Loading...
HomeMy WebLinkAbout0391 MAIN STREET (COTUIT) - Health i 391 Main Street, Cotuit _ A=022-026 i� 4 i TOWN OF BARNSTABLE LOCATION f OiA j/J S1 SEWAGE# ,®/ ? O `VILLAGE c U_rU 17 ASSESSOR'S MAP&PARCEL 0��P -0C�� INSTALLER'S NAME&PHONE NO. 0 O N C--- R t�,In + SEPTIC TANK CAPACITY( A %&6 f— /5 8 0 LEACHING FACILITY:(type) Q,.k A VK 6el�5�re (size) NO.OF BEDROOMS OWNER PERMIT DATE: '1 COMPLIANCE DATE: LJ Separation Distance Between the: / Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility p^!` A` 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 'ST,c ►tea d d � �W � 'Ica w r e7 1 m TOWN OF BARNSTABLE LOCATION �gl = SEWAGE # VII.LAGF �YSSO 'S MAP & LOT CPHONE NO. �� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: �� 0 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 No. Fee �© i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for bisposal 6pstrttt Construction j3erttit Application for a Permit to Construct( ) Repair( ) Upgrade(30 Abandon( ) ❑Complete System /K Individual Components Location Address or Lot No. 3'5( ✓IA•rrt ST Cc -rul O<< er's Name,Address,and Tel.No. 6J l= eO se Assessor's Map/Parcel ZZ' 0 Z_(v S i t M A ut S-7 co7o17 Installer's Name,A dress,and Tel.No. Designer's Name,Address,and Tel.No. 64e--ffal(i 4A&. P—iatW(t,��cA W4 P, gcb-tolcc" 501111cJ2.i./erle Type of Building: Dwelling No.of Bedrooms Lot Size ( � !7 I Z. sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd gpd Design flow provided D gpd Plan Date ?— ZS —(-7 Number of sheets Z Revision Date A,O /i R Title Size of Septic Tank Type of S.A.S. 3 .a ✓C.c:'`l S'7 CGI -Lj e tS Description of Soil ,Q�2 �f-�-✓) Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board ealth. Si Date Application Approved by Date b Application Disapproved by Date for the following reasons Permit No. Date Issued No. /< Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' F BA PUBLIC HEALTH DIVISION - TOWN O RNSTABLE, MASSACHUSETTS Yes 01pplication tf�or'Zisposar *pstrm Construction Permit Application for a Permit to Construct( ) Repair( "Upgrade(X Abandon( ) ❑Complete System Klndividual Components 4 Location Address or Lot No. 3 r v'11%A(ol S T CvT i : ner's Name,Address,and Tel.No. +(Z 0+r e /tic �X.iS ter, Assessor's Map/Parcel Q ZZ' 0 Z!0 -' (,'0 7, -7_ Installer's Name,Address,and Tel.No. � � Designer's Name,Address,and Tel.No. /� t7 C t 1,.S 7 Q/cR a �4 -cc t 1 S i C/2 C.�e✓i Cir- Bax (�6� SAd�c9c, cat,,tr�c� � & 217oo rtJ / r' 2 2 ' d`ins c. e -��i.t 82, r 7+�' Li Type of Building: Dwelling No.of Bedrooms Lot Size �. T1 Z- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �h/t� gpd Design flow provided .5 o gpd Plan Date 2?, /7 Number of sheets 2_ Revision Date A v Title a,✓ \ f� Size of Septic Tank `j�C> Type of S.A.S. 3� L ft C q S J Description of Soil j' x- ( � a e �- Nature of Repairs orAlter Alterations Answer when applicable) a Date last inspected: Agreement- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board 0,;Mealth. Signtr'd--7! , Date Application Approved by Date 10 a._ Application Disapproved by Date for the following reasons . Permit No. 4� Q j Date Issued THE COMMONWEALTH OF MASSACHUSETTS -- BARNSTABLE,MASSACHUSETTS Certificate of Compliance . t. . THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( �) Abandoned b ( ) Y �✓� at 39 1 M k c ,l S 7/—R?' C � O'Tt%t 7 has been constructed in accordance G with the provisions of/Title Sand the for Disposal System Construction Permit No..^,I�' -65/dated p Installer 1 /p, � �ji Designer U`t c,C 0J , \ i #bedrooms Approved design flow 'CI gpd The issuance of this permit shall�of be construed as a guarantee that the system w'1-1,165—c R Date 1 ✓� � Inspector ----- ------ No. Feej��------------------- -------------- ----------- -- C�'' �-� ------------------ --------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -isposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade(A Abandon( ) System located at Cc'A -7- d 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 m sstt be completed within three years of the date of this permi. -------- Date Approved by \ �I a 3�5 Town of Barnstable .�IINGE Regulatory Services Richard V. Scali,Interim Director BMWffABM 634. ,p Public Health Division i Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Desi ner Certification Form Date: / // Sewage Permit# Assessor's Ma \Parcel 00 Designer: �6�ig_. �,�,�vyr, �'�' Installer:. /,j���!•;K�y�i:� '�X C_- � ��l Address: �, L � ��� Address: 9 D u F On 3 was issued a permit to install a (date) (installer) septic system at 3 t�3 f based on a design drawn by (address) 6 ,t,v D�'�`�+'t' dated (designer L/ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the"soils were found satisfactory. I certify that the system referenced above was constructed in corn liance with the terms of the IAA approval letters(if applicable) NQF (Instal er's Signature) .R N 70 '(Design es Signature) (Affix De QWerer ) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc Town of Barnsiable P# Departitnent of RegWatory Services { zu►rw�ruar�a Public Healih Division Hate .:. Meas , •200 Main Street,Hyannis MA 02601 Date Scheduled rF I Time. `l Fee Pd_ f� j Saul Surtabzl� Assessment or . - �. Assessment.for ag ,Dzs • . .