HomeMy WebLinkAbout0020 HIGHLAND AVENUE - Health 20 Highland Avenue
Cotuit F/R
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: A,-`_�/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipprication for Migozar *pztem Construction Permit
Application for a Permit to Construct(V)Repair'A
Upgrade( )Abandon( ) El Complete System dividual Components
Location Address or Lot No. 2G Vkwg+l,Av(D AJ F— Owner's Name,Address and Tel.No.
Assessor's Map/Parcel O ZG/ck,2,6 Ldi Q (J ..1_ (,2 n y� gp-k�{ 6�� 20 1
F-+uT►t7�-V x�'++•-�� S ' i1 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
J 5 Se�1 ►c j�.ru'icE � Ccass�2►�c.T►o�
Type of Building:
Dwelling No.of Bedrooms L ea're Lot Size i II 3Z(o sq.ft. Garbage Grinder( )
Other Type of Building `rrw V- Pyy,4 a No.of Persons 3 Showers( Z.) Cafeteria( )
Other Fixtures
Design Flow 3 5_11 Z- gallons per day. Calculated daily flow 330 gallons.
Plan Date 6'3r��� Number of sheets I Revision Date
Title
Size of Septic Tank t&oea Type of S.A.S. v
i
Description of Soil 12"^ awl-T �/�����++r�►.�' ��yit\�� /� f��J ��,1r3�' s Xo2
�P�Z �V{j•'T
Nature of Repairs or Alteratio s(Answer when applicable)
Date last inspected: a G
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 Certifi-
cate of Compliance has been issu d by this oard of Xe .
Signed Date
Application Approved by IV., Date 711 zA'A
Application Disapproved for a following reasons
Permit No. Date Issued ? 0'`
c
oC0d� �3d✓ �.�_ �;�_ -�. = Fee ! k
Entered in computer. ,
THE COWONWEALTH OF MASSACHUSETTS ✓
�. Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE `MASSACHUSETTS
1(aprication for Migpogar *pgtem Congtruction Permit
Application for a Permit to Construct(✓)Repair( Upgrade( )Abandon,( ) O Complete System
dividual Components
Location Address or Lot No. Z.O Vkt(51-E"LA,+ t17 W6 Owner's Name,Address and Tel.No.
30AtCsAA,j kJ:+Cow I L z63S'
Assessor's Map/Parcel ' , 0 7-0/ �j& -;j eo7 4 �
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Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Sc 3 Se, 11 ic. See-Vice Cc,sS�2Jc.Tu 1i�C
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Type of Building: ,�.. ` ► f�faJ
Dwelling No.of Bedrooms 2- Lot Size i 1,32 to sq.ft. Garbage Grinder( )
Other Type of Building 'st"iGtL F'vno WE No.of Persons 3 —Showers(,Z•) Cafeteria( )
Other Fixtures
Design Flow SI L gallons per day. Calculated daily flow 330 gallons.
Plan Date 44?Jaly Z Number of sheets / Revision Date
Title
Size of Septic Tank l040 Type of S.A.S.r 00 ,, r L, o
Description of Soil 12 `f- 3 6 " Loom 4 SA+uD l��,Y
3z;-77- Low MEt)«m .5,4,aJ
77-- t 2,Z- 4al' j!� S OA1j) _
Nature of Repairs or Alterations(Answer when applicable)
/,1srh.s, Box A <__I� Soo 0,4-,4.0/i 46ge-4 / -t tk
Date last inspected: IoLzq& I
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 iff operation until a Certifi=
cate of Compliance has been issued by this Poard of He 1 .
Signed Qv� Date
Application Approved by I iAa., IV. Date d�
Application Disapproved forYhe following reasons
Permit No. oZ GO Date Issued -7 ?10.:2- °
THE COMMONWEALTH-OF,MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS Certificated Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Upgraded( )
Abandoned( )byrr
at t4jr,h 4" (o has been constructed in ccordance
with the provisio s of Title-5 and the for Disposal System Construction Permit No.bow _.?O f dated / 7 /a
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syste will fug c ion as d�si
Date 0)- Inspector i ,
---------------------------------------
No. a 004—30.S Fee UU THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ligool 6pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )U grpde�Abandon
_ ( )
System located at ? 0 �� ��„ A,-e f a �ff--
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 thisserc t.
