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HomeMy WebLinkAbout0108 MAIN STREET (COTUIT) - Health � 108 main Street (Cotuit) � I �L uit P = 023 009 •' Commonwealth of Massachusetts W Title 5 Official Inspection Form 21 o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 108 Main Street Property Address t-ZI Katie St. Pierre ;; Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. City/Town State Zip Code Date of Inspection f Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information 51 filling out forms /a891 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey _ use the return Name of Inspector key. B&B Excavation _ Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority % ,, 3-9-18 Inspector's Signature Date The system-inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or . has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 108 Main Street Property Address Katie St. Pierre Owner Owner's Name - information is Cotuit Ma 02635 3-9-18 requiredquired for every 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: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate.of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t _ t5ins-3113 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 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 1 ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required 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 III Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is Cotuit Ma 02635 3-9-18 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: f 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i II , Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments ^M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ 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): 3 Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 336/GPD t5ins•3/13 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is Cotuit Ma. 02635 3-9-18 required for every page. CityTTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information.in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016- 105,000gallons 2017-87,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: l5ins-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 �qM 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 8-2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes,-volume pumped: gallons How was quantity pumped determined? Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1, Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank Is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallons 3„ Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 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 33" - Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ' ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Scum thickness - Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions:• Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑. No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition'of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. Cityrrown State . Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump'chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required).- If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching-pits number: ® leaching chambers number: (2) 500 gallon ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching had 1' of standing water with no higher staining when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 °M 108 Main Street _ Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): C t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 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 B _ ,..J Al-33' A2-42'6" A3-59' A4-49'6" Lo . B1-15'6" 132-30' 133-46' 134-2[7 r4rr 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 „M 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 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: No GW @ 132" 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: 11-18-03 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Main Street Property Address Katie St. Pierre Owner Owner's Name information is required for every Cotuit Ma 02635 3-9-18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 A s, �y w sfe ) O� If t'Y'S + fib' = 7 a°=ID n � —32=4• 24 r-to` 9 Z b b 0 `� / 9 9• N 3� O\A41 - 7-2" 7'2" 5 6 j. R 26 0- 9-0" o° q� 4 ,a, 0 6-11• —18, 6-11• 24' 3'1" 25 R 5 32'�4" 7-10• v -� V YYII ._. .' q.. .,...�. r a 5-2 s h y y V 36W g 1 x 10. 'T d M 4'0" 6=2" 8' x 7=2" 7=21 5 6" VA ff r. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out I forms on the computer,use 1. Inspector: 2Z only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name � P.O.Box 763 Company s a P Y Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails,; ❑ Needs Further Evaluation by the Local Approving Authority -n i 3/22/2010 -" - Inspector's Sign ur Date j The system inspector shall submit a copy of this inspection reportjo the Approvi g Autho'ji (Brd 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. I � t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sawa Dispos System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. J The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 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 c °M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 'i ❑ 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 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 %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 II , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every 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? ® El available 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 L15ins-C9/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: System consists of a 1500 gallon tank,D-Box and two drywells. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2008:63,000 g ( y g (gp ))' 2009:110,000 Detail: 2008:172gpd 2009:301 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 3/22/2010 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•09/08 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 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No- If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate_of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon 4" Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.N6 evidence of leakage.Tank appears structurally sound. i 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•09/08 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 108 Main St. M Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 108 Main St. Property Address P Y Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Chambers has 6" of water at time of inspection.No stain line higher. 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•09/08 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 ,M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . ' M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name reformation is required for Cotuit Ma. 02635 3/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately +Jb so t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 30' 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: 2003 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 117 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 108 Main St. Property Address Richard Shalhoub Owner Owner's Name information is required for Cotuit Ma. 02635 3/22/2010 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 57'1 14' 6'6 24'10 11'9 UP— v 0 BEDROOM -- LIVING AREA 2 o HALL ci {BEDROOM ON SECOND FLOOR N EQUAL BR 2 i o N MASTER BEDROOM MASTER BATH KITCHEN AREA N 13'9 7' 122 12'5 11 9 57'1 EXISTING FLOOR PLAN C 0 IAe We'll � 2,r�1�' h�ICI"r. sk /� 1.�MISEot�� n I (ova ul�f1 �r c/nIv,l > CA 'J TOWN OF BARNSTABLE �- LOCATION 11,E S74 SEWAGE # ®3- s-Gr VILLAGE Irolvl ASSESSOR'S MAP & LOT 6 2 3—OD INSTALLER'S NAME&PHONE NO. ��� �.ncyia•✓ 5/1 p�92� SEPTIC TANK CAPACITY 3-6'0 G#L l�a��4.-, sue io A 30 ,ie LEACHING FACILITY: (type) � (Size) NO.OF BEDROOMS BUILDER O WNER �✓ / PERMTTDATE: 1/ G COMPLIANCE DATE: b 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 e-pc Ls�-rn4 V` v V , C As IT O c� O C-3 J L 2003- S - ✓ No. � � Fee. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: T ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for 30iopozar *p5tem Conztruction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) 17Complete System 0 Individual Components Location Address or Lot No. Owner's Name,Address and Tel N . Assessor's Map/Parcel J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size �D sq.ft. Garbage Grinder(_e�91 Other Type of Building A/71,0!9 e- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �l gallons per day. Calculated daily flow 3,30 gallons. Plan Date Number of sheets Revision Date TitleA S 4Z Size of Septic Tank ! Type of S.A.S. i Description of Soil; Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by VZV�__ I� Signed Date Application Approved by w Date 1�10 Application Disapproved for the fo owing reasons Permit No. ;� 6 o 3 Date Issued i1 107 ` Fee—� ^� , O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS application for -Migpozal *pztemc Con.5truction Permit Application for a Permit to Construct( . )Repair(V)Upgrade( )Abandon( ) ©Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.N,9: Assessor's Map/Parcel Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. Type of Building:Dwelling No.of Bedrooms Lot Size Wd 5k sq.ft. Garbage Grinder(1 Other Type of Building e5lWpo/ . e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 11V gallons per day. Calculated daily flow 3 3� gallons. Plan Date �/.s X,�?j Number of sheets Revision Date Title .S 5%# /ryN O/, /D`3 72 Size of Septic Tank / 3Dd Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oarril of+Health. _--• Signed � j/ Date l/// '_1_3 Application Approved by Q S . Date I i //,11/Q 3 Application Disapproved for the fol owing reasons r I I Permit No. 2 o o 3 .S l7s Date Issued 41 / U —-------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CER FY,that the On-site ewage Disposal System Constructed( )Repaired( 4upgraded( ) Abandoned( )by at >4"t.f1/ .1— has been constructed i�accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 00 3 '5-65 dated /1 Installer Designer The issuance of 9s permit shall not be construed as a guarantee that the system ill functioths design ff d.- Date . "I Inspector --�------------------------------------- No. 2 00 3 Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpozar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(V/)Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to /' comply with Title 5 and the following local provisions or special conditions. E Provided:Construction must be completed within three years of the date of tl .per Date: II i) Approved by h . TOWN OF BARNSTABLE LOCATION S i%/��� S SEWAGE # O2 — Gr `TILLAGE �v� %/ ASSESSOR'S MAP &LOT n3—j�I INSTALLER'S NAME&PHONE NO. v+ d SEPTIC TANK CAPAC LEACHING FACILITY: (type) GtL ` d.�1 (size) NO.OF BEDROOMS ' BUILDER O WNER `wo PER3vMI T DATE: COMPLIANCE DATE: Q Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist �..., Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by a -3.3 ✓Srv� _ ab 4 s LOCATION�/ _ SEWAGE ' PERMIT NO. /6 © VI AGE ' l i ADDRESS BUILDER OR OW DATE PERMIT ISSUED DATE COMPLIANCE ISSUED O Q�1 e 0� �qj � roro � n A 3�� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL MAP 1 4 2003 PARCEL L. ' ®�� AUG ' LOT � TOWN OF BARNS TABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION. FORM -NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. _ A Owner's Name: Owner's Address: ,4 U S Date of Inspection• 3 Name of Inspector: please print) C� �-�• rCC ' Company Name: Mailing Address: -U- `7 D�VT Telephone Number: SQ?