
CMR 15.252(2)(h
Materials specified (310 CMR 15.251(5)specifies various pipe
types allowed)
DISTRIBUTION BOX
Stable compacted base [310 CMR 15.221(2)and 310 CMR
15.232(2)(a
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)]
Riser if deeper than 9" 310 CMR 15.232(3)(
Inside minimum dimension 12" [310 CMR 15.232(2)
Minimum sum 6" 310 CMR15.232(3)(e)]
Watertight cover if<2000gpd);waterproof manhole if?2000gpd
[310 CMR 15.232(3)(d)]
PUMP CHAMBERS
Capacity (emergency storage above working=design flow)? [310
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE 310 CMR 15.231(5
Service components accessible(not too deep with piping,
disconnects accessible)
Alarm floats-alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and(8) ✓
Stable Compacted Base 310 CMR 15.221(2)]
IBuoyancy calculations needed?Provided? [310 CMR 15.221(8)
Address 14 6 7�// Sheet 4 of 7
N/A OK NO
SOIL ABSORPTION SYSTEMS(SAS)GENERAL
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(1)]
Required separation to groundwater? [310 CMR 15.212)]
Aggregate specified as double washed [310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) 310 CMR 15.241
Inspection ports specified and within 3"final grade? [310 CMR
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and /
Guidance Document]
GALLERIES,PITS,CHAMBERS 310 CMR 15.253
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole(if>2000 gpd must
be tograde) [310 CMR 15.253(2)]
Aggregate I'minimum-4'maximum. [310 CMR 15.253(1)(b)]
2' sidewall credit maximum 310 CMR 15.253 1 (a)]
In bed configuration,inlet every 40 s . ft. 310 CMR 15.253(6)]
TRENCHES 310 CMR 15.251
Width 2'minimum 3'maximum 310 CMR 15.251 1
100 feet-maximum length[310 CMR 15.251(1)(a)]
Minimum separation 2x effective depth or width whichever
eater(3x if reserve between trenches) [310 CMR 251(1)(d)]
Situated along contours 310 CMR 15.251(2) c/
Breakout OK? 310 CMR 15.211(l)[41 and Guidance Document
BED SAS(Maximum size of bed or field 5000 d)
minimum 2 distribution lines [310 CMR 15.252(2)(a)] /
Maximum separation between lines 6' 310 CM R15.252 2 d /
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. [310 CMR 15252(2)( ]
Separation between beds 10'minimum. 310 CMR 15.252(2)(f)
Bottom area used in calculations only [310 CMR 15.252(2) i)]
Address_ �� � S/ C.1!f//1� Sheet 5 of 7
I
N/A OK NO
DID THE PLAN INVOLVE
Pressure Dosed System ? Provided pump and piping
calculations as required 310 CMR 15.220(4)(r)] ✓
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2)and I/A /
Remedial Use Approvals]
✓
If used in gravelless system-make sure jet is directed as not to /
scour soil interface Guidance Document]
Inspections once per year(systems<2000 gpd)or quarterly
>2000 dgood to note on plan 310 CMR 15.254(2)(d)] ✓
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)? �✓
Impervious barrier and/or retaining wall? [Guidance Document
Impervious barrier installation must be supervised by
designer 310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer[310 CMR 15.255(2)(a)] z�
Side slope not exceed 3:1 ? [310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2)and
Guidance Document
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) 310 CMR 15.255 2 e
Gravelless System[EA Approval Letters]
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
Alternative Septic System[UA Approval Letters]
Was DEP Approval Letter provided and/or have you �✓
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all ✓
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for ✓
perpetual maintenanceagreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applicant submitted a coy of a maintenance
Variances
Are the variances listed on the plan ? [310 CMR 15.220 /
4 ]
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414
Address ati—Ilt Sheet 6 of 7
t.
O
N/A OK NO
Nitro en Sensitive Areas
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216-also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well?
