Loading...
HomeMy WebLinkAbout0146 LITTLE RIVER ROAD - Health 146 LITTLE RIVER ROAD, COTUIT `• A= 054 024 I 1 l TOWN OF BA.RNSTABLE LOCATION e/ALL Aa6ad— SEWAGE # os-y, oa VILLAGE ASSESS -S,MAP & LOT fJCrS , ASP- `Y-'=NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type). ��) (size) /OlY1 !�Z. A,. NO.OF BEDROOMS BUILDER OR� AA�4 PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished,by I I , r i i o I � i i No. gLo7 Fee 75, 11_**" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLation for Mispo8al .pstrm ConstCULtion permit Application for a Permit to Construct( ) Repair k�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. J(/(, L L- A�,,W Owner's Name,Address and Tel.No. Ji Assessor's Map/Parcel ©J y�G�5/ CU 8—3?WAS' Installer's Name,Address,and Tel.No.,�bg-'7'h-93 Designer's ame,Address,and Tel.No. /G� Grist o�,�n� po /fix�6� ,vIX 4 � ,�,,�and 132te YR Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1-14 Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Z 66xal �/U®J►u(Ml/ � V 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 C n to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed _ Date O 6 Application Approved by Date 6 Application Disapproved by Date for the following reasons I on Permit No. Date Issued G" . a i No. �O�� {/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: u PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for ]Disposal Opstem Construction Permit Application for a Permit to Construct( ) Repair k�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. N4, 4-A/le /<j uV44 Owner's Name,Address,and Tel.No.`2A� -Cof/S'• ,4 o S' / e5/-ujor�7 a Assessor's Map/Parcel OS y/63y CU u'� 4�xyv, i-A P jv-o �S Installer's Name,Address,and/Tel.No.� 7'7/ 93 Designer's Name,Address,and Tel.No. is n.,r54111 U A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `gpd ' Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ti Nature of Repairs or Alterations(Answer when applicable) /S:�rrl c /SvOS � )6A-aJ- 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 n to place the system.iri operation until a Certificate of �' Compliance has been issued by this Board of Health. ter' Signed Date /aA Application Approved by Date .G" 6 G j y Application Disapproved by Date for the following reasons , Permit No. Date Issued G --------------------------------------------------------------------------------------------------------------------------------------- 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 ebr;,a/O- . »�y5` �rt.�'�n/c�� �►'i at /y� 1�t` je- A,-e.r has been constructed in accordance //� with the provisions of Title 5 and the for Disposal System Construction Permit No�016 S� / dated 16—61 I> Installer 8rLjo—tt� I�GY�S{ 'K�ort Designer nJ/A #bedrooms IV Approved design flo4 gpd The issuance ofris permit shall not be construed as a guarantee that the system wi, fund*on as desi 'ed. Dated I Inspector !n •v ----------n------------------C------------------------------------------------------------------------------------------------------------- No. o ✓ Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS IDisposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(rX Upgrade( ) Abandon( ) System located at ��� �� le Ri oe_r- �Gt — co and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit,—,—_ b f� 2 Date G— (/o Approved by �' Assessing As-Built Cards Page 1 of 2 G� 144 WF BARNSTABLE LOCATION 11-0l-3 SEWAGE# VILLAGE h rrT/ t ASSESSOR'S MAP 4 LO� �� 1 INSTALLER'S NAME & PHONE NO. rLi Ca,;I C'trw� y�zt F{, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) PI-1 (size) G-4 /V NO. OF BEDROOMS �- PRIVATE WELL OR UBLIC��� BUILDER OR �o M E r7'► DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ��� VARIANCE GRANTED: Yes Noj o c� 0.5 37' 47 ' P http://www.townofbamstable.us/Assessing/HMdlsplay.asp?mappar=054024005&seq=1 9/28/2016 OF SHE tp� Town of Barnstable Barnstable ti Regulatory Services Department M�fte'caC j BA"SPABLL XAffi. Public Health Division fD"" A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 8988 October 4, 2016 Bretz, Peggie Griffin 31 West Woods Yarmouthport, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 146 Little River Road, Cotuit;MA was inspected on 09/12/16 by Michael DiBuono, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Septic tank is leaking. Will need new seal or replacement. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH c9ek Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\146 Little River Rd Cotuit.doc ti Town of Barnstable anxxsr�Bc,E, + Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA'02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS) (Town Code §360-44 and Title V: 310 CMR 15,000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code§360-20 h) OTHER Repair deadline: �. Q:\SEPTIC\DEADLINES TO REPAIR FA LED SYSTEMS.doc ' Commonwealth of Massachusetts 0 DZ� — QZ?S — W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments U11 146 Little River rd M Property Address Peggy Bretz Owner Owner's Na"� information is required ✓ Ma 02635 9/12/16 _ required for every _. 0___ _ page. City/Town State Zip Code Date of Inspection t� Inspection results must be submitted on this form. Inspection forms may not be altered in-iny way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information r t ���• on the computer, k s4p�L use only the tab 1. Inspector: / key to move your a r I j,Q CC,V P cursor-do not Michael DiBuono y the return key. Name of Inspector �) Uj)^o DiBuono Sewer and Drain ,y Company Name 8 Johns path Company Address SSYarmouth Ma 02664 Q vl errvf' City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number t / sr e•�nc AA k OMMe�t✓ B. Certification PY 1 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 9/21/16 Insj is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the.appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform 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 17 t/ V, Commonwealth of Massachusetts N _ Title 5 Official Inspection Form I' 8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address `+ Pe gy Bretz Owner Owner's Name information is required for.every Cotuit Ma 02635 9/12/16 page. City/Town 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: 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): Septic tank is leaking at the middle seem and needs to be sealed. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for every page. City/Town 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): Septic tank is leaking at the middle seem and needs to be sealed. ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I r Commonwealth of Massachusetts W Title 5 Official Inspection Form _ — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name. information is required for every Cotuit Ma 02635 9/12/16 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 function.ing in a,man.ner-.that protects the public health, safety and environment: ❑-The system has a septic tank and soil a bsorption-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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I , ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El _ ® 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•3/13 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 146 Little River rd Property Address Peggy Bretz Owner Owners Name information is required for every Cotuit Ma 02635 9/12/16 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? ❑ ® 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): . 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 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 a 146 Little River rd Property Address Peggy Bretz _ Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for every _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information Description: System containes a 1500 GI septic tank as well as a concrete distribution box and two 1000 GI leach pits. Number of current residents: 2 — 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 Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 186`Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ® 146 Little Rive r rd Property Address Peggy Bretz Owner Owners Name information is required for every Cotuit Ma 02635 9/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Last date of occupancy/use: Date Other (describe below): I General Information Pumping Records: Source of information: Pumped in 2011 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 record s, 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 �L\ -Commonwealth of IVlassachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd _ Property Address Peggy Bretz Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2.5 __----- feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 'feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑.po-jyethylen.e ❑ other(explain) 1500 If tank is,metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth ofMassachusetts - Title 5 official Inspection Fora —- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a / 146 Little River rd Property Address Peggy Bretz Owner Owners Name information is required for every Cotuit Ma 02635 9/12/16 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 24 Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How w sions determined? Tape Measure omments (on pum 'ng recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relate o outlet invert, evidence of leakage, etc.): No evidence of leakin ees and or baffles in lace at time of'inspection. 