-, -7/ • �v�99 CERTIFICATION STATEMENT I certify that.I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and.complete as of the time of the inspection. The inspection was performed based on my training and experience in the.proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes onditionallyPasses Needs.Further Evaluation by the Local Approving Authority--/, . Fails Inspector's Signature: Date: r7rd 3 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/1.5/2000 page 1 9 t Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: g, Owner: Date of Inspect' n: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any-of the failure criteria_described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the Board of H.ealth. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed.pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: U ` 1�1A Owner: Date of Inspecti n: C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that.the system is not functioning in a manner which..will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a.manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100,feet.but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are'tiiggered. A,copy of the analysis must be attached to this form. 3. Other: 3 Q � f Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) .Property Address: Owner: u Date of Inspecti n: c D. System Failure Criteria applicab.le to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ t1 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _1/ 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 _J Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 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. _�i Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface r/ water supply. _ V Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. Any portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis..[This system.passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] �(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,the the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large'system:the system must serve a facility with a-design flow of 10,000 gpd to 15,000 .gPd• You must.indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a signif cant 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 I5.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 1.1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE`DISPOSAL SYSTEM INSPECTION FORM CHECKLIST Property Address: Owner: Al d Date of Inspecti : 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 _ZWere.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? ZWere the septic tank manholes uncovered,.opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth.of sludge and depth of scum Was.the facility owner(and occupants if different from owner):provided with.information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site.has been determined based on: Yes no Existing information. For example,a plan.at the Board of Health. ✓_/__ Determined in the field(if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION-FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: A Owner:. A0,4XZ Date of inspectiffnf 1,11,i , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 . Number of bedrooms(actual): o� DESIGN flow based on 310 CMR 15.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence,have a garbage grinder(yes-or no) Is laundry on a separate sewage-system(yeys,.or no)/I"r�f if yes separate inspection required] Laundry system inspected(yes or no)y="" " Seasonal use:(yes or no): Water meter readings, if v4f ailable(last 2 years usage(gpd)): ���D® (Z 43��Ul� Sump pump(yes or no Last date of occupancy: COMMERCIAL/INDUSTRIAVZ�- Type of establishment:.. Design flow.(based on 310 CMR.15.203): gpd Basis of design flow('seats%persons/sgft,etc.): . .. Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. � �- Was system pumped as part of the i spec (yes or no). If yes,volume pumped: gallons--How was quar`ftity pumped determined? Reas:bn for_pumping: . TYPE OF SYSTEM Swic tank, distribution box,soil absorption system Single cesspool Overflow cesspool _'Privy _Shared system.(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP.approval _Other°(describe): p rox ate a ge of all components,date installed(if known)and source of information: Were:sewage odors'detected when arriving at the site(yes or no): 6 Paee 7 of I 1 iv OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .O A . Owner: Date of Inspectio : 03 BUILDING SEWER(locate on site plan),/%/J'" Depth below grade: Materials of construction:_cast iron_40 PVC_other(explain):.. Distance from private water supply well,or suction line: Comments(on condition of joints,.venting, evidence of leakage,etc.): SEPTIC TANK (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): —(attach a.copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were.dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): GREASE TRAc�locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address:f�� J Owner: Date of Inspect' n. j� TIGHT or HOLDING TANK:Amftank 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/day Alarm present(yes or no): Alarm level:} Alarm in working order(yes or no): Date of last pumpin': Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX;, &) (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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:A&(locate on site plan) Pumps in'Working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): _. 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: JM �1 Owner: Date of In,spec on: �G SOIL ABSORPTION SYSTEM (SAS):fs y (locate on site plan,excavation not required) If SAS not located explain why: Type 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.): CESSPOOLS: Z(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: (a Materials of construction: Oyrt' Indication of groundwater inflow.