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0018 JACKSON DRIVE - Health
18 Jackson Drive Cotuit P A = 019 080 i I i 1 I I a r t TOWN OF BARNSTABLE WCATION \, ��`�'�'SU� SEWAGE#��`()(a VILLAGE /'rn'�j�"� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. S r_® SOX acl'4 0oo 7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Gc L C i1 l i-. 3D X2r NO.OF BEDROOMS `-- OWNER PERMIT DATE:��Ca � _ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility eet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) ©et� Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY IL aS- o v eAA No. ���,� — 01/ Fee Mo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for Disposal *pstrm Construction 3oermit Application for a Permit to Construct( ) Repair( KUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. "V a c.C.(Z5QA 10C er''s Name, ddress,and el.No. Assessor's Map/Parcel CCN, ' (� Installer's Name,Address,and Tel.No. UA Desi er's Name Address,and Tel.No. o ?6 CS(3 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage GrinderA0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _33d gpd Design flow provided .3 b gpd Plan Date \ ` UkS Number of sheets Revision Date Title Size of Septic Tank vu�>Q 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. Date Ll Application Approved by Date Application Disapproved by Date for the following reasons Permit No._,? U r,�-off 2- Date Issued / No. G�� -. G�.`�� - _ Fee Mb THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for -Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( 1Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �,L�SQA �)C O,�er's I�ame,gdress and el.No. �C `` C Assessor's Map/Parcel _ $ � Cd�V Installer's Name,Address and Tel.No. Desi ner's Name Address and Tel.No. 5��e... �-t G�j 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) 33D gpd Design flow provided .�} 4 gpd Plan Date \ O(S Number of sheets Revision Date Title Size of Septic Tank �' (� �b�U Type of S.A.S. rn��S Description of Soil 2 w-Uly-, Nature of Repairs or Alterations(Answer when applicable) CrXO5 (� 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. / e Date 1 Application Approved by / J=e Date /U / Application Disapproved by Date for the following reasons Permit No. 2 U /_S_ -j12 t/ Date Issued aA / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance j THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(L ) Upgraded( ) Abandoned( )by SC OVA ^. k - at C r_ ( l,L S A \JC C_6 UNkA has been constructed in accordance j with the provisions of Title 5 and the for Disposal System Construction Permit Nord 'd�C/dated Installer ( c& �lc-, - Designer `tip ��G C"S #bedrooms - Approved design�o, �(��� gpd The issuance of this pe6it,ssh`all now e construed as a guarantee that the system w'1\fu �tion as design d. Date �� J ) Inspector ) (/ 1 ----------------------------- - -------------------------------------------------------------------------------------_- ------ No. G(J^ ' o_? t. Fee i�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Prrm-tt Upgrade(Permission is hereby granted to Construct( ) Repair � Abandon( ) System located at GC, S�,n C y 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 permd Date ___�. y //_ Approved by TRANS. NO.: CITY/TOWN: APPLICANT: }->/tw L � y ADDRESS: �ba_"V. DESIGN FLOW: -356 gpd REVIEWED BY: DATE: I N/A OK NO Legal boundaries denoted [3 i0 CMM 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan[310 CMR 15.220(4)(u)] 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(l)(a) for / upgrades]- if 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 dunensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required and provided) soil absorption system (required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing.and proposed contours [31.0 CMR 15.220(4)(g)] 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)(j)] Observed and Adjusted'groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 3.10 CMR 15.220(4)(n)] Address / Sheet 1 of 1 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 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)(1)} Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.2'1(l)[1]) Profile.of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] 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(l)(k)] ' Test hole adequate to demonstrate four feet of suitable material? [310 CMR 1.5.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.1030)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36" deep (unless Local Upgrade j Approval or LUA requested) [310 CMR 15.405(1(b)] Address 19 Sheet 2 of 7 N/A OK NO Size OK? [310 CMR 15.223(l.)] 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 orapproved 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" (by 7/07) [310 CMR 15.228(2)] ✓ Access to within 6 " of grade - one port for systems<1000gpd 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] ✓ sa p^*.�:-� q Y A :.ar.s Yz�. �..,� n.. .fit •.: Required when other than-single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow[310 CMR 15224(2)and(3)j "U"pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] ; Address l g/�� Sheet 3 of 7 --- _......_ .. N/A OK NO Located at least ten feet from any water line? [310 CMR' f. 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 1310 CMR 15222(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)] Siphon problem/(leachfield below pump chamber) Endca s or vent manifold specified? 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) 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 j CMR 15.323(3)(a)] ✓ Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b,)] Minimum sump 6" [310 CUR 15.232(3)(e)] Watertight cover if<2000gpd);waterproof manhole if>2000gpd f 1310 CMR 15.232(3)(d)] V yt 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)] Buoyancy calculations needed?Provided? [310 CMR 15.221(8)] Address fir/8� Sheet 4 of 7 - N/A " OK NO 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) [31.0 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(l)[4] and Guidance Document] GLLEI2IES,PX3'S,C BERS�310 CVIR 15'253rf " { ; 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 to grade) [310 CMR 15.253(2)] Aggregate P minimum- 4'maximum. [31.0 CMR 15.253(1)(b)] ✓ 2' sidewall credit maximum[310 CMR 15.253(1)(a)] / In bed configuration,inlet every 40 sq. ft. [310 CMR 15.253(6)] `TRENCHES 31U CT >7�5 251 <kr : 5 �� �, r � �xX3 T s v_ .w .4 -xa.,r.25 .:hc btrz:?, .„zz;wz�,a.M ac2 _u"a max"G'ra' rt, r..ssi. ".'+ :W:ca's`r. Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet-maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OIL? [31.0 CMR 15.211(1)[4] and Guidance Document] BED SAS{ll�axitnum siie1 of`bed or OK'd,d)x 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 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only [310 CMR'15.252(2)(i)] ` Address 9�a Sheet 5 of 7 N/A OK NO DTD•�H°E�LA��IN�VO.L�'�` x �-�r,=��; �,,�,r��.