Date: //�/�2 Approved by V
� v
TOWN OF BARNSTABLE �C
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LOCATION D I'fPrall1 14-1 211tL SEWAGE #Zoo2
VILLAGE ASSESSOR'S MAP & LOT 020-0
INSTALLER'S NAME&PHONE NO. \Toe�nr .SeA I
SEPTIC 'SANK CAPACITY �
LEACHING FACILITY: (type) fflT (ID G(4&,, r Aoj& (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER 'X)Aaf d 4ENY
PERMITDATE: a X COMPLIANCE DATE: 7 61;1
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 facili Feet
Furnished by *4�
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
RECEIVED i
Property Address: 20 Hitzhland Avenue
Cotuit, MA
Owner's Name: Rick Barry OCT 3 0 2001
Owner's Address: P.O. Box 4 Cotuit. MA 02635 TOWN OF BARNSTABLE
Date of Inspection: October 24, 2001 HEALTH DEPT.
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:020
Osterpille,MA 02655-0049 Lot.036
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
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Nee F her Evaluation by the Local Approving Authority
4copy
Inspector's Signature: Date: October 26. 2001
The system inspector shall su t f 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: 20 Highland Avenue
Cotuit, MA
Owner: Rick Barry
Date of Inspection: October 24, 2001
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: 20 Highland Avenue
Cotuit, AM
Owner: Rick Barry
Date of Inspection: October 24,2001
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board'of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 wafer 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.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Highland Avenue
Cotuit, MA
Owner: Rick Barry
Date of Inspection: October 24, 2001
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'/s 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.]
Yes (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
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Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 HiQhland Avenue
Cotuit,MA
Owner: Rick Barry
Date of Inspection: October 24, 2001
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: 20 Highland Avenue
Coto, MA
Owner: Rick Barry
Date of Inspection: October 24, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [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)): 2000- 77,000 gals.;2001- 72,000 gals.
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): gpd
Basis of design flow(seats/persons/sgft,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: Pumped in 2000-per owner
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:
Apr. 21194-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11 t
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Highland Avenue
Cotuit,MA
Owner: Rick Barry
Date of Inspection: October 24.,2001
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)
Depth below grade: 6"
Material of construction: ✓ concrete metal __fiberglass _polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: —
Scum thickness: 1"
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.):
The outlet nine is at the bottom of the cement tee, approximately 15 lower than it should be Solids are leaving the tank and
Koine to the leach field
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
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Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Highland Avenue
Cotuit, MA
Owner: Rick Barry
Date of Inspection: October 24, 2001
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: allons/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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Approximately 3"above
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.):
The D-box was level. The liquid level was 3"above the outlet invert, backing up from the leach field
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
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Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Highland Avenue
Cotuit, MA
Owner: _ Rick Barry
Date of Inspection: October 24, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 3 infiltrators with 3'stone-per as built card
leaching galleries,number:
leaching trenches,number;length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovativelalternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The infiltrators were not dug up. Liquid was backing up into the D-box. The system is in hydraulic failure. The bottom to grade
was approximately 48".
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): .
Comments (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: 20 Highland Avenue
Cotuit, MA
Owner: Rick Barry
Date of Inspection: October 24, 2001
Map: 020
Lot. 036
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.
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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: 20 Highland Avenue
Cotuit, MA
Owner: Rick Barry.
Date of Inspection: October 24, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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 maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach field to grade was approximately 48". Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 40'+/-to ground water. Using the Cape Cod
Commission Technical Bulletin, the high ground water adjustment for this site(Ml W 29 Zone A 9101)was 2.3.
This report has been prepared and the system inspected and failed 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
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TOWN OF BARNSTABLE .
