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HomeMy WebLinkAbout0085 JILLIANNS WAY - Health 85 Jillian's Way _— - — - — Cotuit A= 040-135 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM 85 Jillians Way Property Address Timothy McAdams =� Owner Owner's NameI information is �+ required for every Cotuit Ma 02635 7-9-18 . page. Citylrown State Zip Code Date of Inspection F4 Inspection results must be submitted on this form. Inspection forms_ may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information lam,'on the computer, /3 02./,3. use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return key. Name of Inspector B&B Excavation Company Name - 374 Route 130 Company Address Sandwich Ma ' 62563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License 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. I 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 Further Evaluation by the Local Approving Authority 7-9-18 Inspector's Signature i 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 in the future under, the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of�f1/�7� i Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is Cotuit Ma 02635 7-9-18 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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: The system was in working order at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the,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): z t5ins•3/13 . ` - ` a k Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 85 Jillians Way Property Address Timothy McAdams Owner Owners Name information is required for every Cotuit Ma 02635 7-9-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms 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 ` ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):- ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C Further Evaluation is Required b the Board of Health: q Y ❑ 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 e . ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Jillians Way Property Address i Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 page. CityrFown 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes . No ❑ E . 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 '/day flow t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System,-Page 4 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 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. ❑ ® 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 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. 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 0 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 1 system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 85 Jillians Way '�M Property Address Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 page. City/Town State Zip 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? El ® 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? • Y ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank, inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation,of distance is unacceptable) [310 CMR 15.302(5)] D. System Information, Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(Actual) _4 DESIGN flow based on 310 CMR 15.203 (for example: 11,0 gpd x#of bedrooms): 460/GPD Y t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 P Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635. 7-9-18 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: / 3 Does residence have a garbage grinder? ❑ Yes ® 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 ® No Water meter readings, if available last 2 ears usage d See below 9 .( Y 9 (gp ))� Detail: 2016-55,000gallons 2017-47,000gallons Sump pump? ❑ Yes ® No Current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: NA F Design flow(based on 310 CMR 15.203): Gallons 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 85 Jillians Way Property Address - Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18.. page. City(rown State. Zip Code Date of Inspection D. System Information (cont.) • Last date of occupancy/use: Date Other(describe below): • General Information Pumping Records: Source of information: Pumper driver Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Tank size Reason for pumping: Maintenance after inspection 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is Cotuit Ma 02635 7-9-18 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 . . Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 6 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): e • Septic Tank(locate on site plan): Depth below grade: 1 6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,:list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallons ' , 9„ Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? Measured 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped after inspection for maintenance. Grease Trap(locate on site plan): Depth below grade: NA feet 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Jillians Way w Property Address .Timothy McAdams Owner Owner's Name ' information is required for every Cotuit k Ma 02635 7-9-18 page. CitylTown 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: t NA Material of construction: ❑ concrete ❑ metal w ❑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? r El Yes ❑ No' t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection ,Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 page. Cityrrown 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.): D-box is in working order at time of inspection with liquid(level equal to outlet invert. D-box did not show signs of back up. Pump Chamber(locate on site plan): + Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i . 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is Cotuit Ma ' 02635 7-9-18 required for every � page. Cityrrown State Zip Code- Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (3) 500gallon - q. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching had 3" of standing water when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration' NA Depth—top of liquid to inletinvert ' Depth of solids layer, } Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 85 Jillians Way Property Address r Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 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.): Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l t5ins•3/13 r` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • e t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 85 Jillians Way ' Property Address r Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 page. Cityrrown 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 ❑ drawing attached separately Front A B Al-15 B1-14' A2-28' B2-18' B3-57 ` 2 C3-61' B4-51' C4-38' t 4 3 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 •, Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name information is required for every Cotuit Ma 02635 7-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells t Estimated depth to high ground water: No GW @ 120" 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 1997 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ` A P ❑ Checked with'local excavators, installers-(attach documentation) , ❑ Accessed USGS database-explain: - You must describe how you established the high ground water elevation: Plan on file with BOH. f a Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 p Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 85 Jillians Way Property Address Timothy McAdams Owner Owner's Name ' information is required for every Cotuit Ma 02635 7-9-18 page. City/Town State Zip Code Date of Inspection 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ,r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Jillian's Way • Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town 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 form. Important` A. General Information When filling out forms on the 4� � I computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License 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. I 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 Further Evaluation by the Local Approving Authority 3/25/2011 Inspector's Sig'nvaturV 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 in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dis•osal System•Pa 1 of 17 i Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due i to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town 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: 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 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 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town 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. ❑ ® 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 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. 