����,�P, .�,� � �* �� `` �` � �`''�` . ' �� t� 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 UA 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 (>2000gpd) good 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)] 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)] '°GraveZZess�S stems l/�4<fl x�rov�lefters x � ��. y F Check DEP Approval letters for credits and design.conditions If used with pressure dosing do not allow pressure discharge to scour soil interface 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 maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are the variances listed on the plan:? [310 CMR 15.220 (4)(q)] 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 ��f'� Sheet 6 of 7 N/A OK NO 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] ste v ms ] is the system proposed on the same lot as served by private well? / [310CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 1.5.216(1)] �2.. YxT +� ..f.. .:�i-.. a w.Si.`.�-.. ;5.4.^af•.-., D :u4. 6 7, cC .x. - Pumping to septic tank? [ 310 CMR 15.229] Shared System[310 CMR 15.290] J Address Sheet 7 of 7 Town of Barnstable aTtiQ Regulatory Services Richard V. Scah, Interim Director �xrvsr�►eta, . 9� 1639. `e� Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: l 5 Sewage Permit# aOkS-Oaq Assessor's Map\I'arcel I.Ci—$v Designer: .5Tz: 'y� - Installer: �SLd Y\ Address: g23 /2oz'-7Z= 6,4 Address: rr.o 0. lg ,a f On _,SGol� oV_r0\ \C was issued a permit to install a (date) (installer) septic system at _. (, ,k s o , Prr, based on a design drawn by (address) S5 dated (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 or 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 compliance with the terms of the IAA approyal�letters (if applicable) 11 lak Of A. AWS (Inst 's Signature) ' CNIL (Designer's Slgna 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. QASeptic\Designer Certification Form Rev 8=14-13.doc Town of Barnstable ; P Department of Regulatory services j w►arrarwers i Public Health Division Date 4 MNB,A - A n6;g 200 Main Street,H annis MA 02601 HI lfD t J Date Sebeduled s`,� x �`� Time. Fee Pd. Soil ►watt biiity.Assessment for Sew is o l o Performed By: � � . �q,`/,'!✓a..�1'`', P E' Witnessed.By: LO� �C�,/ATION.4 GENERAL MFORMAT N Location Address_ l I J C�(,1'K 9-O� U Owner's Name, n Address d-L . W�S� �r. t. wV �r Assessor's Map/Parcel: ` Engineer's Name Sig its NEW CONSTRUCTION REPAIR 1/ Telephone# Land Use �CS%� 1�—C Slopes(%) 5 Surface Stones Distances from: Open Water Body ft Possible Wet Area / + ,ft Drinking Wafet Well ft Drainage Way ft Property Line /O P ft Other ft SHE'TCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) Parent material(geologic) t!),CX7 c)•-N" Depth to Bedrock 26c)-4 Depth to Groundwater. Standing Water in Hole 0''�i L Weeping$'om Pit Puce Estimated Seasonal High Groundwater ~ DETERMINATION FOR SEASONAL HIGH WATERTABLE Method Used: R //4 Depth:,Observed standing in obs.hole in, Depth to soli mottles: ltt Depth to weeping from side of obs:hot, 6i," Groundw'uter Adjustment ft. Index Well.# Reading Date: lndex Well lei+el,. 'Adj,fhetor` m a A�.0roundwater Level v PERCOLATION TEST bate/ , '11ng Observatiot► Hole# �. Time at 91, Depth of Pere "f L Time at 6" Start Pre-soak Time.@ .usJ Iime(V-6") End Pre-soak Rate Min./Inch L--Z Site Suitability Assessment:. Site Passed .. Site Failed: Additional Testing Needed(WN). Original: Public Health Division Observation Hole Data To Be Completed on Back`----------- ***If percolation test is.to be conducted within 10W Hof wetlaind,you must first notify the. " Barnstable Conservation Division at least one(1) week-prior to beginning. Q:ISEPTIC\PERCFORM.DOC . DEEP.OBSERVATION HOLE LOG Hole# , Depth from Soil Horizon ' Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onmistency.%Gravel) 7. DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o Sistency.%Gravel) iP /L DEEP OBSERVATION.HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%G DEEP OBSERVATION HOLE LOG Bole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consist n Flood Insurance Rate Map: email UY.:,Si)t,'"'e?Y r:CrPxt 1Pu iii ail. ANo __ Ycg. t.✓ r. �. y ry Within 500 year boundary No 1.1 Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y If not,what is the depth of naturally occurring pervious material? -— -- Certification I certify that on (date)I`have passed the soil evaluator examination approved by the Department of Envlronmental Protection and that the above analysis was performed by me consistent with . the required traini expertise and experience described in 310 CMR 15.017.. Signature '_. Date QASEPTIC�PERCFORM.DOC Health Master Detail Page 1 of 1 Logged In As: TOWN\miorandd Health Master Detail Tuesday, November 18 2014 Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 019-080 Location: 18 JACKSON DRIVE, COTUIT Owner: GROVER, PAUL E - Business name: Business phone: Rental property: ❑ Deed restricted: ❑ Number of bedrooms :F 01 Contaminant released: ❑ Fuel storage tank permit: ❑ -, Save Parcel Changes = Return to Lookup , Parcel Info Parcel ID: 019-080 Developer lot:LOT 12 Location: 18 JACKSON DRIVE Primary frontage:130 Secondary road: Secondary frontage: Village:COTUIT Fire district:COTUIT Town sewer exists at this address: No Road index:0786 Asbuilt Septic Scan: 019080_1 Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: GROVER, PAUL E Co-owner: Streetl:24 WEST DR Street2: City:MARION State:MA Zip: 02738 Country: Deed date:6/26/2003 Deed reference:17157/244 Land Info Acres: 0.47 Use: Single Fam MDL-01 Zoning:RF Neighborhood: 0108 Topography:Above Street Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1981 3445 1379 3 Bedrooms3 Full + 1H Buildings value:$116,100.00 Extra features: $41,600.00 land value: $202,200.00 r http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=019080 11/18/2014 V UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS g { �y Permit No.G-10 a. • Sender: Please print yotat I'me, address, and"ZIP+4 in this box • I I Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 � I I I I I I I� SENDER: COMPLETE THIS:SECTION, COMPLETE THIS SECTION ON DELIVERY s Complete items 1,2,and 3.Also complete A. S' nature item 4 if Restricted Delivery is desired. ❑Agent X ■ Print your name and address on.the reverse Addressee so that we can return the card to you. B. Received by(Pn- d Name) C. Da of livery • Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item VI ❑ es 1„ Article Addressed to; If YES,.enter delivery address below: No I � I i Paul Grover i 24 West Drive Marion, MA 02,00 3: Service Type ❑Certified Mail ❑Express Mail 0 Registered ❑Retum Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) p Yes I 2. Article Number 7 012 '-101 D 0 0 0 0 '2 8 51 3 917 (transfer from servfce label) PS Form 381 1, February 2004 Domestic.Return Receipt 1.02595-024-1540 o�t"E roy, Town of Barnstable -,.,-, Barnstable Regulatory Services Department , Q p , Z SA.RNSI'ABLE. "'" s6g9. ��' Public Health Division qjA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 3917 November 5, 2014 Paul E. Grover 24 West Drive Marion, MA 02738 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 18 Jackson Drive, Cotuit, MA was last inspected on 10/7/2014, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: a Backup of sewage into facility or system component due to overloaded or clogged SAS. Be sure to schedule a percolation test for the repair with enough lead time. o Liquid depth in pit is less than 6" below invert or available volume is than ''/Z day flow. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PE ER OF THE BOARD OF HEALTH J,�l Thomas McKean,, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\I8 Jackson Dr Cot Nov20I4.doc If i ,e http;f f issgl2f intranetjpropdataf ParcelDetail,aspx?ID=;29 (G• j? Live Search `p Application Center(3) ®Application Center(2) http--www,town.barnstable... Application Center ®Suggested Sites• Web Slice Gallery �J Favorites ®ParcelDeta1 of iH re AL a u1Awn EAIlhStAlll.E * u MA55, 11 1 ® .In As: rcel Detailt M I q l i T Parcel Info Parcel Developer ;_ ID 019-080 tot LOT 12 I Location 118 JACKSON DRIVE I Pei Frontage Frontage �. i Sec I Sec I ' is Road Frontage I; I Wage COTUff I Fire COTUff Distract Town sewer exists at this 1 address No Road Index 0786 --- .,�. Asbuilt Septic Scan: Interactive ' N ` , 019080 1 Map T ;I T Owner Info a1 Owner GROVER,PAUL E I Co-Owner Street124 WEST DR I Street2l I City MARION ( State N1A Zip�38Country v Land Info 9 9� g Acres 0.47 Use Sin le Fam MDL-01 Zoning RF N hhd 13 00!0 StartjJ ilj Mail Label 9.22.14,doc ,,, O Parcel Det=windows f F 11,39 AM Computer name : HEALTH899JF User name : flvnni Operatinq Svstem : Windows NT (5.1) f�OsT Ac D-�� r CEA ,Ic p.1 ct 0714 09:15p , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuit MA 02635 10-7-14 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the farm. Important:When filling out forms A. General information on the "�ppnuut►l�rrr use only the tab mputer, r1,� / / ��� �H OF/ySs�c 1. Inspector: key to move your = JAMES cursor-donol James D.Sears use the return Joy—S key. Name of Inspector =c�: Ca ewideEnterprises,LLC Company Name .,���'• cRtIF�.•• � .�` rmt : 153 Commercial Streets,nNttv L�G�``�`` Company Address Mashpee -- — MA. _ _ 02649 Cityfrown State Zip Code 508-477-8877 S1623 Telephone Number Lroense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function.and maintenance of on site sewage disposal systems.!am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Furthei•'Evaluation by the Local Approving Authority 10-7-14> spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP, The original should be sent to.the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform 1n the future under the same or different conditions of use. 15ins•W13 .. TNe 5 Official Inspection ubsurrace Sawaue Disposa;System-Gage 1 of 117 Oct 07 14 09:15p p•2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 18 Jackson Drive Property Address Paul Grover Owner Owner's Name Infor Is reqquireduired f for every Cotuit MA 02635 10-7-14 o page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A B,C,D or E 1 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: Failed system. The system is a 1000 Gal. Tank D Box and Pit. ystem Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic-tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing'tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally'sound, not leaking and if a Certificate.of Compliance indicating that the tank is less than 20 years old is available." ❑ Y ❑ N ❑ ND(Explain below): 4. 1Sins•W13 7We 5 Official Inspection Form:Subsurface•Sewags bsposal System•Page 2 of 17 Oct 0714 09:16p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover _ Owner Owner's Name , f F r information is required for every Cotuit MA 02635 10-7-14 page. Citylrown` State Zip Code Date of Inspection B. Certification (cont.') ❑ Pump Chamber pumpsialarms not'operational. System will pass with Board of Health approval if pumps/alarms are repaired_, B) System Conditionally Passes,(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled'or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ .N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more.than-4 times a year due to broken or obstructed pipe(s). The. system will pass inspection if(with approval of.the Board of Health): ❑ p P broken i e s are rep laced' � ❑ Y ❑ N ❑ NO (Explain below): obstruction is,removed ❑ Y, ❑`N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health:' ❑ Conditions exist which require further evaluation by the Board of.Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh deg-3n9 Title 5'ONipal Inspection Form:Subsurface Sexsge Disposal System•Page 3 of 17 a.. Oct 0714 09:16p PA Commonwealth of Massachusetts .i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Jackson Drive Property Address Paul Grover Owner Owner's Name informatifor every on is required Cotuit MA 02635 10-7-14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.). 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment. ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory; for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: w D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® . Backup of sewage into facility or system component due to overloaded or FL 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 GeaMM is less than 6"below invert or available volume is less than%day flow 0/7— r5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Oct 0714 09:16p p.5 Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuit MA 02635 10-7-14 page_ Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation- El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system falls. I have determined that one or more of the,above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered'yes"to an question in Y i Section E the system is considered a significant threat Y Y q Y 9 t, 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 15ins•3113 Title 5 Official Inspection Form:Subsurfaw Sewage Disposal System•Page Sol 17 r Oct 0714 09:17p p.6 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Jackson Drive _ Property Address Paul Grover Owner Owner's Name information is required for every COtuit MA 02635 10-7-14 page, cityrrown state Zlp Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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 