I.6CP:fION 490 Nl �l.Qn AVC_ SEWAGE # 0`'/' a0I
VILI.AGE C 0_rQ ASSESSOR'S MAP & LOT Oa0 - 03 Co
INSTALLER'S NAME&PHONE NO._
SEPTIC TANK CAPACITY I MO 6AI
LEACHING FACILITY: (type) lel l'4&57 (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE. DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to theBottom 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
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Furnished by
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TOWN OF BARNSTABLE CC
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_ LO:i,�TTON Z a-1 26 SEWAGE #2002
VILLAGE C ASSESSOR'S MAP & LOT 020-0
INSTALLER'S NAME&PHONE NO. oe7�t SPOh'L
SEPTIC TANK CAPACITY X /000 baA,t
LEACHING FACILITY: (type) (?) LAndkt (size)
NO. OF BEDROOMS 3 /
BUILDER OR OWNER ' APr Gr
PERMITDATE: a 7, COMPLIANCE DATE: 7761
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). Feei
Furnished by `iCJat2�ti'�
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4 TOWN OF BARNSTABLE
= OCAtTION a Ll /t/4&Lj Altke , SEWAGE #
VILLAGE dol�>/ ASSESSOR'S MAP LOT 090-6-!�P'
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 16C
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LEACHING FACILITY:(type)
NO. OF BEDROOMS PRIVATE WELL O PUBLIC_ WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/ _
w .
No......*,ao FBE
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
a n a Corservati BOARD OF HEALTH
` TOWN OF BARNSTABLE
,� Da
Appliration for Diripniul Wi nrlai Tnntitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (--j—•an Individual Sewage Disposal
System at:
.......go N4 a A-•1Gt A4/, fib• �� �
••---......_..• --•---•-------------------------- -•-•--•••---•---•---•-----•-•--••--•---•-•--••------- •
-atcon-A ress or Lot No.
G bad(—
'ddress
dD—
Installer Address
C� Type of Building Size Lot............................Sq. feet
U
..� Dwelling—No. of Bedrooms......... ..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ----------------------................................................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow.............................
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
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 Test Pit.................... Depth to ground water........................
�T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-••-••---••------------•----------•----••-•----•------•-•-••-••-•-•--•----•-------•---•----••...............................................................
0 Description of Soil........................................................................................................................................................................
x
U
U Nature of Repairs or,Altations—Answer wh r�. a p icable.In.S �-ct.I....�� .y .. ...�� ¢......................
---------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compl a e has beenn iss y e board of health. /�
Signed ..... -64...'L.�..:... `7
......... . ........................................
Dace
Application Approved BY - Date
-. .....-
....... l
Application Disapproved for the fo lowing reasons: ...
.... . .............................................................. . ..................................................... . ..................................
Permit No. .......9.. P-....'. ...................... Issued ........................ ..........................Dace
Dace ......
^�,�_L.�'e,--"._*vr`,""'i-.�—._`I r+v`.!`ri�.r�.--«r .fir-,�-.���,,. L� ��...�-�-.�.,.,,...,,,"e,��+...-.. ... _.. ,,.,,s..-s v- vti. .-. .•v �vr.,-r..-..
No......
� Faa..
THE COMMONWEALTH OF MASSACHUSETTS
1 r BOARD OF HEALTH
TOWN OF BARNSTABLE
Alipfiratinii for Diripwial Wnrk,i Tomitrnrt"inn 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
.----..�U......•••-•�----••� ••.................1�'---•---.�.......--------•• ----•--'--'-------'-------.._..-------•--•- •--•---------------•-----•-•------•-..............._
C� Idiea6011.:\dd'ress or Lot No.
---------------------------------
••-------
W A ✓(n^bce-/ .l_(l(I{-�.I;s t ; l�J ddress`���
r go Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__________________-------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther 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.
3 Seepage Pit No-------------_----- Diameter-------------------- Depth below inlet-:.................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test-Results Performed by......................................._.................................. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ---------------'----------------'---•--'--'---------------------....----•-•--'--------........._._.....••---•-•-......---........_------..._.................