51 c ' 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•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name ►r) information is required for every Cotuit Ma 02635 9/12/16 s page. City/Town State Zip Code Date of Inspection co D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Evidence of Ieaking,Tees and or baffles in place at time of inspection 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•3/13 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 146 Little River rd Property Address " Peggy Bretz Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 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.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: ------- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•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 146 Little River rd Property Address Peggy Bretz Owner Owners Name information is required for every Cotuit Ma 02635 9/12/16 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 Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(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. Soil Absorption System, (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: 2 ® leaching pits` number.` -- ❑ leaching chambers number: ❑ 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.): Pits were dry at time of inspection and show staining only up 18" off the bottom i 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts- W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /y 146 Little River rd Property Address Peggy Bretz Owner Owners Name information is required for every Cotuit Ma 02635 9/12/16 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.): No ponding no-break out 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 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: 10+ ft 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: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Property sits high above nearest water venue. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 9/21/2016 Assessing As-Built.Cards � 0WOF BARNSTABLE Cy LOCATION (�% L9T/Z IG+� SEWAGE VILLAGE » i i O 5 y cxy^ ! ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) cshe} G /y NO. OF BEDROOMS, �— PRIVATE WELL OR USLIC�V-ATEX BUILDER OR �,o m r--rrl DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N. L 1 U .35 37' L 4-7 ' http://www.tow nofbarnstabi e.us/Assessing/H M di s pl ay.as p?m appar=054024005&seq=1 1/2 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 146 Little River rd Property Address Peggy Bretz Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -3.. y e ` DORTOLOTTI CONSTIRMCTION,.I�IC:` 765 WAKEBY ROAD,MARSTONS MILLS, M:A 02648 508-7714399' ' 508428-8926 FAX: 508-4287,9399 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A,; CERTIFICATION 1 Property Address' a Date of Inspection: qZA2 Ins tor's Nam : ow is Name a4 Address: - F :•' <CERTIFICATION STATEMENT: I certify;that I have personaliy:inspected the sewage disposal system at•this address and that the informs-. lion eported,tielow.is true accurate'and complete as of the time of inspection�The?inspect on',I am,per formed based` '"my tr4ining and experience in the proper function and mai`iitenance of on site sewage disposal �}'�tems. The System: �l/ Passes _ '+• . . . a& �.117`11-Conditionally`Passes' � . "Needs`Fui he�Ev lion Local'Apwving Authority s�.1 -Fails'`" F It Inspector's`Signature r Date. ( °, The�System Inspector=shall submit a.copy:of this inspection report;to,tbeflipp[oving authority,within thir- ty(30);days of completing this inspection. If the system is a shared sysletn;vr:has'a design flow of'10,000 gpdtorlg"ter;Yt e$inspector#and;U;e�system owner shall:submitttlipumpo;,t to.,11;e ,p{tlopriate;regional r 'office of the Departmenl•of Environmental Protection. The original should'.be sent to the system owner' u androopies sent tolhe,buyer,if applicable and_the approving authority. INSPECTION SUMMARY:, 1 •5 ? .. °� ',A):5YST II+I;PASSES•.>, t,, :;:t have not.found any information which indicates that the systumviolates any of the failure criteria as defined in 310 CMR 15.303. Any failure crileria:nut evaluated are indicated ti { below.. {it',,B),SYSTEM..;CONDITIONAWY,PASSES; _ ' .' • ''. One=or,morelsystem components need to be replaced or repairs& The system,upon eomple- !..; Ti,$tion of.the:replacement or repair,passes inspection. .,is, Indicateyes,'nor;4or not.determined(Y;N,VR ND):Describe basis of deWmination in all,instances. If. not determined",explain wiry not. ,. .,: .