� � . �. • e posaL � . . Performed-By: Witnessed By: LOCATION&.GENERAL INFORM,A.TION Location Addressp .� �� Owner's Namo D 1L°��6L�0�� �7A•���-���tLldU�od/ ¢ �` ` Assessor's Map/Parcel:` t /�/f,� a sg S�rLv Corr COV5 ` Engineer's Name^ ! NEW CONSTRUCTION REPAIR`` / TeJe honeLan . /7-1 Slopes(46) � -Surface Stones Distances from: Open Water Bed ft Posslblc Wot,A ca /"' ft Drinung Water Well eft Dmihaga Way ✓vi ft Property Une ft Other. 7vU w f-ft" SIK.ETCHC(Stmct name,dimensions of lot.exact locations of test holes&Para tests,loeato wetlands•tin proximity to holes) i �- - •fir ....:..�,r _- `_� .s._�z«- _ ,.- j - - - - Parent material(geologic) l�'`Z QV` Va ' Depth to Bedrock r, z Depth to Groundwater. Standing Water In Hole: 'v 6 �� Weeping from Pit Fo'ce D Estimated Seasonal High Groundwatcr s DETERMINATION FOR SEASONAL'I[IGH WATER TABU' Method Used: Depth Opsorved standing in obs.hole: Afk In. Depth to soil mottles:.tl,' Dc weeping from atdo of��a/hole: In, GCtlundwate ustMnnt ft, _ Index Wall-# RoadingAato. ..v //F Index Well]'Vol Adj.•thetbr�Adj Groun : ator- eval,,,�/o f -'PERCOLATION TEST note s / 'iY1ne /� Observation ` � ` Hole# Z Time at 9" Depth of Pam t��'? /• v7"�`!� , Time at 6" Start Pro-soak Time @ f 36/ -__`� Time(4"•6") End]?ro-soak _ Rate Min./Inoh Site Suitability Assessment: Slid Passed 31tp Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back-- ' ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conselrvation Division at least one(1) week prior to beginning. QASEPT[WBRCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole Depth from Solt Horizon Soil Texture Shcl Color Sall. Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stone,Boulders, o ialstency.%6 Qravan -' � z ZS 6 r If !714VAW 410WI, DEEP OBSERVATION HOLE LOG Hole Depth from Sall Horizon Sall Texture Sall Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Va 711 y �d p T-I ,e 5! i— r _ � a 21- 3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil horizon Soil Texture Soil Color Sall Other Surface.(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sall Texture Sall Color 81311 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,SSow'.Boulders, Flood Insurance Rate Map: . / e 00 year ood bound No Yes V Above 5 Y � �Y - Within 500 year boundary No= Yes,:,.,,. Within 100 year flood boundary No-,, Yes death of Naturally Occurrine Perylous Ma>erlal Does at least four feet of naturally occurring pervl u mtterial exist in all areas observed thrpughout the area proposed for the soil absorption system? - I .• If not,what is the depth of naturally occurring pe lous material? ....... Cer'ti.�on I certify that on '�� 95 (date)I have passed the soil evaluator examination approved by the Department of Environmen 1 Protection and.tha he above analysis was performed by me consistent with . the required tra1 ,exp Use an a cc scribed 1n 410 CMR 15.017. Signature Date Qc1SBPTl0PB1tCPORM.DOC EX. DWELLING LF TANK Z SHED " cs EX. 341.41 o, BARN a SHED PROP.16'x21' SHED R&R c4 0 CER TIFIED P_L 0 T PLAN : . SEPTIC FROM ASBUILT MBLU 22-26 ST ON FILE AT THE TOWN I CERTIFY THAT THE IMPROVEMENTS SHOWN OF 391 MAIN HEALTH DEPARTMENT HAVE BEEN LOCATED BY A FIELD SURVEY. Ass9c COTUIT, MA BUILDER TO CONFIRM ti DRAWN: RBS DATE: JUNE 22, 2016 ROBB �, JOB #: 5250 4 SCALE: 1"=60' FLOOD ZONE X No.YKES 35418 H DWG. CPP LOT AREA 1.25 AC. EASTBOUND JG y/ 'o� O LAND SURVEYING, INC. / P.O. BOX 442 FORESTDALE, MA 02644 ROBB SYKES, 01S. DATE 508-477-4511 Commonwealth of Massachusetts Doha 6�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t` 391 MAIN STREET Property Address r• NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 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. Impg out forms When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not JOHN P GRACI SR use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS LLC r� Company Name PO BOX 2119 Company Address I TEATICKET MA 02536 . City/Town State Zip Code 508-641-6694 S11468 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 Evaluati by the Local Approving Authority 01/23/2017 Inspector's Signature Date The system inspector shal bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 3 ays of completing this inspection. If the system has a design flow of ;. 10,000 gpd or greater, the spector 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 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: AT TIME OF INSPECTION SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY. 