0 Description of Soil.................................................
x
UNature of Repairs or Alterations—Answer when applicable-/!15 f_�--<--_!/....�D�__ ��f �� �'�
.._. /k.,L � �n. i/rG�i. f l....... (4. ------/-`e-------------- ----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance, with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health. .-
Signed ..... ............... ........................
Dace S
Application Approved B .......... ....y �e/ — L/
Application Disapproved for the fo lowing reasons: .... ... ............... . ......... ....... .................. .................. ........................
............................................................................................................................................................................................................... ........................ ----------
Permit No. ..... .. _..... L--0-- --------------------- Issue'd .....................
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cez#tf rate of Cfomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
C% `. .......................................-rc t ---------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ........���-�...-..."ld .�._.... dated _.................._...----------------_.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................`�._"....... .`..l... ....._........._....................� Inspector .......... ..�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No......7#. / -
�i��r���tl
Permission is hereby granted r C== --!---................?---------/`---------- ............................ .........................
to Construct ( ) or Repair ( ) an Individual e Sewag Disposal System
- l
atNo------------------------------------------------ ---- ?-I/4 r � C f.(< 1........-•----.f-�/l 1. ......---------------- •--.............
1 street QQ
as shown on the application for Disposal Works Construction Permit No.-(--y_,26 .-- Dated-----.--- 1 ...._..
.......
----------------------
��._-. y
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS -
{ NOTES
/ 1. All construction Methods shall conform to the Title V (310 CMR 15 )
and the Barnstable Board of Health Regulations
MENN�. 2. There are no known private or public wells within 150/400 feet,
PLAN OF SEPTIC SYSTEM / P'� respectively, from the proposed leaching area
Scale: 1'=20' CIVIC op .` 3. Existing Distribution box & infiltrators shall be abandoned
4. No.changes are to be made in the field without the approval of the
qF O G� Board of Health and the Design Engineer.
5. Proposed Leaching area is not designed for use with garbage disposal.
NA1. .6. Contractor to notify Dig Safe 72 Hours prior to construction.
OPQ / (800) 344-7233.
1 , 7. Property Line information taken from Plan of Land of "Existing Conditions"
for 20 Highland Avenue, Cotuit ,MA. Prepared By. Yankee Survey
consultants, Marston Mills, MA datyed May 4, 2001. Septic system not
to e used as8. Existing Septic Tanketoyben pumped prior to installing the Dbox & Dry Wells
�VERNEA l� \ 9. A new outlet tee on the septic tank is required to be installed to meet the
.1A requirements of 310 CMR 15.227.
n �5 Dc 10. All Covers for Leaching Dry Wells to be set within 2.0' of finished grade
11. Lot is essentially level, all grades within 1.0'.
12. Groundwater elevation taken from Title V Inspection Report , By. James M. Ford
9� �� \ o��� \ Q Dated October 26, 2001
rn
= PROFILE OF SEPTIC SYSTEM
/ i \ ry0 SHED j SCALE : AS SHOWN
------------
/ Strip Bad Material & � 50 j ♦ "a, 49.50
Replace w/Clean Sand 3.0--I
�VLi yod cfl
To the bottom of ��� o� oQo1�o� Op lExist. 4"sch40/retain r
chambers elevation �00 \ Q`Pad 48 ____________+-----------J'-----I at'.a°t+o
\ e -------------r--------- 47.16
. / -I 46.67
' 2.O' 4 1 47.4 I0 31.5 Foundation 47.00N05'10'57"W 18.00' -- ---
46.83
/ •• F,+`��c 44 Exist. 1000 Gal.
O O Septic Tank �- ___� D)'st. B x
42 Retain (H-10� 43.50
• i 3 Leaching Dry Wells
• j 40 Cape Cod Commission Groundwater Contour 31.5'L X11'W X2'H
Map, the maps were showing approx. 40 +/- 35.50
-T- -- -� % to groundwater.