•, .., r , < . , t , ;_;a b .f .W -! -=`tiThe septic antis metal;cracked,>structurally,unsound show&substantiel infrltrstion or cAltration,or tank failure is imminent. The systent-will`pa,S�Pnspection if the existing pep- rri tic:tank is replaced with a conforming°septic tank.as approved byMThe�Board,0Health:`.• Sewage backkup or breakout or high static water level observed,in`thwdistribudon box'is"due to=broken=or-obstrucled.pipe(s)`or�due to a broken,-settied:c+r u,ievendisWbution box. The system will pass inspection if(with approval of The Board of Health): t M : ; '" �^4z `'! a P # . M"a a,.,2 ,.�" ,�,a '� 1,, - , ... ,-,r;1 `F, ._ $ •fie' t ir i .•` d 1 'V S j t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'4'ION FORM PART A CERTIFICATION (continued) <" Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System rgquired pumping more than four times,a year due to broken or obstructed pipe(s). The system.will'pass inspection if(with approval of The Board of I�ealth): a ;n .41 Broken Pipes)are replaced Obstruction is removed,$ ' , C)FURTHER EVALUiTION 1S REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health,in,orde uto determine if the`system is faiting'to protect the public health,safety and the environment.r { ' .� 1)�SYSTEM WILL PASS.UNLESS!BOARD OF IIEALTWDETERMINES THAT THE SYSTEMS IS.NO'1tITUNCTIONING IN A MANNER WHICH WILL.PROTECT THE',,tPs PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTr: i Cesspool or,privy is within 50 Feet of a surface water Cesspool;or,privy is within 50 Feet of a bordering vegetalediwetlaod ur a-salt marsh. 2)SYSTEM WILL FAII.aUNLESSjTHE:BOARD-.OF,?IIEALTH ;(AND.PUBLIC, WATER A. SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM1.S,•FUNCTION ING IN kMANNER THAT PROTECT•.THE PUBLIC HEALTH AN-0 SAFEW'"0,;1THE ENVIRONMENT: 'The ith system has a septic tank and soil absorption system and ivn.100`Feet to°a surface ;, water sapbl}t#or�tributary to a surface"water supply, y The'systentfhas'a+scptic`taiilc acid soil absorption system and Is with a Zone'I of a ptiblk P t,°"water s6pply well. The system has a septic tank and soil absorption system and is within'50`Feet"ofa private water supply well. r The system has aseptic tank and soil absorption system and is leiae then+l00 Feet butz'S0 Feet or more from a private water supply well unless a well water analysis for coliform . p pp Y Y q :, .. . �; bacteria and volatile organic compounds indicates that the welFis free`6 pollution from the'fi . ci►ity,,.and the presence ofammonin nilroacsi and nitrate eil!, Vg-it`is equal;to,.orless 5,ppm: D)SYSTEM FAILS: I have determined that the system violates one or more of the following'failure criteria as defined in1310 CNM 15:303. The basis for this determination is identified bellow The''Board'of Health should:be"eonlacted:to determine what will be necessary to correct-the fallure y Backup of sewage into facility or system component due to an'°vedoaded or clogged SAS or cesspool. y g DischargeFaupondin&of eDuent to the surface of the groundw surfaee,waters due to tan overloaded or clogged SAS or cesspool. StaticDliquid level in the distribution box above outlet invert�due tc+;a.n overloaded or clog- i:N, PI, ;,,,gedSASor�oesspool: Liquid ndeptb wcesspool is less than 6"below invert oravailableivoGume is less than 1/2 r•f ) ,a1,ff i :t.A�1,�l.be.'#.day.11Ow.:7- .. 4" 3: .. r::;, .., �•. . <f }d3 fk '�i Js':"a. Required;pumping'more than 4 times in the last year NOT; dwto clogged or obstructed pipe(s). Number of times pumped t S s -2- I't; i i R ;H t SUBSURFACE SEWAGE,DISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,'cesspool or privy'is below the high)groundwater i elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to 3°F., ,a,,surface,water supply:, , fi , 5 Any portion of a cesspool or privy; is within a Zone I of a public-well Any portion of a cesspool or privyjs;within 50 Feet of a private water supply well. :Any portion of a cesspool or privy is less than'1110 Feet but greater.than 50 Feet from a private water supply well with no acceptable water quality analysis. 1f te well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. I pj,;&,t E)LARGE;SYSTEWFAI1S: The following criteria apply to a large,system in ndditiorrto the criteria above: The:desip,flow of a..systemSystem is 10,000 gpd_or greater(Large and the system is'a significant threat to public health and safety and the environment because+one or.more'of;the following conditions exist' iz r 3 ! 