(yes or no); Comments(note condition of soil, signs of hydrau ' failure, level of ponding, condition f vegetation,etc.): r ir ' J 79 PRIV (locate on site.plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM . NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: Owner: Date of Inspecti C Qj SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: �a w Owner: 44 A I )7;;;1V/1 Date of nspecti XO,? SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 20 feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked-with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Permit Number: Date: Completed by: � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: S Lot No. :Owner: / �'/ OG %�� Address: Contractor:_ �D� �O �5; Address: G/✓`r,aa �'TY / �I��ifi/�_ Notes: STEP 1 Measure depth to water'table g/V/3 to nearest 1/10 ....................................... . ................:.................... Date U month/day/year STEP 2 Using Water-Level Range Zone _ and-Index Well-Map-locate site and determine: A Appropriate index well.......:--....................................... L I Water level range zone ................... STEP 3 Using monthly report "Current Water Resources Conditions" y. determine current depth.to / —� �/`®J • � water level-for index well .................................. y month/year L STE.0 ^— Using Table of.Wa'ter-level.Adjustments for index well (STEP 2A), current depth to water level for index.well (STEP 3), -and water-level zone (STEP 2B) determine water level adjustment ............................:..... ...... STEP 5 . estimate depth to high water by subtracting the water- -level adjustment (STEP 4) I . irom me-asured'depth to water ��� level at site (STEP 1) 3 ...................: i Figure 11--Reproducible corrIpuiation form. r, �............ J I r t I -- f _r l MA )M SCALE = )L Q' APPROVED BY: DRAWN BYe'' . DATE: ju de8i n Hyannis,MA DRAWING NUMBER BARRYJONES-HENRY DESIGNER f r =rt+ • 7 _. 1 ��'• f � � w In�17 cTW���^�n 1�G �KTix I — �L�P L - --- - --- �_ I _- - _ _ _ _ 64 j C,��-T ..._.. iD ---- - _ j --- — _----.. 2.�- _ f?. SCALE: _ DRAWN BY G—O APPROVED BY: _. B p DATE: i e8i n y DRAWING NUMBER - Hyannis,MA CIO BARRYJONES=HENRY DESIGNER TOP FNDN, AT EL. 67.3' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN ENGINEER: ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE AH OJALA, PE 6 7 .O' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 60.0' �. SAM WHITE, RS WITNESS. RUN PIPE LEVEL 2" DOUBLE WASHED EASTONE-,,P DATE: FOR 1 1/17/03 , FOR FIRST 2' 3' MAX. PERC. RATE _ < 2 MI IN H Locus y PROPOSED 1500 N/ GALLON SEPTIC 57.83 CLASS I SOILS P# 10620 SLAB AT EL. 58 0' t�57.75'60.9' TANK (H- 1O ) GAS ' �0000 7 48' cx� Y [Q 00 � 0 [� 0 [] !� SpNppNER o BAFFLE 57.65 ----- 0 57.0 C7 0 0 I� C7 [� E-1 L-.l. t§t�--��2�6- ctuFMED STONE OR MECHANICAL a E� 2 g Q ELEV. * 2 COMPACTION. (15.221 [21) oS , 2 a o a ca o 55.0' >� si VERY APPROXIMATE INVERT( �° 'LOPE) � MirJ 2 A 61 .0 � OUT DEPTH OF FLOW = 4' ( % SLOPE) ( % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHY-D STONE TEE SIZES: SL INLET DEPTH a 10" 8 10YR 4/2 OUTLET DEPTH = 14 B LOCATION MAP NTS FOUNDATION- 20' SEPTIC TANK 5' D' BOX 18' LEAC!-'ING SL FAC"LIrY 5, ASSESSORS MAP 23 PARCEL 9 35" 2.SY 5/4 58.0' *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL C BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF PERC SEPTIC SYSTEM N MCS 50.0' I 494.73' (PER DEED) 2.5Y 7/4 ' PER PLAN BK212 :C� 1 493.17 CB FND II o 132" 50.0' Q I / NO WATER ENCOUNTERED NOTES:`° ca HE I LOT AREA 1.5 Co SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) 1 . DATUM IS APPROXIMATE NGVD I nG rGP: FLO'4': 3 r��nnr,r�Ac^ ( 110 (,--Dr,) :^ 330 rP�7 2. MUNICIPAL WATER IS EXISTING Fw� 60,860t SQ. FT. % I .9 USE A 330 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. -� N SEPTIC TANK: 330 GPD ( 2 ) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 6 .3 co �- n 2.6 I } � 61.9 USE A 1500 GALLON SEPTIC TANK 5. PIPE JOINTS TO BE MADE WATERTIGHT. I --- 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. �N .6 + 7.5 LEACHING: ENVIRONMENTAL CODE TITLE V. + 61. 6 .5 cr"'� , 2(30 + 9.83) 2 (.74) - 118 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT } OVER HEAD UTILITIES o SIDES: TO BE USED FOR ANY OTHER PURPOSE. _ y _ EXIST. DWELL I H �6X _ TF 67.3' 6 6 v� 5818 `o+ W BOTTOM: 30 x 9,83 (.74) 218 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. Ic,so --- - �a rn -v' 4' TOTAL; 454 S F 336 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT G u' INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 73 �6�:6 o USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH. EQUAL) WITH 2.5' AT SIDES, 4' AT ENDS, AND 5' + 42.0 10. PUMP & REMOVE OR FILL W CLEAN SAND EXISTING CESSPOOLS I p BASEMENT 60. p / ) I C SLAB = 5 .7 BETWEEN UNITS 60.9' + 1.1 45.0 W (WALKOUT) �6b. �_ _ 6.7 LEGEND - --��- _ + 65, 62 TITLE' 5 SITE PLAN I GRAVEL DRIVE 67 + 2 100.0 PROPOSED SPOT ELEVATION OF , - 67.1 66 108 MAIN STREET 100x0 EXISTING SPOT ELEVATION ,,y I�66,9 1 � - 6.2 7 s 49�'.10 100 IN THE TOWN OF: � i �� 5.4 s � PROPOSED CONTOUR (COTUIT) BARN STABLE 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI CONSTRUCTION GOODWIN 67.1 0') � + 66.7 + b CESSPOOL LOCATIONS SHOWN AS APPROXIMATE ONLY / 40 60 BENCH MARK - NAIL SET IN 20 0 20 28" TREE EL. = 63.2 BOARD OF HEALTH REMOVE ANY CONTAMINATED APPROVED DATE MA SCALE: 1 " = 20' DATE: NOVEMBER 18, 2003 SOILS WITHIN 5' OF NEW LEACHING FACILITY AND REPLACE WITH CLEAN M off 508-362-4541 D.SAND fax 508 382-9880 down cope en ineerrno Inc, ARNE H. °f "r�ssy P 9 9� y� OJALA �J,� ARNE r( CIVIL H. CIVIL ENGINEERS No, 30792 � OJALP v�r LAND SURVEYORS Ago I ST e. c d� 939 vain st. yarmouth, ma 02675 ARNE H. OJALA, w 03-330 P.E., P.L.S. DATE