depot of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) D. System Information Residential Flour Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example:•1.1.0 gpd x#of bedrooms): 330 a i5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage 01sposal System-Pape 6 of 17 p.7 Oct 0714 09:17p Commonwealth.of Massachusetts Title 5 Official Inspection (Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 18 Jackson Drive Property Address ` Paul Grover Owner Owner's Name information is required for every COtuit MA 02635 10-7-14 page. cityrrown State Zip Code Date of Inspection D. System Information Description: {. _ The system is a 1000 Gal.Tank D Box and pit. Number of current residents: 01, Does residence have a garbage grinder?,., ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes 0 No ' 2012-139,000Gal Water meter readings, if available (last 2 years usage(gpd)): 2013-169,000Gal's Detail: � [] Yes [0 No Sump pump- NA Last date of occupancy: Dace Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gauons per day(gpd) Basis of design Flow(seats/persons/sq.ft.,.etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -- t5ins-3113 Title 5 Official.Inspection roan-Subsurface Sevage D'aposal System•Page 7 or v Oct 0714 09:17p p•8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is - - 4 02 35 1071 o ui MA 6 Ctt required for every page. C— ltylTown Slate Zip Code Date of Inspection ect ion D. System Information (cont) Last date of occupancy/user Date Other(describe below): ' General Information Pumping Records 08/12 Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: - Type of,System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach,previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract. ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): i 15ins•3113 Tide 5 Oifcial inspection Form:Subsurface Sewage Diopcsol System•Page of 17 Oct 0714 09:18p P 9 Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuit MA 02635 10-7-14 s page. Cityrrown State Zip Code Date of Inspection. D. System Information (cont.) ;. Approximate age of all components, date'installed(if known) and source of information Around 32 years old Were sewage odors detected when arriving at the site? ElYes ® No Building Sewer(locate on site plan): Depth below grade: ,feet Material of construction: ❑ cast iron ®40 PVC ®other(explain). Distance from private water supply well or suction line. feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing House to tank�4"'PVC SCH 40 Pipeing tank to box and Box to pit 4"PVC SCH 20• Septic Tank (locate on site plan): ' Depth below grade:. feet ,. Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal,list age:,; years - ';. !sage confirmed by a Certificate of Compliance? (attach a copy of certificate). ❑ Yes ❑ YNo Dimensions: 1000 Gal Precast H10 Sludge depth: 15ins•2113 _ - _ s. TWO 5 Offidal Inspection Form:Subsurface sewsoe Disposal system•page 9 or 17 Oct 0714 09:18p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuit MA 02635,, 10-7-14 page, Citylrown State Zip Code Date of Inspection D. System Information (cunt:) Septic Tank (cost.) Distance from top of sludge to bottom of outlet tee or baffle NA,- Scum thickness Distance from top of scum to top of outlet tee or baffle NA f Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert.evidence of leakage, etc.): Tank and outlet cover at 38".below grade. Inlet cover at V. Inlet tee,No outlet tee or baffle. No sign of leakage. Grease Trap(locate on site plan) - Depth below grade: _ ':. feet Material of construction: ❑ concrete El metal ` ❑fiberglass El,polyethylene ❑ other(explain): Dimensions — Scum thickness,• f 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: t Date t5ins-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 10 of 17 Oct 0714 09:18p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner . Owners Name , Information is Cotuit MA 02635 10-7-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: -_ —• Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: ........... gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes. ❑ No 15ins•3113 Tile 5 official Inspection For:Subsurface Sewage Disposal System-Page 11 d 17' t s Oct 0714 09:19p p.12 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuft MA 02635 10-7-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid.level above outlet invert 0 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.): G D Box is 1Tx21"-31"below grade w/one line out. Box wail's are gone,need to replace. D Box is in black top drive,H-10. Al Pump Chamber(locate on site plan): Pumps in working order. _. ❑ Yes u❑ No` Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on.site plan, excavation not required): If SAS not located, explain why: 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Oct 0714 09:19p p.13 " Commonwealth of Massachusetts �. s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuit MA 02635 10-7-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits ,number: 1 ❑ leaching chambers .number: ❑ leaching galleries number- El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: a Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): Leaching is under Black top drive, per.plan 1000 Gal.Pit Camera from D Box, Pit is full. Need to replace leaching: Cesspools (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 ❑ N61-' ;Sins-3A3 Title 5 Official Inepaction Forth:Subsurlaoa Sewage Disposal Syslem-Page 13 0117 -Oct 0714 09:19p p.14 Commonwealth of Massachusetts uivTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is required for every Cotuit MA 02635 10-7-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): R, s, Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Z. t5ins-3113 Title 5 Offldal Ins milon Form:Subsurface Sawe Disposal System•rage'14 of 17 P 9e p Ys -Oct 0714 09:20p p.15 4 Commonwealth of Massachusetts Title 5 Official Inspection ,-Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments 18 Jackson Drive ' Property Address . Paul Grover Owner Owner's Name information is Cotuit i MA 02635 10-7-14 required for every page. Ctty/Town j -State Zip Code_ Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® .hand-sketch in the area below El drawing attached separately -3 .=d- 3 -� ` >f x fq -Vf 30� r UU.- t5ine•3/13 Title 5 ORdd Inspoollan Forth:Subsurf=e Sewage Olspbsat Systom•Page 15-of 17 Oct 07.14 09:20p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is reg wired for every COtUIt MA 02635 10-7-14 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑, Check Slope ❑ Surface water ❑ Check cellar ' T ❑ Shallow wells NU ' Estimated depth to high ground water. 