'The'system is.within 400 Feet of a surface drinking water>supply l .,- > 3 � ' The;sysfemxts:within 200 Feet of a ributary" to a surface"drinking;,waterhsupplY�> � dt The system is located ins -nitrogen sensitive area'Inierim4 Wellhead Protection i (IWPA)or'atmapped Zone 11 of a public water supply well U Vi.9 i�' � . J 9'�tay '�he,owner or operator of any such system shall bring the system and facilityl into full oomphance�wtth the �.r or . groundwater treatment program requirements of 314 CMR`5,00 and 6.00:%•,-Please°consult the loc at,�,{a� ;z regional office of the Department for further information. l ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B t � { CHECKLIST Check if the following have'been done. " Pumping"information was requested of the owner,occupant,and:Board oF Health ./Flone of the system components have been pumped for atleast two week saad.the system has' been receiving normal flow rates during that'peri .�°�Large'voltimes`of water have not been introduced into"the system recently or as part of this inspection. N _ As-built plans'have been obtained and examined. Note if they are root`available with<N/A A ✓'['he facility or dwelling,,was inspected for signs of sewage,back-up ( a if[p J 4 fMesystem does:not receive non-sanitary or industrial waste flow. , was rnspected for signs of breakout. Ff .; systerYtoomponents,excluding the Soil Absorption System,have been located on.site septic tank iii mholes were uncovered,opened;`and the interior of the septic'tankwas in- - spected'for condi — of baffles or tees;`material of consWction,dimensi{ons,utiepth;o -liquid, }j}' 4 S�,T 7is .• yI #2`C'I . { },e•E. E; {}..t�.t }'�''.;A} '•YM. de`th'of sludge;depth of scum. e size.and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3. . ,•a .r r s�• +};,qhr �t:-' ',, Y f !,�. i -b q¢ '� � y1"k,'l 6.f''t �y a !r;€ 2 'f;�P.'nJ 'xP Y kt t:, + �d,; T t y.t �j' f�.a�`.'� ON t `�;';e7Yt•,i",�Pi' y,$'�Cd•y .ii �++``Y R..�'w .X.!r rk Mt ^f � ::..- r�,.:.wrx rr�{,H *r-!x..`'o'.f.., r •:.' .:%e `p[ x �^ '3f$`"+x'y`. , ,. 4'� � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 'e!6e facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP9C TION'FORM PART C- SYSTEM INFORMATION ` t,r FLOW CONDITIONS I Design Flow:{ lions Number of Bedrooms: SNumber of Current'Residents:' Garbage Grinder: Laundry Connected To Systen,:� Se,lsonal Use- * ' 'Water'Meter.Readin s,:iffable: Last Date of Occupancy: • ,9, O.A A — t , . AL/INDUSTRIAL! Type of Establishment d Deslgri Fiow�, lons/dav,:-Grease,Trap Present:(yes or no Industrial Waste Holding Tank Present Non-Sanitar�WWasteiDiseharged To(The Title V,System. .� WateiFMeterlReadings,•If Available:` Last Date oCOcoupancy__'< x�= sr ' �s .` x..t OTHER: Describe) Last Date of Occupancy: ; ' GENERAL INFORMATION PUMPING RECORDS and source of information: _ System Pumped as part ofinspection: /+ ) if yes;volume puu� Gallons M t 7 laa nt.; t r .. ti #eason'forpumping•.• Y Fk;:fit aYO St � TYPE' 1YSTEM:1*$,; �24p% tic Tank1Distribution Box/Soil Absorption System . Single Cesspool p Y ,, ' a�1 Overflow Cesspool y 9 ,4 Privy Shared System If es,attach rexous ins tion records,if any) Y ( y p p Other(explain): OXIMATE AGE ofall,components daW installed(if luiown)and source of information: . 4,= • ,� t Y Sewag6 odors detected when arriving at(lie site: ;. -4- i t 9.1 ``� • ''$UB5URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .GENERAL INFORMATION (continued) SEPTIC TANK: f Dep&,,below grade:- :" Material of Construction: V concrete metal FRP_OtheP. Dimisions:l, �! 6 p A ' („'!',�$� Stud a Depth: �' Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom`of outlet tee or baffle: 7 Comments!(recommendation for pumping;condition of inlet and outlet.ttes or ballles,.depth,of liquid el in elation t oudet,.invert,strut ural integrity,evidence off leak ge,�etc;j ' r ` U' "FI yj� k 7" �.tEz. t .. Yt. F,�: ny - s p, �ve f`iy.•. GREASE TRAP: Depth Below Gradei.` Material of Construction:_concretc geetal_FRP Other ` (explain), Dimensions: Scum Thickness: ' Distanee.1from top of scum to top of outlet tee or baffle: - � - Comments:(recommendaiion`for pump►ng'condition of inlet and outlet tres orbaillbs,vdept�t,ofllquld level in'relation to outlet invert,structural integrity;°evidence of leakage, 1, r g -: w .t'e.',G .Par..••:... �. i.7, .. �} ...o".t z,+ ,j ,.,f1 ;Q�`6"Li,,.}'.ti7�`'F�r A��.xv�f",'',f;'a.� z �. .,!rr . 3`'.i N,4 ...f .: itti' 4f- s.".i ;ti:•:_ ;��2j�r I���Ci�4:�d'��.�fJ,m'>. TIGHT OR.HOLDING.TANK: A)d �{ ;.Depth Below Grade:, Material of Construction:_concrete_metal FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day rrAlarm Level: . ; :.;.�omments:.