310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(l)] �p-
Miscellaneous
Pumping to septic tank? [310 CMR 15.229]
Shared System 310 CMR 15.290
Address �5 ,�lL/�/I J/K�/f (.6 / Sheet 7 of 7
lugCOMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
1lyl VL®INA ® J '
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 81 Hikh Street
Cotui_t,MA 02635
Owner's Name: Margaret Dunnicliff
Owner's Address: 457 Mount Auburn Street#2
Cambridge, MA 02138
Date of Inspection: May 2, 2005
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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 the inspection. The inspection was performed based on my , c?
training and experience in the proper function and maintenance of on site sewage disposal systems. I ain a DER
,approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:r -<
. c
✓ Passes
Conditionally Passes C) —Q
Needs F her Evaluation by the Local Approving Authori N
Fails
Co
Inspector's Signature: Date: Ma 4 2005 0
rn
The system inspector shall subm' copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 81 High Street
Cotuit,MA
Owner: Margaret Dunnicliff
Date of Inspection: Ma 2. 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 81 Hieh Street
Cotuit, MA
Owner: Margaret Dunnichl
Date of Inspection: Me 2, 2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CM 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well.water analysis,performed at a DEP certified laboratory, for colifonn
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
I
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 81 Hikh Street
Cotuit, AM
Owner: Margaret Dunnicli ff
Date of Inspection: May 2. 2005
D. System Failure Criteria applicable to all systems: '
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
f
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 81 Hwh Street
Cotuit, MA
Owner: Margaret Dunnicli(f
Date of Inspection: May 2. 2005
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 81 High Street
Cotuit, MA
Owner: Margaret Dunnicli ff
Date of Inspection: May 2. 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: I
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: _ Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): epd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
✓ Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Age unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
a
Property Address: _ 81 High Street
Cotuit, MA
Owner: Margaret Dunnicliff
Date of Inspection: Me 2. 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as.a septic tank)
Depth below grade: Cover to grade
Material of construction: concrete _metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 5'W x 5'T x 6'bottom to grade
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
An outlet tee was present. The cesspool had Y of liquid on the bottom The cover was to krade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 High Street
Cotuit, MA
Owner: Margaret Dunniclilf
Date of Inspection: Mav 2. 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 High Street
Cotuit, MA
Owner: Margaret Dunnicliff
Date of Inspection: Mav 2, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: I
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The overflow cesspool was 5'W x S'T x T'bottom to grade and was dry The scum line was approximately 2'up from the bottom
There did not appear to be any signs of failure The cover was to grade
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Coirunents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 HiQh Street
Cotuit, MA
Owner: Margaret Dunnicli jf
Date of Inspection: Mav 2, 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
as sa
1 � y0
/�►5� Sr,
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 Hiph Street
Cotuit, MA
Owner: Margaret Dunnicli f{
Date of Inspection: May 2, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours snaps, the snaps were showing approxitttately 30'+/-to!;round water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied, relating to the system,the inspection and/or this report.
11
...._.. .o .. •- ... ... _._- _—�_ .. ..... .. _..
i . 4 _ . .. ... ... _. __..._ -.. .... .... .. ..... .._._.
. _ I
.. _......... ........... - _ i
_ S..L ..�
..... _
�40
..
. 9��p�
.. ..
- _. -
.
. .
. .
.
. . . .
(
.
. f
�ii�(/� l �icuS�
. _... ..
r
t : .. ._ ..-. ._.. ... _ ... ..... ........
......,yl v�,. + _/ �
t
( —r
. - - 0 J
.
. S
:. /O_.-
t
; ':
_. ....
.........."..- ... . ..._.. .
. .... .. ...... . . . .. .. . .... . ..
.. ....
//s
. ...-. .:
: ; -
. .
. . I
. . .
.
_...
D
0
I
... ...
:
... f .. ...
. :
N
.
.
.
_ . L _ l/r�7- . m VV:..
_...-...: ..... ...
. a _ _ ....
: .
! ,
1 �..
SN�W
.
.�.
.
.... _..........__..-. ....... <.
.;
— —. —
�/
.
I
-. ——.. .
_ ...
I I 5� o a
1
. —
_ - - — —
:
:
. _ _.
. .
. .
;
P
I
_. _.. ..
.
l r
I
30
6
; .. .......... . .... ........ ........ _
. . . , . 0
�o NEit•J....
.
.
.
.