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Per Past Report ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per Past Report 5-16-03 20'+ No G.W. area and lot High. Gr Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mrs•3113 Idle 5 Offidai Inspection form:Subsurface Sewage Disposal System,Page IS of 17 Oct 07 14 09:20p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Jackson Drive Property Address Paul Grover Owner Owner's Name information is Cotuit MA 02635 10-7-14 required for every State Zip Code Date of Inspection page. Cityrrown E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 151ns•3/13 Title 50frical Inspeclion Form:Subsurface Sewage Disposal System•.Page 17 of 17 �-� RECEIVED MAY 2' 8 2003 LCT D AT E: 5 16 0 SOWN OF BARNSTABLE - - ---- ---HEALTH DEPT. PROPERTY ADDRESS: 18 aackaon Da.ive Coi-ait, /jazz D ------------------------ 02635 -------------------- On the above date, I inspected the septic system at the above address. This system consists of the following: 7. 1- 1000 ga-gion zept.ic .tank. 2. 7-Dizta.igut.ion Sox. 3, 1- 7000 gai.Pon 6e/?t.ic tank. Based on my inspection, I certify the following conditions: 4. 7h.i-6 1,6 a t.it.ee dive zept.ic zyztem. (78 Code) 5. The zept.ic 3y.3tem .iz .in 7zaopea woak.ing oadea at the /2aezent time. 6. lde did not o9eeave the d.izta-igution Sox oa the Peach.ing p.ii_ ` Doth o/ the,3e un.itz aae undea the da.iveway. SIGNATURE: , Name:-J. P. Macomber Jr .__,___ Company: Jose_ph-P. Macomber_& Son , Inc . Address: Box 66 Centerville , Ma . 02632-0066 Phone:- 508-775-3338 -------------------- THIS CERTIFICATION DOES NOT CONSTITUTE, A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds = Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • r 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 Property Address: 18 7ack-6'on Da- Ue " Coa u- , Razz. Owner's Name:Ca z P Si-aag Owner's Address: Sclmp Date of Inspection:5/16/0 3 Name of Inspector: (please print) Joseph P. Macomber Jr. Company Name: Joseph P. Macomber & Son Inc Mailing Address: Box 66 r rpntprvi 1 1 e Ma 02632 Telephone Number: 508-775-3338 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: -le-11Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails I�IWAIv-nature:' Ins ectors SiDate:P g � � �✓ The system inspector sha bmit a copy of this inspection repo 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 i Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 7ackzon [Dlz.ive Owner: rrin.P Date of Inspection: 5116103 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 3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Coed nod o �se2ve .the di,6t/zi&u.tion Sox o2 .the ieachiny pit a46 aaa unr/on fho r/niuo way, B. System Conditionally Passes: 6 40 One or more system components as described in the"Conditional Pass"section need t.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: ik? SAT O d0 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: W 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: P 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 18 aack son Dlt-.ve Cotu.it, Ma.6.6. Owner:Ca2i S.taag Date of Inspection: 5/16/0 3 C. Further Evaluation is Required by the Board of Health: X)OConditions 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: / f 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 et 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 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: 18 ,tack.6o2 /hive Coiu , Ala.6.6. Owner: Ca/zi S at Date of Inspection: 5116103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No �ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool scharge 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 /-41 ldoa L4,kwAJx) ''/,d Liquid depth in=speel is less than 6"below invert or available volume is less than flow equired 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. 41JAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i y 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.] /U (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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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� l/ the system is within 400 feet of a surface drinking water supply a system is within 200 feet of a tributary to a surface drinking water supply 6� the system is located in a nitrogen sensitive area(I,nterim 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 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:18 aackzon [hive o Z U7 ¢a,6. Owner:Cali Q S as Date of Inspection: 3 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 Z_ Has the system received normal'flows in the previous two week period? P/ 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. . l 11 _ Determined in the field(if any of the failure criteria related to Part C is at issue_approximation of distance is unacceptable) [310 CIAR 15.302(3)(b)) 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 18 Jack.6on DIL ive ' Property Address: - Owner: Cali Staab Date of Inspection: 5/7 6/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x# of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): 2 ' Is laundry on a separate sewage system,�yes or no):APW— [if yes separate inspection required] - Laundry system inspected(yes or no): /4 Seasonal use: (yes or no): /1/b Water meter readings, if available(last 2 years usage(gpd)):20 0 7=70, 000 ga'.P P o nz = 7 91 78 gP D ` Sump pump(yes orno):VP 2002=79, 000 gaPPon.=216. 44 'giPD Last date of occupancy:7�� COMMERCIAlANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): W0 Qpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):4J4 Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): ,]Jig Water meter readings, if available: ti,4 Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records - - Source of information: 1 11'r2cl" Q2 Was system pumped as part of the inspection(yes or no): -6�V If yes, volume pumped: ,allons--How was quantity pumped determined? X/ Reason for pumping: �f TYPE SYSTEM YP _Septic tank,distribution box,soil absorption system w Single cesspool Overflow cesspool _Privy Y (Y )(' Y P p Shared system es or no (if es attach previous inspection records if any) - y�Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - . ,dTight tank 64 Attach a copy of the DEP approval R .4 X4 Other(describe) W,� o t Apnw�41� ate age of all comp vents,date installed(if known)and.source of information: , Were sewage odors detected when arriving at the site(yes or no): •s 6 - _ Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 78 aackzon DlLive o a z. Owner: Ca22 Sa r � , l'l Date of Inspection: 5/7 6/0 3 BUILDING SEWER(locate on site plan) 4" Lite w ieght PPVC Depth below grade: 69 / /2.il2e. 7haough out #.he Materials of con srmction:,�j 0 cast iron ,)d40 PVC other(explain);syhtem. Distance from private water supply well or suction line: /D')L- Comments(on condition of joints, venting, evidence of leakage, etc.): The ayztem iz Dented e ou.se Zoo ven z. SEPTIC TANK: /(locate on site plan) /DOD 914�" Depth below grade: � Material of construction: ✓concreteWh metal.)e)fiberglass426polyethylene iUdother(explain) ,vim If tank is metal list age:/Ud Is age conf=ed by a Certificate of Compliance (yes or no):•t'�Z,1 (attach a copy of certificate) '0 N ` Dimensions: ,pc14 �l�� �j�jtoj Sludge depth: _� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: /,riot—ram Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integriry, liquid levels as related to outlet invert,evidence of.leakage, etc.): tllumR .fhv_ 6o2L1a tank aNI/IIALLI aaggogo r ,pnAQPjA �e A en TD_Pof R 0111 PQf 1006 474g in oCann 74a Z a n 4 b-4 44 ; ,E�1�.