(condition of inlet,tee,condition of alarn►and'float switches, t»+e t� r , .. ,: :. :.. •x .,ter€t vg,r-� DISTRIBUTION BOX; ✓ - . w Depth of liquid level above outlet invert: li _ Comments:(note if le�add�istribu�tioiequal vidence of sot s carryover evidence of leakage into or out of box,etc.) V PUMPtHAMBER:'` Pttmp is in working-order..,... Comments:(note-condition of pump chamber,condition of pumps and appurtenances,etc.) -5- �'�i�'1 :}s 7g 'r} c:z 3�# >.. i '� �' "�x'���`,«ti' �0�4'� :,�4 k� 9.�WP �ik�t Pt :tl � �°f�• P, r t �s' ., r r' 7r; a.. �.,.y�; "p '"E.t •�� �. -. x r�::l'&w'4%ds�ra`,r""� is a �':;,. <{�-T�tz� S �y,i �kt��' .L�"� �4' "��,. ,� �a; ����,� x°'„�.a rt..� •; '�{'� � t ��,at+�,��"�°u'u�+ -`r}��' ra,,,.'ti.. ,q, . h. �-a•c 1., „ fit. Y, t �:'E:?�'�'i�i�� � ad;. r R+� k a r " 'SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conliemed) , SOIL ABSORPTION SYSTEM(SAS): (I ocate..on sitiplia0f possible;excavation not required,but may be approximated by non-intrusivTe t T methods) If not determined to be present,explain: ,4 a Type. 4'rti-dtteaching pits,number: Leaching chambers, number: Leaching galleries,numbert,. Leaching trenches,number;length: 4's�-,A eaching'fields,'number,dimensions: '{ `pveiflow-cesspool,number: ' -Co :(note condition of soil,signs oft ydraulic failure level of. ndul ;` ndlUon-o vege�tao> t, . '�.. s:C�11717i 0�01J►7i� _ .S' ." ..i 7, r E r t5 iri��"..� Number and'coniiguiatione iDepth-top of liquid-to inlet invert: Depth of solids layer: '' Depth of scum layer. Dimegtsi,pps.of Cesspool Materials of construction: Indication of groundwater Lttlow:(csspool must be pumped as part of inspection) " . Comments:(note condition of soilk,signs of hydraulic failure, level of pondin&ondition of vegetation, etc.) ; , .,.;PRIVY. i� • i a7,C s 1, lr(Iateriels of construction: Dimensions: ;x --- DFpth,of;Solids: '6mments: (note condition of soil,signs of hydraulic failure,level of pouding,condition of vegetation, etc.) 3 -6- a ' i -tug; 1:SUDSU!11FACE SEWAGE DISPOSAL SYSTEM iNSdDECTION FORM PART C SYSTEM INFORMATION (contimsed) f ` SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent rcferencm. landing ks or benchnilrks. Locate all wells within 100 Feet. ... .. Ili r �� 4t s� O r V- DEPTH TO GROUNDWATER: Depth to groundwater: Feet � Method of Determination or Approximagoa: A e A? ® T:s�9hr' u� -7- r•ta�i.,^i^B�{W, �2r�r."�J sl,� `u�r.��.�xp£x+�a'�,k S,,iS.?i - Y4 j r. ,. �l/ 1, , . ,G O OF BARNSTABLE Of N. LOCATION SEWAGE # �� VILLAGE_ ASSESSORS MAP & LOT ti INSTALLER'S NAME &.PHONE NO.e�&d CLd)- (2VA.R l SEPTIC TANK CAPACITY /, Zwa pp LEACHING FACILITY:(type) F/ / ��) (size) NO. OF BEDROOMS- 5 — PRIVATE WELL OR UBLI —'� BUILDER OR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• VARIANCE GRANTED: Yes Noj k r:v O L 4-7 ' t IR f�ie�, b 7z4 _ .. ASSESSORS MAPNO' ✓ � e 1 = ���� No...._...' PARCEL N0: 0 r, Fr;:s....... Q U,� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allphratiun for BiuVaiial Wur1w Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at .......................... ovation• \ddre s I ' - w G � t� yn►•/ (, (,�'td-f�Y.... Q ✓111.SS/ti � Installer Address d Type of Building Size Lot_____.....}.J�_�...Sq. fDwelling—No. of Bedrooms._ ... ...........................Expansion Attic ( Garbage Grinder�JVTI04Other—Type of Building _--_-� �............. No. of persons_......._._..........._.__.. Showers ( ) — Cafeteria ) a' Other fixture ----------- ----------- - --- W Design Flow..........:..... gallons per person p r d v. Total d�ilyAflpw._.___.-----�__------------------_.__._____ lons., fy Septic Tank—Liquid capaci y..t allons Length__1� .. Width s Diameter_l .._. Depth.. t�•�IIAJ W Disposal Trench—. o. _._N........... Widt �} of l Length.._..... Total leaching area...... .............s ft. 3 Seepage Pit No...................... Dtameter._.�__...` __ De h below inlet..... Total leaching area..,+..V .sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ 7 Percolation Test Results Performed by.--------A.: i0'c-?! ....... ... ............ ... Date-__.IA.-oi-_-�4............ W . Test Pit \To. I________ _____minutes per inch Depth of Test Pit.--- ... Depth to ground water. rioxif----.-. fs, Test Pit No. 2........Z...--_-_minyuttesper inch D�eptth oof�yTesst�Pit____�Z.i�_.. Depth to ground water.t (.,)ex, �!! W . �v_r '-•-----��.__Jnt�-�_.�1...!g� __..- ..................................................... Description of Soil.... i 12a , MX_�121t2 '\..._.� A= --------------------------------------------------------- W ----------- ---------------------------------------------------------------------------------------------------------------- -------------------------------------•---------------------•------------. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------- ------------ •------------------------------------------------------------ ........