K•
1
S ,
I
-_- :_ 0. -.
: _
: :M
M 0 0...
- -
, : .
D
..... ......: _ .: ......
r
1
.
. . •. ............... .. -
. ... ... .. ._. .... ..... ... ..
. -
. . —
. , : .
. , . ..
. :
,
... .. ., .: .._: . ... : . . :
A M�
..:... ..... -- -
- . . _:
. ...
. . . _. �w
.
. , .
I Lb. _
1 J C
t. (f jl. c J .,
.-. - -
- !'I C a C _
. �, i t1
...._...-.. i ....__..�_...... \. . _ �� -.
/0 __. /G
tJ ) U ..:
_ .. ... c--�.
:
: -
�� -'
. .. .. .. . -
�o ao w� ..vim
>I .. ............... /n/t�
. __ . : _. ...._ .�.�- _ -
.
.
.,.- _
�_
- _
.
. �,
. .
. _ ,f,
,. -,Lo �.
. .
: -
t
� �
. ,
. .
.
-
. .
. ;
I
,
.
�:
. - - -. ..._ - .. ... .. ..... ... _ . . . _._...
b
. / .
.
.
I :
/ .t.
TG�
_.._
,
,, i - 7 u
..
l
:.
l;
3 C^— X �,
I
�� Y ; /
_ _
— — _ --
f : - — — J — - - — - -- — - - - - —_
,.. 0.
....- .... .... '.._.._ ..... ; ...� - i .,
_ — —.
..._ ... __ .. .... .. .._._ ... ...... -
r L: ,
I . "
.. .... ....._ _ -. -- -.
: ( 1
; ,
- -- -
. rr r
_ .
,
/ . �c%,��
.
. i ,
,f
. : -, r
5
6 _
l X TI
_ - 5
. . _ . ... :..... _.: :-. ._ . .
t S_... tN►-M7UvJ
. - - _..
. , R ,
. S �
:
r
II
U ,
.... .._
... .
f _._:.. I if ./Y���!�
_.-
. .
. .
1 , 7 .
: ;
. r
. _. __
L
_ .. 7v
i
ry
_ -
. 6
/6 o c —
_� - -
rr
)( -- --
r
.. .._. :..._.. ._..... __.. r_
i
l U
.
I
�.
: _ ..
. -
: " . , ;
. , . .
. 1 .
I _ : - _ r - -
.. 1 — ��� _ I/ _ -
.... .. .. ...:.. :._: -.: -.
1
S : : : : ._ _ ... .. _._ _... _.. ... ... .._ _...._ ..._. ..... _._. _. .__ ...... ._. .._ .._.. .... _ ....
:.
. - f : : : e -
. - F vJ c�-U`F
: N�
_;_ .,
T� � a
....._ . ..
� .
S -- u-
/;��s�oVE' u/A
3u �6
.,
, ;�.x,
—a t' �� ^ D
I_ I 1.�1 P
: r �F Cb \L / t7C0 U FxL�G
r� -- -
f - -
. :
; I , , - - — —
.. ._...
: ... . - . .. -.... _ .-..... --
_. ..
. �_._... . . . .... -.... : _.. . .
i
7�
Lci n ozJ U
�/ — =
u. . (�
.. . .. . ... ... :.
_.. . _ .. I r <{
21 / -n CN�Nt�f ( 9
0 s y fx.
- .. :
-7N
c ``
�: - - _ - --- - -
. : , : .
7-5
. .
sx....
l �
.. .... .... ...... ... ..
/ r
.
.. . ,. . Z
.: _..
. . :...... : ._ . . ....:..
:.. . :..... . . .. ....
: ... .
. ,
.
:
.
: - :
..;.......
...... . ......: .... . _... _.... .. -
. .r •
. - . .
.. ..... ..._. ..
: .
k .
.1:
':.. X ... .. ... l S Tl�c16 ..
.....
_.. .... .. .. ..
D
r
_ _
; \ I I
LJ:
— : —
" 1. � .
- . ,-
__. ..
-
. _.. - . . __ .. _
. .... .. .. _. _
: :
.
..
:.
�
L.�..�rN G... USG!-�. ....