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): NA t5ins.doc-rev.6/16 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 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B System Conditionally Passes ((cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): NA ❑ 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): NA 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. Cityrrown 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: NA **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: NA D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: i 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.doc•rev,6/16 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 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 GALLON SEPTIC TANK DISTRIBUTION BOX AND 9 INFILTRATORS Number of current residents: (1) ONE 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 TOWN 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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: NA t5ins.doc•rev.6/16 I Tit e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 P 8 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 391 MAIN STREET Property Address . NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information a Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 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: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: (8) EIGHT INCHES feet Material of construction: ❑ cast iron ® 40 PVC 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.): SEPTIC TANKS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERTLY AT TIME OF INSEPCTION Septic Tank(locate on site plan): Depth below grade: (2) TWO INCHES feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK MATERIAL IS CONCRETE If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON SEPTIC TANK Sludge depth: (4) FOUR INCHES t5ins.doc•rev.6/16 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 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 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 (30)THIRTY INCHES Scum thickness ZERO Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES Distance from bottom of scum to bottom of outlet tee or baffle 0 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.): SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5i6s.doc•rev.6/16 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 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. Citylrown 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.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 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 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/2312017 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 BOTTOM OF PIPE 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.): DISTRIBUTION BOX APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. 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: NA t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: NA ® leaching chambers number: (9) INFILTRATORS ❑ leaching galleries number: NA ❑ leaching trenches number, length: NA ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number: NA ❑ innovative/alternative system Type/name of technology: NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (9) NINE INFILTRATORS WERE VIDEO INSPECTED. AT TIME OF INSPECTION SYSTEM APPEARED TO BE FUNCTIONING PROPERLY. INFILTRATORS WERE EMPTY AT TIME OF INSPECTIONS. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA G2635 01/23/2017 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.): NA. Privy(locate on site plan): Materials of construction: NA Dimensions ' NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..J° 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 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 r0KcH zv z 5NED [fil 0 3 ' I Al- 14 I2- 10 0- 10 t5ins.doe-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is COTUIT MA O'2635 01/23/2017 required for 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: 12+ FEET 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: HAND AUGER t ` Before filing this Inspection Report, please see Report Completeness Checklist on next page. _ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 391 MAIN STREET Property Address NICKERSON DEIRDRE Owner Owner's Name information is required for every COTUIT MA 02635 01/23/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' i _ �\ COMMONWEALTH.OF MASSACHUSETTS EXECUTIVE-OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: CD P .Owner's Address: "� st1.- / sZ 7 - tr Date of Inspection: 1,6A Car) Name of Inspecto (please print) CD X Company Name..' 3Z �f(�iLG�� Mailing Address s .. Telephone Number: S- C)q-.. / ._ ; 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.] am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). .The system: (1 Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority '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. '~ Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I p.. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: Owner: r Date of I spection: ` 4EJ taQch . Inspection:Summary:. Check A,B,C,D or E./ALWAYS complete all of Section D A. ystem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.30�,orin _10 C�IVIR 15304 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, vyill pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined'.'please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank.failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the.Board of Health: *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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: r 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: r. Owner: Date of I spection: d o, ((� 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 wilt pass unless Board of Health'determines