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HomeMy WebLinkAbout0018 JULIE LANE - Health 18 JULIE_LANE, COTUIT A=021.101' f a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address i Rogers Owner Owners Name information is r required for every Cotuit V MA 02635 7/16/19 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 form. A. Inspector Information SL# (3953 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 s City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector-in full compliance with Section 15.340 of Title 5` (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/16/19 Inspecto gnatur 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. J//kf Vr Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts ,. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Julie Ln. Property Address Owner Rogers information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: t 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. r *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): I t5insp.doc•rev.7/2 612 01 8 title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �uv Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if , pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken-or obstructed pipe(s). The system will pass inspection.if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):. 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coot.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal, coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts re Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every COtuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts F Title 5 official Inspection Form k9tw Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Fil P 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �e F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name ' required for every Cotuit MA 02635 7/16/19 page. Citylrown State Zip Code Date of Inspection D. System Information , 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owners Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2015 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:- gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system . ❑ Single cesspool ❑ Overflow cesspool _ ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1997 per BOH record Were sewage odors detected;when arriving at the site? El Yes ❑ No 5. Building Sewer(locate on site plan): 1811 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.): t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts q�rw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments� 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): n Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace >2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 18 Julie Ln. Property Address Rogers Owner information is Owners Name required for every Cotuit MA 02635 7/16/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass El 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels,as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.W26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 18" below grade and in average condition for its age t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �e 18 Julie Ln. Property Address Rogers Owner information is owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ❑ leaching pits number: . _® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,l 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers were video inspected and are damp at this time, no indication of past hydraulic failure, top of chambers is 2' 'below grade 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every COtuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address