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 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. Cityrrown State Zip 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 0 El Pumping information was provided b the owner, occupant, or Board of Health P 9 P Y P ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] El Yes 0 No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA g ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3/25/2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2811 Depth below grade: feet Material of construction:` ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well.or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: e0et Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon 5-1 Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town 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 No 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.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is Cotuit Ma. 02635 3/25/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching chambers were dry at time of inspection.Stain line observed 20" below invert. 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 ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town 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.): 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 a •� !!w: E3 i f x P �' ' � ✓7 fir F y.�y� ��� f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 35' 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: As-Built r❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. L - t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 85 Jillian's Way Property Address Weldon Fizell Owner Owner's Name information is required for Cotuit Ma. 02635 3/25/2011 every page. City/Town State Zip Code Date of Inspection 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Q TOWN OF BARNSTABLE ow "'" ':. :;•: M E — SEWAGE# 7 7 LOCATION ar�SLl�� �. ...4 ... VILLAGE •-I ASSESSOR'S MAP&LOT . ciA/ INSTALLER'S NAME&PHONE NO..�ot-'Ia l'o ► Cnn : ���'S 9�G SEP'1;'IC:TANK CAPACITY / S'O0 ! Q LEAMING FACILTTY: (type) me �j CACt c[S(siie) 39 X /6 NO:.OF:BEDROOMS BLIIIpEROROWNER 4;9c. ' 'roDc' cs PEi MITDATE: /Z-3' 7 COMPLIANCE DATE: Separation Distance Between the: ::::...,.:,.... Feet. Mazimiunt Adjusted Groundwater Table and Bottom of Leaching Facility Pr(.v Water Supply Well and Leaching Facility (If any wells exist ;oii:site.or within 200 feet of leaching facility) Feet: Edge of,Wedand and Leaching Facility(If any wetlands exist *dthin;300 feet of leaching facility) Feet Furnished by r A2 - q l33 B ► C3 "L►1 cq : . y 3 _ r 4. . � No. � Fee ®CO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: of Jf Yes i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprtcation for Migogal *p5tem Construction Permit Application for a Permit to Construct( .✓)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C a s i ,j:II a 0-1 (M Owner's Name,Address and Tel.No. lisrz-4 ?15- AresI f� Fra/9ert-- Assessor's Map/Parcel S-1 / I - 1 5711/X 0 /—7 -1-1 t - 6 C 0 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Te No. g�r CIO 16Cd% C'aP., �owr q-5 Type of Building: Al Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow q y o gallons per day. Calculated daily flow Y 0 gallons. Plan Date '?