._ ._ -
....... ..._.......
4
... .. ...,. .......... .-'. .-.
.. ......... ... ..... - ._.
. - ... ....._. .... :.... ...:.. ... .. -. ._... .... ... .... .... ..._ .....
.... .. - -
..
,. .... ..
; : 4 . :
:
:.
Y. ! ..;..
.
:..
- : : ;
.
.... .. I..." _ ._..._
1
/�f
16 6 ..
I ..... .
X ... .... ._
: ,
-__
. . -
.. . . .
.
�. _ I ESN
. ; : v
:
.....................
... .
`/
h
............. .........-....._ _. ........._. .......................:...._........................ .. ..
: , .
Wl: DUI �.,�1��.(r
c .
: :
;.. ....:
-; ..._.. a .....: .. 5 . _ :. ;Wf d, 1
.... .....:..:. .... _.. _... .... ..._. .... . .
9 to �)
. E j
:
... ...: ... ........ ..... .. ... .... .
.. .. ........ .............. _... .... .. ........ Yr : i
... ... .. ....... ...... ..
'..
I
_.i
. .. .....
: , - - -
: - -
. - :
._
.
. . :
ii .
I .
....4.1. .-. _... .. .-.. ._..... ._.. - .
__
• .
.
e.
-
- - - _ _ -
.
,
: . i ,
. ,
: :.
....:. ....4.... ...
,
__ --
. -_ -- ... ...
. - :
. ±..
{ —
1 :
: .. _.
�. .... ... ... _
. .
1a - ; . _ _ .
.
.
} S.
/ -
The record information and physical L� GENERAL NOTES
��F' ,� TI-�EE T
evidence indicate that this way may be 96 1. Contractor is responsible for Digsafe notification, Verification of Utilities
_ abandoned. The setback requirements (40 FOOT RIGHT OF WAY) / and protection of all underground utilities and pipes.
—~ 2. The septic tank a distri ution box shall be set
have been eliminated. (see agreement � level on 6" of 34 —1 12" stone.
with Thomas Perry, Building Commissioner \ 5. Backfill should be clean sand or gravel with no
.� dated Januory12, 2006 121 N 85D 37' 10" E � stones over 3" in size.
�� 4. This system is subject to inspection during installation
96— —�� ` 160.00 •� \ by Carmen E. Shay — Environmental Services, Inc.
5. The contractor shall install this system in accordance
Road as shown on �� I I GRAVEL rt'p with Title V of the Massachusetts state code, the approved plan
Town layout of Lake Street DRIVEWAY PROJECT BENCH MARK �O, I and Local Regulations.
Plan #11-3 #7 Feb 18 1938 _/ Top of Foundation ` ' 6. If, during installation the contractor encounters any
98 No evidence on ground ELEV. = 100.00 (ASSUMED) ^ soil conditions or site conditions that are different
td Neck Road an ancient way) (D from those shown on the soil to or in our design
• See note above L �_ � I 9 9
J installation must halt & immediate notification be
HOUSE #8 f \ \ / I / / � w I � � made to Carmen E. Shay — Environmental Services, Inc.
/ L �I r 98 7. No vehicle or heavy machinery shall drive over the
17,280 Square Feet SEASON Q M septic system unless noted as H-20 septic components.
/ 0 8. Install Tuf—Tite gas baffles or equals on all outlet tee ends.
ROOM OO I 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
2 '
O 0 10. All solid piping, tees & fittings shall be 4" diameter
TEST HOLE #2
• .- A� I Schedule 40 NSF PVC
es i with water tight joints.
04 C0 ELEV.= 98.50 '. pipes 9
r` p D 11. Municipal Water is Connected to ALL OF The Residence and Abutting
cp ' •�.,: EXISTING
3 BEDROOM WtorricipaF Water-tine— — THE PROPERTY LINES ARE APPROXIMATE AND
PATIO HOUSE {
�j •`•r` '- DBOX I COMPILED FROM THE SURVEY PLAN BY CAPESURV, OSTERVILLE, MA
SHED 3 ��r '
#81 ENTITLED: "PLOT PLAN OF 81 HIGH STREET, COTUIT, MA"
6/25/2007
O ,I7`y� AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
FAILED IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
DECK CESSPOOL THE SEPTIC SYSTEM INSTALLATION.