P Rogers Owner information is Owner's Name ' required for every Cotuit MA y 02635 7/16/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARN TABLE LOCATION U o - SEWAGE q VILLA ASSESSORS MAP&LOT AL INSTALLER'S NAME dt PHONE SEPTmc TANK CAPACITY O -! LEACHING FACILITY:(type) ice.4 G C (siu) NO,OF BEDROO 3 —IO BUILDER O O e r PERMT 9TDA COMPLIANCE DATE: -/1. A Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and-Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet f leaching�f�ility) Feet Furnished by U P V K VO J -c = I� fa q-D=a7� �o v5e 4 q-i-= 3r so 37 -CID 4-�13f` �t1 Jl,e �..>u f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar �I ❑ Shallow wells Estimated depth to high ground water: >12'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 1997 If checked, date of design plan reviewed: Date Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4'seperation per compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, the site is 50'msl and nearby surface water is at 6'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 —�C-\ Commonwealth of Massachusetts (P Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Julie Ln. Property Address Rogers Owner information is Owner's Name required for every Cotuit MA 02635 7/16/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 NO. t .THZ,;COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH 0 OF bWjW+,,_U�, Appttratton for Uwvvs 14ppiArm Tomitrnrtion ramit ADDlication i's•hereby made for a Permit to Install ( or Repair/Replace ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. YOwn Address Designer or Installer Address Type of Building Size Lot 66 0- Sq.feet Dwelling—No.of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No.of persons (P Showers ( )—Cafeteria ( ) Other fiaq-Les Design Flow 2 gallons per person per day..Calculated daily flow gallons. Septic Tank—Liquid capacity t)gallons Length f0 (r'Width 5 1 P Diameter Depth 6 ` )" Disposal Trench—No. Width Total Length 13 l 7." Total leaching area sq.ft. Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft. Other Distribution box ( Dosing tank .( ) i C, Percolation Test Results Performed by(P--,— Gt 4 � Date r� �� Test Pit No. 1 2 minutes per inch llepth of Test Pit Deptb to ground water Test Pit No.2 v minutes per inch D pth of Test Pit 1,52", Depth to ground water Description of Soil tO . IN 2— 1—1Z't k u -- 6 r 3 Z 4T _ (u . t>L r I 1Z"--3i-" YS lu s td i?��" a d •emut , 4 Ae -1!5V Vka-d Nature of Repairs or Alterations—Answer when applicable Date Last Inspected Agreement:—The undersigned agrees to install the aforedescribed Individual Se ge Disposa stem in accordance with th provisions of TITLE 5 of the State Environmental Code.T ndeis ne r r grees not place the system in op rati until a Certificate of Compliance has been issued by the and of H th. CI ) Signed Da Application Approved By ate Application Disapproved for the following reason(I Date Permit No. Issued Date I�� V t "NO•' .T.H ' FCOMMONWEALTH OF MASSACHUSETTS EEv / BOARD OF HEALTHsY°. / 0 / OF I ,Z vvitratton for. D,t,iVosat 1�ttptrm Tonstrnrtton Prrmtt A lication is hereby made for a Permit to Install ( 4r Repair/Replace ( ) an Individual Sewage'Disposal System at: Location-Addles., or Lot No. - - �,/ Address `Ty DesiRncrorinstaller Address -.