-I Number of sheets r Revision Date Title Size of Septic Tank 1 s 0 o 3 a 110 r Type of S.A.S. Description of Soil a s C-0-,- o I a 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 Certifi- cate of Compliance has been issue y thisBo A�of alItl / Signed ��('" 7 ' Date z�' Application Approved by Date Application Disapproved for th ollowi g reasons Permit No. 7 - 1; 21 Date Issued L Fee ee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Mie;pool *p6tem Cow6truction Permit Application for a Permit to Construct( 4Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 5 Owner's Name,Address and Tel.No. H 5.E_4 R 5- F,,,S t-7, P,fre f ( — Assessor's Map/Parcel .5-11 1 - , 77///,Y( 7 -7-1 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I-S 16(4 : 06,-, Cf F, -7-11 U ? - 15qi 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 &1 410 gallons per day. Calculated daily flow r gallons. I Plan Date,, Number of sheets Revision Date Title Size of Septic Tank Sall". —Type ofS.A.S. Description of Soil 'a 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 Certifi- cate of Compliance has been issued Oy this Boar of f1palth. Signed Date 1 r /1-7 Application Approved by Date / .L-j -22" Application Disapproved for thgollowlqg reasons Perrnit.N_o. Date Issued c. -———----—————— 51 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired Upgraded Abandoned by 161�. C(,-)L 'fj, at t­- 4,J 3 i I r has been constructed in accordance with the provisions of Tide 5 and the for Disposal S,)Ys.te5Construction Permit No. __L dated /Z '7 Installer /IZ-Designer I I The issuance of this permit shall not be construed as a guarantee that the sys ill function at desiglied. Date 07-7 Inspecto ,I- --------------------------------------- No. !7- :2 - (01 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mfi6poal *pztem Con!arurtion Permit Permission is hereby granted to Construct Repair Upgrade )Abandon System located at C. f., and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this nerinit. Date: Approved by 4�� N. D7 hk0_N_ 10 :29 DOWN CAPE ENGINEERING - 508 362 9880 P. 02 r rc s x. r LOT 3 LOT 2 S i U t.th l b 11 hi L X 2._. �`' 60.12 JILLIANNS IVA 9 •09 R�60.00 C. FNDN. 2� \ 62.5 �` �, ;� sp •�, 22,786 s.f. T oQE� �-o �' (.52 oc.) 1p 111f t10 L ! 4 N i 3C� T._E HV T 2S` TU V-1c,i IT i a L.q.T`C' JOB #97-343 C.E R TIFIED PL 0 T .PLAN LOCATION : LOT t ,IILLIANNS WAY PREPARED FOR: BARNSTABLB, (COTUIT) MASS. PRESTIGE PROP RTIES SCALE: 1" 40' DATE: DECEMBER 16, 1997 REFERENCE PB 533 PG 4 f ASSESS. MAP 57 PCL f-1 1 HEREBY CERTIFY THAT THE STRUCTURE �y� Of SHOWN ON THIS PLAN IS LOCATED ON THE O�� ARNE rya GROUND AS SHOWN HEREON. — H. OJAIA N0:263ti8 o � io :rn cape sineettn& Ina.: Z s ►Si OrvrL 9NGngmxR8, _----_- MIND U11 L Page 1 $' TOWN OF BARNSTABLE OOU-COO -/V( LOCATION Mdi lf a NS a)n, e SEWAGE#9 7`6 VILLAGE ��-� ASSESSOR'S MAP& v;•-1 INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPACITY /. LEACHING FACILITY: (type),f=cA;nca Cilttn.f�C rT(size) �?9 'x /0 " NO.or-BEDROOMS BUILDER OR OWNER__ -e_s- , PERMTTDATE: r Z-3 %7 COMPLIANCE DATE:. /2"!•s- 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fee Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fee Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Fes; Furnished by ,A C'3 . ! !Sy Cy ., � 3 littp://issQI2/intranet/i)roi)data/prebuilt.asl)x?maDDar=040135&seq=1 2/22/20 ASSESSORS MAP NO- No.- ---------------- - Fee-- -------------- -- TOWN OF BARNSTABLE ApplicationArVell Con5tructionj3erutit Application is hereby made for a permit t 1,Construc_t ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owne Q Address ----------------------- -- - `` _ - ----------------------- ��u'r----�1 �a -� '�7oL- Installer Driller Address Type of Buil ng Dwelling----------------------------------------------------------- Other - Type of Building---------------------------- No. of Persons--------------------_ Type of Well--� '� -- -----------= Capacity YP ----- --------- -- Purpose of Well--- -`- `--''=----- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Cer 'ficate C is a has been issued by the Board of Health. Signed __-- --- - — -� °� -�- — date Application Approved By date Application Disapproved for the following reasons: =-------------------------------___—_ ____—_ ---------- — - --- ----------------------------------------------------- °"� c� date Permit No. ` ' - _- Issued—`- �--< - Ar date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS �TIFedual Well Constructed ( ), Altered ( ) or Repairedby—at--- .5 " ' S has been installed in accordance with the prow' ions of the Town of Barnstable Board of Health Private Well Protection G Regulation as described in the application for Well Construction Permit No. °-� ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - Inspector---- -------�_ • ` .