SHED / :*,.� - '' l 1, EXISTING CESSPOOLS TO BE PUMPED OUT AND FILLED IN PLACE
4" PVC I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
,Y�ST�FIOLE 1 1 1 FROM THE EXISTING CESSPOOL/LEACH PIT TO BE DISPOSED
/EL 98.50 O 00 _ • CLEANOUT OF AS PER BOARD OF HEALTH SPECIFICATIONS.
1500 GALLON -NATt4kL• 6AS• NNE
too - - 1 , SEPTIC TANK FAILED
-- (New) 14 f.9z' CESSPOOL
\ 85D 39' 40"r W • PLOT PLAN
00 OF PROPOSED SEPTIC SYSTEM UPGRADE
U 5 PREPARED FOR
s SITE LOCUS STACEY ROSOFF
81 High Street, Cotuit, MA P'q AT
(Description— By Owner) = a 8 � HIGH STREET
3 BR HOUSE FLOOR SCHEMATIC 3 r`Spo�aaa.._ #coaaiesc_- �
.Levi
PARCEL ID: 035-031 & 035-032
2nd FLOOR 1st FLOOR SEASON
9p` C OT U I T MA
.."'k +�+asg� PREPARED BY:
Dining Living' Room z�
CARMEN E. SHAY
Lake sc....^ "'.. �• ~O - � � �.
o ENVIRONMENTAL SERVICES
Kitchen
m Et N P.O. Box 1576
0 20 40 50 0Ea,ssE MASHPEE, MA 02649
Bedroom m N $ANItaR�� TEL/FAX : 508-294-7498
SCALE: 1 "=20' m m r r � °rci SCALE: 1 "=20' DRAWN BY: CES DATE: JULY 19, 2021
—711t
som PROJECT#81 HIGH ST FILENAME: 81 HIGH.DWG SHEET 1 OF 2
s:
r, l
SECTION A A
' 10' min. from 'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. PROFILE VIEW OF. LEACHING SYSTEM
EXISTING Foundation house to septic tank SAS cover must be
Septic tank covers must be —D-BOX cover must must have riser and be within 6- of GRADE
{{ within 8 in. of finished grade within 6 in. of finished grade • /s"to/ f/k ►awwd avrMd stow. "qt 1/0"- f/s•►ee"d t°roeeo.0
l ' Grade over Septic Tank- 9&50 —Grade over D-Box-9&SO i—Grade over SAS - 98.50 INSPECTION cover must be
within 6 in. of finished grode
S.: 0.02 3 HOLE H-10
Sa0.01 DIST. BOX TOP OF SAS 95.65
. C3 C7 O
EXIST. PIPE so' NEW. 1,500 G Sa0.01 C3 C3 C3 OC3 C3 C3 C3
C3 C7 C7 O
FT2Gt FOUNDATION r H-10 In 15' / ' Dose` f a woor swr r•Bowe awrr
1 rn SEPTIC TANK 25' M
CONCRETE FULL FOUNDATION- > II ZABEL FILTER a'�, i 0 ,� 0 0
II 11 II 5 Units 6 ' = 30'
SYSTEM PROFILE m I �•b'
Not to Scale d _J "1 5' OVIDED
0 4. 4' rn
c c M Effective Length
6 In.of 3/4"-1 1/2" �' o
compacted stone - Effective Width Ta SDIL ABSORPTION SYSTEM (SAS)
0
O
m LC-6 H-20 LEACHING UNITS / WIGGINS PRECAST
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE Bottom of Test Hole 1 Elev.= 87.50 Not to Scale
2-18" DIAM. ACCESS MANHOLES
to' PERCOLATION TEST DICTION BOX SHALL BE ,z•
SET LEVEL FOR AT LEAST 2 FT. CONCRETE COVER
Date of Percolation Test: JUNE 22, 2021 3- s•OUTLET 2
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. te