-Type of Building ; Size Lot 0(JO Sq.feet ' Dwelling-No.of Bedrooms _3 Expansion Attic,( ) Garbage Grinder ( ) > Other—Type of Building No.of persons (P Showers ( )—Cafeteria ( ) _£ Other fixtu es ` Design Flow : gallons.peIr person per day.Calculated daily flow 530 gallons. •'""• Septic Tank—Liquid capacity 1�gallons 'Length )U Width t a Diameter De th', Disposal Trench—No. I Width o�5 t, Total Length 3 12 n Total leaching area sq.ft. #' t Seepage Pit No. Diameter 'Depth below inlet . Total leaching area sq.ft. Other Distribution box Dosing tank ( ) '•.Percolation Test Results Performed by t Date, 3"�(O ?r Test Pit No. 1 2- minutes per inch eptli,of Test Pit 3 't Dept to ground water Test Pit No.2 7i minutes per inch D , thof"Test Pit Z`` Depth to ground water Description of Soil ''_ 2" 1 o b yr 3 1 "-u u 8 12" ts" 6 u tc� , stvma� 15Z11C o d (4 Nature of Repairs or Alterations—Answer when-,applicable' ^Date Last Inspected .Agreement:—The undersigned agrees to install the aforedescribed Individual Se ge Disposal S�stein in accordance with the ( provisions of TITLE 5 of"the State Environmental Code.T�}1 es dersi ned r grew no to place the system in op rati i 1 until a Certificate of Compliance has been issued by the oard of"IIe th. Signed. r � � Dat Application Approved,By Date/ Application Disapproved for the following reason; i Date Permit No. Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tatifiratr of Turdptittnrr THIS IS TO/j CERTIFY, That the On-Site Sewage Disposal System installed ,(,-� ) �o�Repaiirgd/jteplaced ( ) / on ! 1 , . by 1��4 ( r rcl57i r� ��T7 �dy j for at has been constructed in accordance with the provisions of TI LE of Th tanvironmental Code as described in the application for Disposal System Construction Permit No. dated 9 Use of this system is conditioned on compliance with the provisiofis set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on Date DATE Inspector , No. THE COMMONWEALTH OF MASSACHUSETTS FEE -I&Aa&RD OF HEALTH Dis,posttt ftfit�r/m Tonst -nrttoc�n,,Prrmit Permission is hereby granted to jt� 4 11 C 6 a.) r�U C U l G; L1 to Construct O or Repair/Replace ( ) an On-Site Sewage Disposal System located at j y Sheet as described on the 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. All construction must be completed within three years of the date below. DATE Board of Health � ' �' FORM 1255 (REV.4/95) H&W HOBBSS WARRENrrn PUBLISHERS - BOSTON ' THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION 4' e 60 TOWN OF BA RNS TABL E � /-�� LOCATION I U o V SEWAGE # VILLAGE ASSESSOR'S MAP & LOT } INSTALLER'S NAME&PHONE NO. N SEPTIC TANK CAPACITY J O6 (GH-1 LEACHING FACILITY: (type) gg /X/- /Q NO. OF BEDROOMS �7 BUILDER 0 0 r^' PERMITDA : o COMPLIANCE DATE:: `� - f- Y Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and-Leaching-Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of le�aching f ility) Feet Furnished by-_� ;.R ./ A�way c !� TOWN OF BARNSTABLE LOCATION I Lo o SEWAGE # VILLAGE ASSESSOR'S MAP& LOT 6 I i 10 INSTALLER'S NAME&PHONE NO. �ffrV69 cXJ SEPTIC TANK CAPACITY 4 O6 1_,A( IIse LEACHING FACILITY: (type) eA C� ,,y-< �l�Ar�t�PY(size) NO.,OF BEDROOMS BUILDER.O O r PERMTTDA : COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well-and-Leaching_Facility__(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and-Leaching Facility(If any wetlands exist within 300 feet of leachinVf ,*Iity) C Feet Furnished by S wo 31c - a2ll� � oam �3 -0; a� LOCATION T t L u `1 NO. VILLAGE DATE 4r APPLICANT FEE_ •G� ADDRESS-?7 q',,«ysArogk Rc( �,•, yrukc ,y - TELEPHONE .NO. (Non-refundable) �ENG INEER G Sh..pl� Lfn f t't t C r t TELEPHONE NO. 'h177- 7'2 7 2 DATE SCHEDULED (Applicant's signature) 4 ASSBSSOR'Sb��lP�6i LOT NU: . . . . . . . . .. . . . . . . . . . . . . . . . . 0 0 0 a 0 0 ..r. . . . . .. . . . . . . . Y . . Q a . . . . . S_ LOG q SUB-DIVISION NAME DATE Z-1 �-9 TIME 11►*A'5� EXPANSION AREA: YES ✓NO Z)g..:c/ le- < ENGINEER: 'R TOWN WATER VEA PRIVATE WELL Ce/w�rr �f /34rr,Y BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc: ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ). s-- o� /V G 7' C �o 50 r / wv v /9y " S Z_ PERCOLATION RATE: L Z TEST HOLE NO: / ELEVATION: 73'0 TEST HOLE NO: Z ELEVATION: 71! 