�. .y-. .�- .� .Mv Yr.,/�.,.A'MprY� -•'{l`"l M"^"`I�M��f'y�+.i✓'R rnl•# -- 4�pe ...��mow•. ,u'hi'w--' �lry,"......,. ` ': �► r Fee--- --------`---��-- BOARD. OF'HEALTH'" TOWN :, OF BARNSTABL. E � Kt - Y PP rAti0ft-j or r11 Congtrnction ermit .: 'Application is hereby made'for a permit to Construct ) Alter ( ) or Repair ( ,,.)an individual Wellat: S L'ocahon� ,Addres se,— ..Asssors Map and.Parcel Owner Address 'Installer Dnller. Address I! Type of Build ng g Dwelling Other - Type of Building---= -- -------- -- No. of Persons--- -- Type of Well-- -- —- -- — Capacity — s Purpose of Well -- — Agreement: � � 1 The'undersigned;agrees to install the aforedescribed individual well in accordance with the provisions of The . Town pf•Barnstable Board of Health Private:Well Protection Regulation - The'undersigned further agrees not to lace the well in:operation until a Cer 'ficate �C , is -e has been issued by the Board.;of,Health. P Q' Signed • � -- ---- --- - - - - --date -- >11 Application Approved By c -- — date. j Application.Disapproved.for the following reasons =' -= ---- . _ ------- t =-------------__ _____ date % > ,Permit No: Issued �t-y --- date t{xaxixiereixilGl9xixie:xb4e+lierxrle e:lrQb9 ! x Rieexe laeuid! a4aea�se ree0li iedifGelSea�aiQtfN.e ei�il2eaeEe6!&l..e ocMi416Oioili9ae.Yl'rebeae e.M+L.l2e64 1do`9`rfiReti4tiwx.14.$ y. d BOARD OF'HEALTH TOWN OF BARNSTABLE � 11 ertif irate Of ,tompliAnte THIS IS CE TI e Ind' •dual We11 Constructed ( ) Altered ( ) or Repaired ( ) by --- --- --'=� ---- - -- ----- - --- — -- Installer — has been installed in accordance with the provisions of the Town'of Barnstable Board of Health Private.Well Protection' Regulation.;as described In the application,for Well Construction Permit No. ''- _ afed �- 00e" THE ISSUANCE OF THIS:CERTIFI,CATE SHALL NOT BE CONSTRUED.AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE --- _ Inspector-- ----- - -- —------- �FQre69a4.�rlrrx�eavas:la8.vrra/rlxeaea4Gaes.K-aQixasaib'iaeieaara3�xs ii+ixrBrliR3:erli9an:.ga4ieisrxaax'ati4-i9i!sxatii!]y.�:}gr9��A�i:cai.a4y'!:.Y�race!�.x�r+a�e+riRsrasie!r�taxrwa,txa BOARD OF HEALTH :TOWN OF BARNSTABLE etC CongtruetionPermit ; No. 1 -=' Fee` " !Grp Permission is hereby granted to Construct ), Alter(,)', or Repair ( ) an Indivi, u 1 Well at Street —— — — — — — —,as shown on the application for a Well Construction-Permit . �y No. — - Dated ---- - •� • / .` Board of Health DATE / _ — , y SEPTIC PROFILE TEST HOLE LOGS r - -- -- __ _--�-�- T.O.F. AT EL. (v 2-95 _ — — -- ACCESS COVER TO WITHIN Ir OF FIN. GRADE (NOT 10 $C -E) A y ACCESS COVER (WATERTIGHT) TO ENGINEER:-_ 0 MINt1HUM .7V OF COVED OVER PRECAST WfiitN 6" OF FIN. GRAPE WIT"JES�: �c 5 2% SLOPE REQUIRED OVER SYSTEIa ,( { * - RWi PIPE LEVEL 2" DOW31LE WASHED PEASTONE DAT • -y9 FOR FIRST 2' — I Q + PERC. RATE - __._'-_ � _ + ►� � PROPOSED •�O 3' MAX -7` t ' GALLON SEPTIC ; f y c� ��2 - _ f —� t' CIAS i_�--_ SOILS P y �!O.2� TANK (H—_10 ) GAS /l # ------ Vp ( X SLOPE) 6- CRUSHED STONE OR MEGN.AN!CAL \ ti �7,!_ 1— Jill C C7 C7 C] C� C7 __' C� C. 2I _ ELEV. ELE�/. r COMPACTION. (15.221 [21) --____._. 1 ' 7 t-� C 7 CJ C7 O C7 C� C7 G < _ 1. -r 1 ,�oil 1 4- DEPTH OF FLOW = __ x61 {_ _�.X SLOPE] Sti Q TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE INLET DEPTH �— , OUTLET DEPTH �- LOCATION MAP SCALE- 1" - - i , ASSESSORS MAP - c PARCEL 1 - , _ - .I LEACHING tc. L` '_ II P w •� :'. FOUNDATION ----- I `� SEPTIC TA!�t� -__ . .-� - --- --- D' BOX - __. _ _ FACtt 17Y �N I t...� c � �� � 1Q- f r. L Gi ! j .t ZONING D!SIRICT: ,�-� (0een 5fkc-c- 4-ek) ) I ( ` A:, f•'� art ��� �.� l YARD SETBACKS: 4q FRONT SIDE _ �v READ PLAN PLF. FLOOD ZONE: ' ! tJ l 'r 'Sri• .-r y + __ ,� ;, NOTES: CIS• _ _ St P.!C DESIGN: (GARBAC-F O+SPOSER ;S- ►-'°f °'"`Y' '� ) 1 . DAT UM IS Ah`-� - - l DESIGN FLOW: '- BEDROOMS v-GPD `--: � GPD 2. MUNICIPAL WATER IS II _ / - I �.__ USE A ` ` GPD DESIC;N -LOW 3. MINIMUM PIPE PITCH TO 8E 1/8" PER FOOT. SEPTIC TANK: f'~#J GPJ (_ ) _ ✓ 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 5. PIPE JOINTS TO BE MADE WATERTIGHT. . __ -, U ! � ..,.