�Eb��1,f .6ound and .6how.3 no evidence o� leakage. The �eigu.id .PeveP ai- the GREARE�k4aeat i s 51" ocate on site plan) Depth below grade: 4M Material of construction:,& concrete,�J) .metal&fiberglassfe:2polyethylene dA other (explain): Alm Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ,VX_ Distance from bottom of scum to bottom of outlet tee or baffle: NA Date of last pumping: 0 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Gaeahe 4aap.6 ate not pae.aent. 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Jackson Dz-ive rnfiiifl7n.t/,. Owner: Caize Staag f Date of Inspection: 5116103 TIGHT or HOLDING TANK ,r 6(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: A)A Material of construction concrete,!/, metal 41,4 fiberglassxl,4 polyethylene r/ other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm present(yes or no): X,J Alarm level: q)R Alarrp in working order(yes or no): Date of last pumping: 10 Comments(condition of alarm and float switches, etc.): _ 7inhi nR hn-Pr/,inn laak.6 aae not Raeheni DISTRIBUTION BOX:Zif present must be opened)(locate on site plan)' ) Depth of liquid level above outlet invert:L3ox .ih unde2 djz-ivewa y. 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.): Pox i,3 unde2 dziveway [did not excavate PUMP CHAMBER4/, L. locate on site plan) Pumps in working order(yes or no): 414 Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n LZM924 iA not 122ebent 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:18 aack.aon Dzive o t u c t, a,6•5. Owner: Caz.P S as Date of Inspection: 5/16/0 3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1- 1000 Ua-tgon R2eca,3.t 2each.ing R.it. If SAS not located explain why: Locat-ion o,' R.i.t ha•s Peen .Pocated, lda.a not excavated. : l it .i.6 undea the a.saha2t cbzive wag. Az .iz the Sox Type leaching pits, number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: ,Il leaching fields,number,dimensions: 0 ;(JD overflow cesspool,number: XU 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.): Loam .sand to coaaae .3and. No .s-i n.6 oZ h daauiic �aiivae o2 ponding. P '# undgz i.+phait dn.ivewau No z ign,3 07-P &ack up .in the 3e/2 tiz tank. Cveaything i.6 at /22o/2ea woak.ing .Peve2.6. CESSPOOLSrI 4cesspool must be pumped as part of inspection)(locate on site plan) Num*and configuration: 0 Depth-top of liquid to inlet invert: Avly Depth of solids layer: Depth of scum laver: 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.): Ce< .6pooib a/te .not /22e,3ent. PRIVY(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 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: 18 aack.6on Dzive ' o u.c , a,3,3. Owner:Ca/ti S t`as Date of Inspection: 3 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. ol . e �F o 10 r Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 auek.6on Dli the Owner: Cali SiCzq_ a3 Date of Inspection: / b 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: N(,L_Obtained from system design plans on record-if checked, date of design plan reviewed:_, N,4 qCS Observed site(abutting property/observation hole within ISO feet of SAS) NO Checked with local Board of Health-explain: NA q( S Checked with local excavators,installers-(attach documentation) q( S A ccessed U SG S database-explain: htt12://town, P.nnn.6ta e. rna. u,6. You must describe how you established the high ground water elevation: eleva ion: �e � 94Vizound war-e2 e eevat.ion,6 move 6ea PeveP. y , � L�-ih dune i y U,6ed: US ec n.cca! tuX2ettn — — a e #2 finnuaZ2angee o 920un watea e.Pevq .eonz. anua2y GroundI up Of i Leaching Pit d 'cc( Groundwater:Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim ter P P Method Therefore, the vertical separation distance between the.bonom Of the leaching pit and the adjusted groundwater table is feet. -ti `` ART TR.TI'r�"1"f-{rR�JRT'I.TPtfnTlTiSfT.!'R1f1`.T7S'R►IlA"T'IRTfiTM1L 1TQ'RTLRRT .. 1T TOWN OF BOARD OF HEALTH J T,-T •-T"n_.SUIISURFACF 9EWF AGF DISPOSAL ,SYYSTF,M I N�9hFCI'ION FORM - PART D .- CERTIFICATION -TYPE OR PRINT CI.CARL1'- PROPERTY INSPECTED STREET ADDRESS 18 aackzon Dzive Cotu.it, 0azZ. ASSESSORS MAP, BLOCK AND PARCEL # d/?_ dPd OWNER' s NAME Ca/zi Staab PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr.. COMPANY NAME Joseph P. Macomber & Sdfi 'Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Strevi Town or City COMPANY TELEPHONE (508 ) 775 3338 scat• CIF FAX ( 508 ) 790 _ 1 578 CERTIFICATION STATEMENT p p I certify that I have personally inspected the sewage disposal system at this nddress and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any -information which indicates that the system fails to adequately protect public health Or the environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* \ The inspection• whicll I have con acted has found that the system fails to Protect the ilublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C -CRITERIA of this. inspection form , FAILURE e Inspector Signature Date copy of this certification must be provided to the OWNER, the BUYER 3nde where applicable ) and the BOARD OF HEALTJr. * If the inspection FAILED, the owner or""operator shall u pgr 'within one Year of the date of the inspection, unless alloweddtayete m otherwise as provided in 3.10 CF1R 16 . 306 . or required partd . doc L O CATION �ACksv►� �AG E PERMIT NO._ ,.Y. _ VILLAGE r-- Lifer INSTALLER'S NAME i ADDRESS c �C 1&7w. 1�6P till 14 Q-\i�'�'�/.C"' ►A f BUILDER OR OWNER , DATE PERMIT ISSUED DATE COMPLIANCE ISSUED G,qr,,c E 1 SEWAGE INSPECTIONS LOCATION 18 aackzon z ive DATE 5116103 VILLAGE ASSESSOR'S MAP & LOT -INS,?ECTOR 10.6gph P. Ma,comaez 7,,z. SEPTIC TANK CAPACITY I000 C/a-fiOn4 Box LEACHING FACILITY: (type) I-L%- 1000 (size) I U0 ga Leon-6 NO. OF BEDROOMS 2 BUILDER OR OWNER Ca2e Staal 2 OWNER MAILING ADDRESS Q Cow, O LUNTca zV� Noc..&QJ��Z FEis ................ ITHE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ..O.W ......-.......OF................... a �r!U .1.. ........ E......... Appliration for Ebpo al Workii Tomitrurtiutt ramit Application is hereby made for a Permit to Construct (Q or Repair ( ) an Individual Sewage Disposal System at: r.7t..Y_E.........................................0r I• S1 .......... . ................................. location-Address or Lot No. .. r A..a..................................... ............................................. Owner A ddress .... .....�... ••.......•..a /... Installer Address Type of Building Size Lot. _ .7: ..4__.-Sq. feet Dwelling—No. of Bedrooms........3...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T' e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -------------------------------• - W Design Flow............... .gallons per person per day. Total daily flow_........_..3.-9®... ............gallons. WSeptic Tank—Liquid*capacity 142.00gallons Length.......`... Width...___.._ Diameter................ Depth....,..... x Disposal Trench—No---------------_--- Width_..7.._._...._._.. Total Length.............�......Total leaching area....................sq. ft. Seepage Pit No......../.......... Diameter....... Depth below inlet........K......... Total leaching area_&_.1!. o4.-k.C2,P' 0 Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..A.OW__.�e..W.X q.trl'.....�.N .�... Date....7 ...� /............ Test Pit No. I...'5.2._minutes per inch Depth of Test Pit----121..._.__ Depth to ground water.&B...c.... f% Test Pit No. 2_.<Z..minutes per inch Depth of Test Pit.... .r` .`..._. Depth to ground water._eOv'v 7_iPV-" a --••••----•••••••------------•••••------•---•-•--•-•-•--•--•...................••----....-•••••.....-•-•--••-•-•-•----•---••------•----•............•....--•- O Description of Soil......... ��E...... ¢1 1?........,C 4Z},/J---------------------------------------------------------- x �., ----------------------------------------------------------- ....... - w •-••••----•---•--• ••--------- ----------------------------- ---------------------------------•••••- UNature of Repairs or Alterations Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bW issued by the board of health. Signed•••. • .t_.. ................................................ .......................... Date Application Approved By------. J ' - ........................ ate Application Disapproved f or the following reasons:.............................................................................................................. -•--•••••-•-••••..............•-•-•-••--..............---................••--••••.....-••-•-•-•••---............_.....-----------------------._............•...•••.......•......•..•. •••........- Date — PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 3'.10" BOARD OF HEALTH ....... ..........OF........ .................................... Trrfifiratr of Toutplitttta THIS IS 0 RTIFY That In ividua ewage Disposal System constructed (�or Repaired ( ) by......... ... ..-- � )------------------------------------------------------------------------------------ Z at............... .--1 Z------.-Zce ,�rv�...... ---------------���- ---�----•-----------------------------------------------------.------------------ has been installed in accordith the provisions of TIT F C of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... ........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... f f Noi.. /�..� � Fus.....ti?. ... K....J 3, 'THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH Z.044,4"V............OF...........<5/5.2....J.s. - .............. Allp iration for Disposal Works Tonstrnrtion Frrntit Application is hereby mide for a Permit to Construct 00 or Repair ( ) an Individual Sewage Disposal- System at: T/-1 G 6YS 0 A/ "i J,ocation-Address or Lot No. lZ .ZLe..................................... Owner Address W � ...........................•--•-----••-•----•-•--.....-•----......------•--...........---......... ...-----•---------------••-----.......----.........-----••--------j•------•--•----- •--- Installer Address Type of Building Size Lot_g G.� !__r2..-5 q. feet �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons............................ Showers YP g --------•----•-----•-----... P (----)._— Cafeteria ( ) dOther fixtures -----•-••-----------•---------------•---.....-------------•---••----••-----------•••-•--••-••------------•-•- ----.•--•- W Design Flow................._.__......__..._a _..gallons per person per day. Total daily flow.........._..::............................gallons. WSeptic Tank—Liquid capacity.='' UAgallons Length....._�-�__...... Width......... . Diameter................ Depth..... �._. x Disposal Trench—No. .................... Width ....... Total Length......._...........Total leaching area....................sq. ft. Seepage Pit No.........a.` ....._.___.. Diameter....... .......... Depth below inlet-.................. Total leaching c> Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by ...1' '._.7...._!n��.��-y.�'._._��`��.:_.. Date..... � -_�� Test Pit No. l....{._O..minutes per inch Depth of Test Pit..... ._`____ Depth to ground water.A�U%:.. (X4 Test Pit No. 2---�. '.minutes per inch Depth of Test Pit.....%`_:<=...... Depth to ground water...C O V t) � a •••••-•---•-••---•••---•-••••••---•--••--••--•------•-•--........•---•-••..........................•......................................................... 0 Description of Soil . . T..t�11-1. � .---... ' ' e x w -------------------------------------------------------------•----•---•---------•-----------------------------•... ................................................................................... U Nature of Repairs or Alterations—Answer when applicable.............................•..................................._.._........_.................. -•-•--••----•-----•-----•---•-•..................•--•-•----..._._....----•---•-----•••••...•..•-----•--•----....----•-•-•-••--•--•------•---....-•••-----•--............................----...•••...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by board of t health. �j�.. 1 Signed 'i/" •�--................................•-----•-----•--• --••------•-Date........_..._ Application Approved BY................ :=::-_k = = �';'_.. '..._.. ��- =' Z Date Application Disapproved for the following reasons---------------•-----•-•--------•----•--•-- -•-•...---••-•---•----------•--------•---•-----•----------•-•....-- f Date PermitNo......................................................... Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t..................r:........................ ............- ........................... ... Tntifiratr of Tuntpliatta THIS IS-TO -CERTIFY That he Individual Sewage Disposal'System constructed ( or Repaired ( ) by ...:�: ............................................................. ------....