LOT B �Exist.3-Infiltrators 08oi OE&*g 38 Cape Cod Commission Technical Bulletin No Groundwater Encountered Bottom of TP-1
AR S.F. ��y"i hf lat(ng 4' SCH - PVC----'J the high ground water ad)ustment for this site No obs. GW
�- �- �__--� - Retain (M1W29, Zone A, 9/01) - 2.3' No obs. ESHwt
Existing Infiltrators and D-Box shall be WOOD FENCE 360+00 0 10 0+20 0+30 0 40 0+50 0+60 0+70 0 80 0+90
Pumped and Filled w/clean sand \-��
enchmark= 50.0' - Assumed Bound Elevation S83'39'59"W 170.00'
LEACHING DRY WELLS - 500 GALLONS
"END" CROSS SECTION - MODEL SHOREY PRECAST CONCRETE LEGEND
FINAL GRADE TO BE STABILIZED DISTRIBUTION BOX FINISHED GRADE SLOPE = 0.02) Q
H-10 SCHEDULE OF ELEVATIONS PERK TEST
REMOVABLE COVER TT 12"(min)_
DISTRIBUTION BOX TO MEET 4" SCH 40 OUTLET LATERALS H-10 INV. IN FOUNDATION 47.
REQUIREMENTS OF 310 CMR SHAD_ BE SET LEVEL FOR A 1/4' - 1/2" DOUBLE INV. IN SEPTIC TANK 47.41 WATER LINE W
15.232 WATERTIGHTNESS. WASHED PEA STONE INV. OUT SEPTIC TANK 47.16
( MINIMUM OF THE FIRST TWO o 0 0 o Depth = 2 IN MIN. INV. IN DISTRIBUTION BOX 47.00 EXISTING ------------
CONSTRUCTION ETC. 2" FEET AND CONNECTED TO
EACH DISTRIBUTION LINE. 30' o 0 0 0 3.0' INV. OUT DISTRIBUTION BOX 46.83
NO OF OUTLETS 3 3/4" - 1 1/2" DOUBLE INV. BEGIN LEACHING DRY WELLS 45.50 PROPOSED
" WITH SOUD SCH 40 PVC PIPE TP
6 O O c� 0 2.0'o o O p WASHED STONE BOTTOM OF LEACHING DRY WEDS 43.50
00 o 0 0 o 00 BOTTOM TP-1 (NO OBS, GW/ESHWT) 38.50 TEST PIT 0
O O.
000 6"(MIN) oO000�-MECHANICALLY CRUSHED _.__ UTILITY POLE Q�
00000 0 0 o STONE (<=3/4'DIA)
l� J LEACHING CHAMBERS
STABLE LEVEL BASE 8'-8" 0O 310 CMR THE
15 REQUIREMENTS
LEACHING DRY WELLS 3 OVERALL LEACHING AREA
e'6"L x 4'10'w x 2'1' 31'-6"L x 11'-O"W x V-0"11', SUBSURFACE SEWAGE DISPOSAL SYSTEM
20 HIGHLAND AVENUE, COTUIT,MA
PROPOSED LEACHING AREA: CALCULATIONS TEST PIT DATA 0'-12' FiII Prepare for: Richard & Hope Barry
ghland Avenue
Hi
Leaching Dry Wells: 31.5' L X 11' W X 2' H 1 Bedroom (Existing) + 2 Bedrooms (Proposed) Performed By. Steve Haas 12'-20" A,10YR2/2 Loamy Sand 20 20 Hi, MA
Side Area: 170 SF X 0.68 G/SF =115.6 GPD 110 GPD/Bedroom x 3 Bedrooms = 330 GPD Witnessed By. Dave Stanton 20"-36" B,10YR3/6 Loamy Sand " = '
2 May Bottom Area: 346.5SF X 0.68 G/SF =.235.6 GP SCALE: 1 20
Percolation Rate - 7 MPI (TP1) Date : 4/12/02 36"-72" C1,10YR4/6 Loamy Med Sand DATE: y 30,
Total Leach Capacity =351. GPD Soil Class: Class 1 (0,68 G/SF) TP-1 (EL. = 49.5') 72"-132" C2,10YR7/4 Med Sand Drawn MaBy. David Del Negro
351.2 GPD > 330 GPD