-------- •----------------------------------------------------------------------------- ------........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s been issue y t oard of health. Signed .......... ........ .................................. Application Approved By ... � `1�--------------_------_r---------------------------------------- Dace Application Disapproved for the following reasons: ................. ........... . ......__................................................... ----------------- ........ . ............. Permit No. ..t.............~-G..... .................... Issued ....%�.�......: ........... Date ,4� value iv©, _{. THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uhnp 1 ial Works Tomitrnrtinn rrrmit Application is hereby made for a Permit to Construct %( Repair ( ) an Individual Sewage Disposal System%t f f l�l F:-:... V' .t -. l ocation-Addd,Ns - or r,t..No. ..................... •.. ....T`f7 l c: Owner --- Address 1 a ........................................�1✓t G s i! ( �.11 t i.� 1 (4 �"/1r lr ( � v AiJl , 8°�'1 I c 4 5 t ....----................................................ ---•--••-------.....•-----------------•-------•••-•-••-----•-•............••.....,............--- Installer Address Type of Building p,� Size Lot._.__ 1-� ...Sq. feet Dwelling— No. of Bedrooms._--._...+.........................:.._--_Expansion Attic ( Garbage Grinder ( )' aOther—Type of Building ___-- ............ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures .............. .. ... . . . d -----------------------------------------•---•.............. W Design Flow.............. --�- --__--_---.__._gallons per person per d4y. Total doily flow__.______ ..................gallons. WSeptic Tank—Liquid capacity..150q___ allons Length._ ._ Width_ .-+_ Diameter_.Q A..._ Depth..4.0.*M_ ;A x Disposal Trench—No. _.-N........... Width------- ..w_ Qtt-}LI Length---------_r_...,.`_. Total leaching'area------t.............sq. ft. Seepage Pit No.....................! Diameter---L, -3—e+_. De h below inlet-_---�: ..._. Total leaching area. .......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by....__--=-�_��� -'--_-CAAA-�r.�?�`-x".. Date---- �................................ a Test Pit No. 1........ .___minutes per inch Depth of Test Pit---- ... Depth1 to ground water_t :t).DA�....... Test Pit No. 2.._.._..r�_-..._minutes per finch Depth of Test Pit____Jr'�y.!_y�...._. Depth to ground water_ U-- t ( . h.� !F?rt-•50..._�- S_.?......_. ..................................................... Description of Soil..................7=!•-�-�•- --- rn1115►'t x W VNature of Repairs or Alterations=Answer when applicable.------......................................................................................... --------------------•------------= -•--•-------•--------------------------•--...................---•----•-•-•--•---------•-------••-------------•-•---------------------------------............---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 1 the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance,has been issued by theboard of health. Signed t f _ ..... Da'e.. ^ Application Approved BY�1 - -�.� ... ......................------------------------------------- Dace Application Disapproved for the following reasons: ...... ..............--- ---- ...... ...... .........................-._...._----------------------------- /fJ --------------------------- ---------------------------------------- .....4....: ....y......................... Permit No. ....'.. �.. - _.- ....... Issued .. - -- - ` Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Cnomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (,:': ) b � .., rrr'.j_ J' tl-,_.l S rJC r %G-3,,J---- ------- `` - In-,t.ler at ... f_-T�:.t. 1 ...t ?L = - - '.............................(..rr7 t �. has been installed in accordance with the provisions of TI'I LE-5�of Theftte..Environmental Code a described in the application for Disposal Works Construction Permit No� ' dated •--:�^-" y THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FF"U CTION SSA-T-IIS-FACTORY "DATE 2L ---- t --- -.... ... -------------------------------------------------------------------------- THE - COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Noy.... ..•••--- FEE .. ................ .•- Disposal lUorkii Tunotrurrtion "rrmit Permission is hereby granted..................... .._..___. ._!..... <' !:' r................................................. to Construct O or Repair O an Individual Sewage Disposal System at No `%' r1 f�`c . ......-••---•.............. ................................................. �.....�.... ----- -- - •_- J ... ' `-`- Street J ,,...