>E •� ���_ GALLON JLr ii� iNivn 2 I' / , o j+ 10 r 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. \ ; I i � l� A � / j' _�AC r IN,� Nv1RONMEr1TAL CODE TITLE V. z t o. �, `I � ' 5 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE SIDES: —-----�-----�--_-_L_._%—_,.— �— I 7 - USED FOR LOT LINE STAKING. BOTIUM: ---- -- -- --- -- —_=' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. - TOTAL: v?11 S.F. _� GPO 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTA^:ED ca L,o ,�... _' -500 i�tat. 1.>r 1 irA - ^ d'(j~ FROM BOARD OF HEALTH. 10. CONTRACTOR SHALL BE REST u: :l.':_[ FOR VERIFYING THE ' i .N ��I`- -T_ +- 1 , i ' _. �- JC�k.S LOCATION OF ALL UNDERGROUND do OVERHEAD UTILITIES PR►GR „ „ 1 1 TO COMMENCEMENT OF WORK. / _LEGENQ �� _ Sl TE AND SEWAGE PLAN PROPOSED SPOT ELEVATON OF 1 - - , ,00yo EXiSiING SPGI ELEVATION } -� U IJ ,� 7�. iN THE TOWN OF: �100' - PROPOSEU CCNTOUR � � EXISTING CONTJUR .��--- 00 _- -- PRLPARED FOR: l // 11 . I t 0 J HOARD OF Kf:kLTH — _ ---- — - - MA SCALE: �, �� DATE: APPROVED DATE un down cape engineering, inc. CIVIL ENGINEERS ?; CIVV LAND SURVEYORS `� -. 939 main st. garmouth, ma 02675 JOB# - AL,I, .L.S. D.lT l SEPTIC PROFILE TEST HOLE LOGS T.O.F. AT EL, 6,2.c� z _ __ �_.�-- �_ _ - �-_---�_- - - I i ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO sr-k , :.- - 4•,._- - ,._, ,��.: z ACCESS ^OV-R (WATEIMG-ff) TO ENGINEER:_ wlTmN, 6r OF FIN. GR,10E r MIIN'►U161 .75' Of G�WFR OVER PRECAST REQUIRED OVER S'15TEan :•I ►-' RUB PIPE LEVEL 2' !)OtiULE WASHED PEASTONE \ t DAZE: - r- -FOR FIRST 2' PROPOSEl71 _� \ 3' MAX. PEKC. RATE _ -_. _ � __._.__ u GALLON SEPTIC — �l CLASS SOILS 1 GAS - . - ------ --- - s TANK H- 1 O I - L . - - -_._---- - - BAFFLE 52- .,% �� I•r,� --- I �,q J L] E70C> O 0C� C7C� !, ; (--__X SLOPE) t 6" CRUSHED STONE OR MECHA.NICA:. ,. T- + Iil" ,-- 0 CJ CJ C7 U C7 L-_J L.J I COMPACTION. (15.221 [2]) '!�i r 1 ELE V. ELEV. �! I 2 CJ0OC3 0 C3C7ClC7 C, - 4 +� Cilr Q I q" DEPTH OF FLOW s _¢ - - �. - ---- -- --__. ,_- _ - ` --- �� -an er,�1 r' r " " ` -- TEE SIZES: 3/4 TO 1 1/2 DOUBLE WASHED 5l TONE A INLET DEPTh 4 -- ,, LOCATIOr. "SAP SCAt 1" _ OUTLET DEPTH = i 1 y.c,, , L_arl - - - - - -- -- - - ii - �T - -- D' BOX - - - FA'f.:7�l> It l:rd ASSESSURfS MAP >_-7 PARCEL 1 _. FUU!�JA:�ION - , `�- - - SEA I,C TA.r:K - - �i --- --- _- � I L ZON!NG DIS1R;i T: r= <�F� �p��c �e�.� ,5 Yi2 lt: -�q '� r zg� '�.5 Y� `°I v 4� � •--------__._..-__...'_ - YARD SETBACKS: _.....-. FRONT . y SIDE -- QLA;` -F. FL-00D ZONE: I f�'� � � f ' r � � 1 � `�G,►.�Y,.� il✓.,� ;t.�. �,. {may,r4 ! i � ', t 1 - � � ! � r i .. �O � {Im,1 �rIG.�4� r-i 1 Ic.f�.-4i,•j —•---- __.__ _ a= ► I; ! ` / S_ TIC DESIGN: c>a u�;:E �Iss� 5 t P A4 � 1 DATUM 1 ►�: s , ,-_ r. i I DESIGN FLOW: 8E(!t?OLN+S ( �✓ GPO) _GPO 2. MUNICIPAL 'wA.ER IS I ( _� , vt °t ', ', - �r USE p. _` `*MCP,., DESI,_N F.OW 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. r 0 SEPTIC_ TANK: '`''� GP3 J!1 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AA.SHO H-- — 5. PIPE JOINTS TO BE MADE WATERTIGHT. L'SE A %' GALLON SEPTIC TAINK -- - 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. �-rt t--•---�-- --�- ,/ ENv;R ►vMENTAL CODE TITLE v, 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE SIDE -1 --- -- -�- �v USED FOR LOT LINE STAKING. ,�--- -.-- 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. OTAL. �-_�._ S.F. o GPD 9. COMPONENTS NOT 0 BE BACKFILLED OR CONCEALED i ✓`''� , 1 r I 1/ _ l ' �,\, r Y 1 ` , INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTA'I:rJ FROM BOARD OF HEALTH. 10. CONTRACTOR SHALL BE RES; =S' �_C R 'VERIFYING THE LOCATON OF ALL UNDERGROUND k OVERHEAD UTILITIES t ` �7 k TO COMM NI T OF WORK. 1_ _AND_ IAA : LAN tGd- '� - 1 a-_- .— -' = s-.==:z-= __., .r- - _tea=-s•- .'.-< �., , (,t v _ r 100.0 1 PPOPOSFU SPOT T Ek,S I;tiG SF';} ELF'v`AT!ON ..- /°',f IN THE TOWN OF: I PROPOSEI✓ CONTOUR 51 - - �1(00,-- -- EXISTING CONTJUR PREPARED FOR: HOARD OF HEALTH - -- - - -- - - _ MA SCALE: 'yO DATE: APPROVED DATE — __-- of 5fA-M2-�1 1QII SOS 3S2-YSSO 1 tw Oy�fw\ down cape engineering, inc. CIVIL ENGINEERS �+� i C)Jh �t J LAND SURVEYORS .T(IB# �'7 -�� 939 main st. yarmouth, ma 02675 . ., .L.S. Da TB