0 3/7- 1 G.vcr Jo a 3/L 2 3 L-,I t_7 to y Z 67r 3 k�( 10 Y R 57r 5 5 7 9 7 R� 61 10 Glc� 10 11 11 12 12 13 13 No �iN••.1...�r �,� G a 14 1a 15 15 ' 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD/, LEACHING PITS LEACHING TRENCHES* UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED .ON PERC TEST APPLICATION ' ORIGINAL: COMPLETED-IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH ' COPY: RETAINED .•BY APPLICANT S YS TSM PROFILE NOT TO SCALE TOP FNON. FINISH GRADE OVER FINISH GRADE � �•, c,, EL . 7 B -5 FINISH GRADE a FINISH GRADE O VER DIS T. BOX " =� OVER TRENCHES ' '4 SEPTIC TANK 7, , •d'O; 12" MAX. o •.o b. d QQ• ,p....o.'i'b•. .Od..4�..A�; O.'::Q,o�Dp":SfO AP.'y¢Wp`!.�,• v �.�;�,AQ�4 O.G.O•. Q „ OUTLET PIPE LEVEL TOTAL LENGTH OF TRENCH ' '3 °' FOR 2 FT. MIN. Ji w a• s, a ptJ qo. Do . . 7)P v aop0�,• A, 73 0 0 40 a.r•a,..Q:. .:o,•f O e Na' A& e C. I. OR PVC TEESom8 -1V P"to 6.: .1500 GALLON LISTRIBUTION BOX BSMT FL . ' ----- EL . 7i s %A a,'o INSTALL ON LEVEL BASE ' VIG INS 500 GALLON DRYWELLS °1 PRECAST CONCRETE ° ab f t ._A' 0 REINFORCED a. bp• •di?'4L'1dg:bq•.Cp"G' 'b;:t?-b..:*x•p:0':!'y:p Dp;D'O•F <+•n' a o' z •s: i/.p.p .p•° .{y0 .V..a.A. .'q•fri,'Ob •,q.a..4'�<?: � SEP TIC TANK T E CH SEC TION INSTALL ON LEVEL BASE NO TE° EXCA VA TE TO EL EV V. OR LOkER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEA TH THE LEACHING AREA s2" MIN. 4" DIEM. - t ` REPLACE EXCAVATED MATERIAL WITH : ;�; .a•;;• .a p'� 'p, b ; a.' OF 1/8"-1/2" t� CLEAN, CLAY FREE SAND 04 a a WASHED PEA STONE 3/4" _ 1_1/2" WASHED , f CRUSHED STONE 44 TRENCH WIDTH S 5, 22 G:E'N .R L TES 170.0 1. ALL EL EVA TION. SHCWN ARE BASED ON ASSUMED NUMBER OF TRENCHES 1 r 2. ALL PIPES IN THE �'YSTEN MUST BE CAS T IRON Y,:1��86'R--- r) � ! OF DR YWEL L S 2 1 .+' :4 . �_-- 3. THE BOARD QF f 3�7-AL TH MUST BE NOTIFIED P 86'5O WHEN CONS TRUC LION IS COMPL ETE PRIOR 1 N w PERCOL A TION RA TE' 1 b TO BACMFILLINlg 4. ANY CHANGES Ili?' THIS PLAN MUST BE APPROVED <2 MIN./IN. - - - - � -- _ L off' .5 BY THE BOARD 6F InZALTH AND CAPE & ISLANDS WITNESSED BY, 17'1 o yy, o p o SURVEYING CO., ,INC. EDWARD BARAY ti 5. MATERIALS AND .:INSTALLATION SHALL 8E IN BARNS, BRD. OF HEALTH „�S,�('j/V DA Tip --_ COMPL LANCE WI7 H THE. STA TE SA NI TARY / - `) ,7r� CODE - TITLE i�� - AND LOCAL APPLICABLE DA TE: FEB. 13r,_,1.- _ RULES AND REGC:LA TIONS o - T'.v ��✓ ° 6. NORTH ARROW IS FROM RECORD PLANS AND Lm�h c -- NUMBER OF BEDROOMS 3 /2,i �eyre 3/a /Z„ it YK 3/2 GAPBA&F DISPOSAL NO IS ND T TO BE USED FOR SOLAR PURPOSES H �b A (� 1. a A i„y 7. FL OOD HAZARD ZONE- C (NDN-HAZAROJ s N pry �' DAILY FLOW , 330 GAL . 8. WA TER SUPPL Y TOI�IN WA TER r '"Y'' s-�f SEPTIC TANK REO 'D. �1500 GAL . ,ovr� rw .,...-w��l�O 3 F,1r.rvr �� �� (�ltj'- r/ !`"' - ••—.•_--,.---....,, - - yin� ' SEPTIC TANK PROVIDED 1500 GAL . LEA CHING REOUIRED 330 GPD. c� ,1c �s s M ri SIDEFALL AREA = 152 S.F. 1512S.F, X 0, 74G/S.F. - 112GPD. � . ,�,1 SOT TOM AREA = 32.E S.F. a y h �\ ti L EGE2SS,F.X a, 74G/S.F. = 243 GPD o � / ��•�' -� ? LEACHING PROVIDED = 35.E GPD � PROPOSED EL EVA TION EXISTING CONTOUR � ODSERVA TION PI T �i 2 N 7f�' � C D. S TRIBUTION BOX ' R POSE SE D. SPOSA L S YS TEM ---'- J L _ FLOW DIFFUSORS - PRE PA RED FOR FO-0-1 SEPTIC TANK ,� BIL L ROGE RS L C T 5 (HOUSE 1 S) JUL IE LANE RESERVE AREA i o / ,� tt (( COTUI T EARNS TABLE MASS. PIPE INVERT EL EVA TIDN ? f' `n' DA TE; � CAPE 6 ,ISLANDS ENGINEERING 33 7 as PLOT PLAN `' '�°` ' r l SCALE AS NOTED 133 ,F'AL MOUTH ROAD SUI TE 2E SCALE: 1 c7�> � MASHPEE MAS r/ SE . . . .PLAN NET .�f' ��� `' .