----------•---•---•------•-----------•-•--------------............-•-•----.......---- `� / r ` Installer ------------ t I. ---•----J ............... -•-• ...............................................................----•------ has been installed in accordant with the provisions of TI T IZ_• 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ .......... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................•-•--......-••--..................-••••...... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ J t Z .......................OF...........................................................- -� �— r � � .......................... No...... ��...�. FEE....................... �i��ra���l axr�� �nn�#rnr�uan prnti� Permission is hereby granted...... r�<:.. _:_....... f.:. ....... - ....'... . ............................. to Construct ( or Repair ( r ) 'age Disp sal System_lan Individual Sewage • ^.Y '...........--...---<Stree �•.=- -•-•-••--•--•..................••-•---••-•----•----•-••--•---...---•-•- as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... , r DATE.............. f�-• ✓------•-•............................. ao Fd of Health =7--��- l� FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r 4-4 40 a / top" _- -- ...._ ,3 ' 36.4c> At 7 e 30 . . -•� (,uas/-7 e d` S one be an S �' G T � --o -- o- _o _ . o _ . Proposeol C/r0 L."r7d or-o f, /e HO�erZ. SCALD: / _ /O -- - /V — !/ E �eT- SGAL � . / _ /O, �\ SCHED. 40 PV G. 02 _ FL O !�/ — --_- -� SE.1=T/G ( �4 `,Er f _ z� o �e - �2' wasfiec/ Store; S, � EQUF�L TO rn�n�rn(Jrr7 -1,v ° � A � O/5T' F30X i d a — i -- 6" Sumpell ' 7 _ c4 e j r� 74o S f t R Z of 414 , CD �O, i /00O sAL. SEPT/G TAiI,/K t _ -- - -- — ----— --— g 3�" i washed stone ' °, ° • ''! , 40-7 L� 4 S G Al - T�- T HOLE- L. ,O G - _ 3�•5 �°'�� / /' �Co•G, _S BEO�E' 00/i/I HC>vSE-- !�F-/ T� � � �% 7 � T E'� >' o%;i 1-;, uvC::L L E)e i frvC. rz. �r,f � E \ ' PATuN7 MSc t PT/ AV, 0 TEST HOSE # / TES7- Ho� E- At 7-7 � E F F O E P T.v (. O /£3 ------t- j�'.�. .`- e% = 35. I 34 37-3 / / 2.S 8Gr4G5�pAY Co „ „ G/ect IJ G��a 1-7 T/OTr9L = SSI. _ GALS. OAy / 33.2 �� q c F � 3 USE' � _— L E i9 C H F�/ T 5 I77 e��v r,7 /7-7 L-1 r-r7 O _ $cznal ��� \� 30.89 z9 9 0 \ V' /44„ ------- - e z 3 l44 e% = ,2'4 G I / (/7o G-.)eX 'f-i 64E )e7-/FY' THrQT THE Bl//LGO/A./G G�OF'OSE•G� OA./ THE GA2OC/NO 95 S I T� - S �� v �� /g=? /V o� S F n ,e O 7- / <�-1 f L /9 N B A . 18 4 f G. (//L C)//l/G S E T- /E! S CJ N D /e / I✓� BfaG/� �E'EgJ/�EMEh1T5 OF THE • � T� // 7- �� S S• 7-O MJ A-/ OFF / 8 9/E'All TF� B L __ SLOG. SETB.9GAcf - - Z=70U/�EE-M&ti/TS P.2EO � � EO GO�e : G � /E' G_ � ST/GJ 9 ,B ,oc",E O AJ T = _3O -- F T OF br- .E OF' EVERE rT 'H�loy��, S 195 S H O "/A./ O A 7- ?�kTEV[REf HINCKLE'Y H. 811G Z A✓ r'' e., T / / ,- / ' �Eb, �s�STEN�,`'.' "� SURv� O !/V (�`/� / G. C.. /�� //�/ G . v } - . . S/pN��E S 4E— !ok/H G �- S Y S T- �- /t-'I / YF� �e M O Ll T-H , -7,9 s S. - . e xr'strr-r C G©r-rfdU,-S " . E3ONkG Of f�E ,9 � TN F,, 0,P ac c0r7tovrs � grIz- NSTr9�SL� ,x ACCESS COVERS MUST BE WITHIN ACCESS COVERS MUST BE TO / N VER T ELEVATIONS : DESIGN CR I TER I A : GENERAL NO TES : 6" OF FINISH GRADE_ F l N l SH GRADE IN DR l VEWAY 9" MINIMUM. ' FIRST 2' TO 3' MAXIMUM COVER INVERT OUT SEPTIC TANK: 107. 1 DESIGN FLOW: E LEVEL CHAR CHARCOAL FILTER MIN 2" OF PEASTONE INVERT IN DIST. BOX: 104.77 3 BEDROOMS AT 1/0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION CHARCO l9" M/N OR FILTER FABRIC INVERT OUT DIST. BOX: 104.6 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4" DIAM PIPE INVERT IN LEACH CHAMBER: 104.5 3/4" - 1 1/2" D I A. NO GARBAGE GR/NDER 2. VER T I CAL DATUM IS ASSUMED. FOR BENCH MARKS 107. 1 104.6 2• H-20 o DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: IO2 5 � SET. SEE SITE PLAN. v GAS l 04.77 �� l 04.5 °� i 02.5 ADJUSTED GROUND WA TER: N/A BAFFLE SEPTIC TANK REQUI RED: 3 OUTLET 2-500 GAL LEACHING CHAMBERS OBSERVED GROUND WATER: N/A 330 G.P.O. X 200% 660 GAL, 3. ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING D-BOX W/4' STONE AROUND. 10'w x 30'1 x 2'd BOTTOM OF TEST HOLE #l: 93.5 SEPTIC TANK PROVIDED: 1000 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL H-20 CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6" CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DES!GN PERC RATE f 5 M/N/l NCH PROF I L E : NOT TO SCALE SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFL UENT L OAD/NG RA TE - 0.74 GPD/St: AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF W1TH- N r PROVIDED: 2-500 GAL LEACHING CHAMBERS STANDING H-20 WHEEL LOADS. W/2.5' STONE AROUND. A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 460 S.F. x 0.74 - 340 G.P.D. APPROVED EQUAL. is 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SOIL TEST PIT DA TA & PRECAST CONCRETE OR APPROVED POLYETHYLENE. INDICATES �_ INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE TEST GROUNDWATER OUTLET. L O T I TP #1 P#14594 TP #2 7. BEFORE CONSTRUCTION CALL "DIG-SAFE". HORIZON TEXTURE COLOR 107.0 HORIZON TEXTURE COLOR 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. 20. 740+ S.F. 0" 106.2 0"A LOAMY IOYR Q LOAMY IOYR FOR LOCATION OF UNDERGROUND UTILITIES. a6 SAND 5/2 F SAND 5/2 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE �tK 8" - - - - - - - - - -LOAMY 7.5YR 105.5 6" LOAMY 7.5YR DESIGN 106 5 ENGINEER TWO DAYS PRIOR TO CONSTRUCTION p O SAND 4/6 B SAND 4/6 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE 24" - - - - - - - - - - - - - - - - - - - - 104.2 24" - - - - - - - - - - - - - - - - - - - - 105.0 CONSTRUCTION INSPECTIONS. C/ MED-COARSE IOYR i^/ MED-COARSE IOYR A SAND 6/6 l• SAND 6/6 9• EXISTING LEACH PIT TO BE PUMPED DRY. REMOVED ob� AND BACKF l L L ED W l TH SAND. \\ aF 42" �y NO WA TER NO WATER 152" 93.5 I20" 97.0 DATE: DECEMBER 17. 2014 TEST BY: STEPHEN HAAS �\ ��\ - ��� gyp• \ EXISTING TANK SEPTIC T ♦ WITNESSED BY: DONNA MIORANDI G \ S C9 DH FND - __ _ I PERC RATE: < 2 M/N/I NCH UP 999-1 I 9M. CORNER STEP V ` \ TPo \.. .. '. ... \El-1 12.02 `o LfA�Cl!lNCHAMBERa -- Wl,?.5• STONE AROUND 105.4 i ` 2-4"OAK ------- /F S E P T C S YS- T EW E7 S G N 18 JACKSON OR / VE . MAP / P . PARCEL 80 -Co DH Ao BARNS TABLE . ( COTUI T ) MA . 2� -- - P R EPA R EU 1c,0 R S L STRE T _ LEGEND 0 CB "CONCRETE BOUND RA UL_ OR O VE7R COTUI T SAY _W WATER L I NE POP ONSETT R� O HYDRANT S CAL E l 2 0 .J A N UA R Y 2 1 . 2 0 1 5 �-L US 6� G GAS LINE h OHW-- OVER HEAD WIRES STEPHEN A . H A A S 2 •�p LIGHT POST -E-- UNDERGROUND ELECTRIC L I NE E N G I N E E R I N G I N C -T- UNDERGROUND TELEPHONE L l NE P . 0 . B o x 16 -CTV- UNDERGROUND CABLEVISION LINE �� i�� / 1 \�� Sou t h Dean i s MA 02660 +40.4 SPOT ELEVATION �// �j�� ( 808 ) 362-8 1 32 .. ..••-40-•••__. EXISTING CONTOUR / LOCUS MAP Q l 0 20 40 � PROPOSED CONTOUR JOB NO: 14-089