-^^..,-•-• as shown on the application for Disposal Works Construction Per o ✓F._ Dated.. ....:. ''`'•. ' 05 Boar)o Health DATE.-" � 1--->�...&�. ....-•-------••-•---- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS f C. B. N�F , I FND. GE'ORGIA TP _ IqI M. PARK. of �s`A c PAt1L r► ,. . MERn V v No. 32098 ; 50,. lgHO suR�F�� e 7p 45 ;s- 1 - - -x= NSF' BUILDING < s (Z) R�'STRICTIpN driveway -�� - - MARY P. AND INE' prop I Iz0P0sED c0 o DA VID GALLO WA Y -HSE._ �l 50 t h 50' ~ ' FND. OF ,r1 AIR JOHN 1<5 0' AL No o - OLE BENCHMARK. l ' ' ASSIGNED EL.=50.00 ES ' # 46 C14 SPIKE IN TREE ' ' o_ J o 473175 6, RES. E. .RF" LOT FLOOD ZONE. „C", ASSESSORS LOT 24-1 q d I y 48,500fs Q� 5 o :e� PROJECT LOCATION. LOT 3 LITTLE RIVER ROAD ti COTUIT, MA I APPLICANT.' PETER POMETTI q P.I O. BOX 20,56 w' 38 COTUIT, MA LOT r YANKEE SURVEY CONSULTANTS °O : . . : I 1 UNIT 5, 40B INDUSTRY ROAD P. 0. BOX 265 MARSTONS MILLS, MA. 00648 TEL, 428—0055, FAX 4.20—5553 SCALE 1" 30\ LDATE 01/161P5 LOT REV RE'v - I JOB NO. 5062.4 SHEET 1OF 2 EL: = 54.5 PROPOSED TOP OF FOUNDATION 20 MIN.' 10' ruin CONCRETE COVERS a 2"LA YER OF VARIES WITH LOCATION-BY SEWERAGE:PIPE 54.0 1/8""-112" CONCRETE CO VERS 52.Of WAS ED STONE 4"" CAST IRON 12"MAX OR SCHEDULE 40 „ 4," SCHED&LE ,40 P. V-C. 12 s` P. V.C. PIPE DIST. M N. S=O.02, �_ Box FLOW LINE 18.6 INVERT S=0. 02, D=18.2 1 10" S=0.02 D=18.5 PRECAST MIN. 19 LEACHING 51. 02_ t � z,� � IT VERT EL IN OR 50. 41 w IN EQUIVALENT _ - LEVEL o� cl EL,--50.66 INVERT, /4 0 6' o< 3 - 1J�00 GALLONS IN INVER o V TO 1 1/2"" EL.= 50.04 EL.=_49.87 EL.'=_49.5_ o oo WASHED STONE SEPTIC TANK ---- - EL.= 43.5 r LEACH PIT I ----- 4' 6' 4 PROFILE OF 14'DIAM.� SEWAGE DISPOSAL SYSTEM r NOT TO SCALE BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL= 3_9.5 ALL ELEVATIONS ARE ASSIGNED BOTTOM OF TEST HOLE # 2 IS 12.5 FEET BELOW SURFACE. SOIL LOG J. LANDERS-CA ULEY PE WITNESSED BY: � OF EDWARD BARRY S. P# 8302ANX v o GENERAL NO TES �,' . 1 PERCOLATION RATE _ 2 _ MINI INCH Na 1. THIS PLAN IS FOR CONSTRUCTION "OF A NEW SEWERAGE DISPOSAL SYSTEM. to 2. PLAN REFERENCE, BOOK 473 PAGE 75, LOT 3, BARN. REG DEEDS. DATE 11101194 DATE 3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM TEST HOLE 1 TEST HOLE 2 AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. EL- = 51.5E EL. = 52 Of DESIGN DA TA. TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 0 NUMBER OF BEDROOMS FIVE 5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN TOP & SUB TOP & SUB 12" OF FINISHED GPADE 2.5 SOIL 2-5' SOIL: GARBAGE DISPOSAL YES •' 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE TOTAL ESTIMATED FLOW 550 GPD SAME, UNLESS NOTED BY FINAL CONTO URS 7 ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE 110 GAL./BR. DA Y x _5__ BR. i OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER ( ----- OR. WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING MED. SAND MED. SAND 1500 SHALL BE USED UNDER OR. WITHIN 10' OF DRIVES OR PARKING: SEPTIC TANK CAPACITY -_-_-- UNLESS NOTED. LEACHING AREA REQUIREMENTS - 8. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL 10.5' BE MORTARED IN PLACE. L2.5' SIDEWALL AREA ?63- GAL.IS.F. 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM AREA 154- GAL.IS/F DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO LEACHING CAPACITY ,(BOTTOM & SIDEWALL) 804*GAL. OBTAIN SUCH'DETERMINATION FROM APPROPRIATE AUTHORITY. -- 10. THE EXCA VATOR\CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES .PRIOR TO ANY . XCA VATION. THE .WA TERGA TE WAS NOT FO UND, THE_..GENERAL _ _ RESERVE LEACHING CAPA CITY - * _ GAL.-s.' :i -`. m .. ✓.;.� �1,a.: t _ LS, .y'+l �.a^ "s'r_.f..:§h, �r - t -- N VERIFY LOCATION. DEPARTMENT ,:Kx -. CONTRACTQR SHALL VER CATION WITH WATER DEP .. . ...r_a. - _.. _a+y w.. _ 1 9:- - .- ... .. eta' .._.. .. -- N.. _ , __._. .. :. ..eta¢. .�.--•.�' .. w. .� ..._ � ..�..- -��' JOB-:;.NUMBER m r. s..+`t`. ..-M.c....a.,.,e,a-�.�-...�.,._a-.:..�..�., � .�-.- ��'-��•st'��,�t.�_ � r:..,..�4rfi.`�`.Rt ,� _ .�,. .�+-�. .,� �.r; ..�.�„ ------------- .x. s __.. ... __w .. .. a:o-...- ... ...�.: . "e .F ..a _.z�.-. .. _ ..._E _ A. ,:- r "-^,c... _ t. :r-wt" ,�•c.. _.._> _ .. .,. .',L .3- -� " •bS•- ..�L zi-. x i .� .. z :.-_ .. .. .... � c-� _ _. '�' .. ••. �- -YR'- i+'^';:: -is:, _ �.... ._ - ... .W� .. . _ ,-.,_ .. .._ _- ... _..... ,.: .. ._ _.^�...__- .... -i- __ .o--.. _T -.. ... »k""q�.-,.st' =-,. fir.. .`;�s'_,•,+;.:z•.:' - a , , ..,._._ _ ,.-._ ._�, 4.. -,.-. -a. k. •':x-w.,..'>X". .�.*,", _ .-.+R.-5.--•t- �i#�cc" ��°.r ".`�` :. - :s.� 5. sue,._ is°' M��,' - - ... ._ .- �... ._ ._ ....+'eY _ _- :: : .. ... ._ .- . .= -.... r .., _ ..... .....-_. •'2-.,-_ .ems`-'` m�' ,�rt'E '-c.s