�,••xNoacauTsResults Witnessed By.BARNSTABLE BOH - DAVID STANTON — -1S•5' 12" INLET
EXCAVATOR: CARMEN SHAY Perc ou TPercolation Rate: Less Than 2 MPI 0 30" Depth#to Perc 30" to 54" 6" e
Perc Rate= G2 MPI 1ss" 4" - SCH. 40 Te 1.�5"
THE ACCESS COVERS FOR THE SEPTIC TANK, Test Hole Test Hole Groundwater Not Observed
i L� DISTRIBUTION BOX AND LEACHING COMPONENT No Observed ESHWT 0 132" PLAN SECTION CROSS-SECTION
t'�.; v .;-' :�: :^;�;'•,Tom:.�.,'� .• SET DEEPER THAN 6 INCHES BELOW FINISHED N O. 1 N O. 2
GRADE SHALL BE RAISED To WITHIN 6" OF ADJUSTED H2O Elev. = None 0 132"
FINISHED GRADE. DEPTH SOILS ELEV. DEPTH SOILS ELEV. 3 HOLE H—10 DISTRIBUTION BOX
X
STEEL REINFORCED PRECAST CONCRETE
PLAN VIEW INSTALL TUF-TITE GAS BAFFLES OR EQUALS 0 Sandy 98.50 0 Sand 9850
3-2e REMOVABLE COVERS Loom Loamy
{ 10 YR 3/2 10 YR 3/2
.: . .::- ..L. 4. �:, D"— 6" 98.00 0"_ 96.00 PLOT P LAN
: . Sandy Sandy
3 min. clearance Y �' 13' slLET Loam
r. 8' mine 2" min. Inlet to outlet
1_-� 6•min. OUTLET Loam
MImIn. Llquu ever Bw
LLJJ 6"— 30" 1°YR 5/6 96.00 6"— 3D 1° 5/6 96.00 OF PROPOSED SEPTIC SYSTEM - UPGRADE
Sand
u�b depth PREPARED FOR
4'-0" min. Med
o.�.. : • sand S TA C EY R O S O F F
2S Y 7/4
2.5 Y 7/4
`
30" 132" G 87.5030•_132 Cn 87.50 AT
4' -' 81 HIGH STREET
CROSS SECTION END-SECTION i
TYPICAL 1500 GALLON SEPTIC TANK PARCEL ID: 035-031 & 035-032
COT UI.rMA
Design Calculations Number of Bedrooms: 3 Equivalent to 330 Gal. ay 330 GPD MIN TITLE
Garbage Grinder: No PREPARED BY:
Septic Tank : - 2 x 330 Gal./Day = 660 USE NEW 1500 GAL. Septic Tank. -,A Of ll '
Leaching Capacity Proposed: 440 Gal./Day (AT CLIENTS REQUEST) SH�4 Y ENVIRONM�'NTAL SERVICES
SOIL ABSORPTION AREA: Using percolation rate of G2 min./inch Sidewall(ENDS) Area: 1 V x 2' = 22 SF
v+
Bottom Area: 0.74 gal/day/sq. ft. x 407 sq. ft. = 301.18 gallons/day 22 x 2 ENDS = 44 SF
Sidewall Area: 0.74 gal./day/sq. ft. x 192 sq. ft. = 142.08 gallon/day Sidewall(Side) Area: 37, x 2' = 74 SF O 6
5 OX B 17
P.O.
Providing: =443.26 gallons/day 74 x 2 SIDEWALLS =148 SF MA 1SHPEE, MA 7 649
i �I sty
Use: TOTAL SIDEWALL AREA =192 SF IANITaR TEL FAX : 508-294-7498
(5) LC-6 H-20 CONCRETE CHAMBERS, HAVING A 1' EFFECTIVE DEPTH,
(3' W x 6' L) TO BE USED WITH 4' OF WASHED STONE ON THE SIDES AND Bottom Area: 37' x 11' = 407 SF SC A i "=20' DRAWN BY: CES DATE: JULY 19, 2021
3.5' OF WASHED STONE ON THE ENDS AND 1 FOOT OF STONE UNDER ENTIRE SAS PROJECT#81 HIGH ST FILENAME: 81 HIGH.DWG SHEET 2 OF 2