in accordance with 310 CMR 15.303(i)(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 Zone I 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 coliforrrz bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen.and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form: 3.. Other: 3 ' - _ 1 Page 4 of 11 OFFICIAL INSPECTION FORM-.;NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE.SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N _ Backup of sewage into facility orsystem 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number J of times pumped 1 a/ 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 I of a.public well. Any portion of a cesspool or privy.is within 50 feet of d.private water supply well.. Any portion of a cesspool or privyis 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.]have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the.system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E: Large Systems: To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following. (The following criteria,apply to large systems in addition to the criteria above) yes no — _ 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.: A 4 . Page 5 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: w Owner: CQ/ `- Date of Inspection: J ,cn / Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes—o _ Pumping information was provided by the owner,occupant,or Board of Health 1/1 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?. / v 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) i/ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for'signs of break out? ' t/ 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: ` ZYeso 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: 9i kl n; zxtee-A Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL i/ r l Number of bedrooms(design): Number of bedrooms(actual): 7 DESIGN flow based on 310 C R 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(yes or no):AID f if yes separate inspection required] Laundry system inspected Vej or no): v Seasonal use: (yes or no. . Water meter readings, if a Table(last 2 years usage(gpd)):011 4 , © 00vo Sump pump(yes or no): Last date of occupancy: -C'1lJtJ�(, t.� COMMERCIALANDUSTRIAL/�/C) 0 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 inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM " eptic 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): pproximate age of all components, date inst fled(if known)alid source of information. Were sewage odors detected when arriving at the site(yes or no) 6 Y Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: ems, /­44 Owner: ee �-2�,• Date of In pection: (p III BUILDING SEWER locate on site lan !D ( P )./1 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) r� Depth below grader , Material of construction:_concrete_metal- fiberglas's_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: lO 6 X& Ica J Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: p. Distance from P c m to of P scum to to of outlet tee or baffle: ---- Distance from bottom of scum to bottom otto of outlet tee,or baffle: How were dimensions determined v' , Comments(on pumping recommendation inlet and'outlet tee or baffle condition,structural integrity,liquid levels related to outlet invert evi grice of leakage,etc): /r f GREASE TRAP (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.): I 7 Page S of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: ace `�t✓1.�0 �l Owner: ' Date of I .spectio 4 fi.Af&(N Cco( 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: V (if present must be opened)(locate on'site plan) Depth of liquid level above outlet invert: &*W Comments(note if box is level and distribution to outlets�ual, any evidence of solids carryover,any evidence of _l. akage intd or out of bo et ): ✓� PUMP CHAMBER-/4L(locate on site plan). Pumps in working order(yes or no): . a 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: .,. , j� ' Owner Date of In ection: ke SOIL ABSORPTION SYSTEM (SAS):_1/ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: i:2, 1eaching chambers,number: 1eaching galleries,number:.� leaching trenches,number, 1e6gth: 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 y Vkhroo ,6. N nX CESSPOOLS: 4) (cesspool must be pumped as part of inspection)(locate on site plan) Number and confwuration:. 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): t n PRIVY:A/� (locate site o it plan)) Materials of construction: Dimensions: Depth of solids: . Comments(note condition of soil, signs of hydraulic failure; level of ponding,condition of vegetation,etc.): r 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address.:' t) .C/L Owner: Date of I pection: r /3, t:)( j SKETCH OF SEWAGE DIS POSAL 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. 6VIM 3 I/_ _ / I, 10, o , 0 ,Rf C4�70 J� 'I 10 - - l Page 11 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: g Owner: r Date of Ins ection: �� • JCa-'S� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6 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: Ii i 1.1 `fx Permit-Number:, �u umti.er:' Dater Completed by: J�� HIGH GROUND-WATER LEVEL COMPUTATION r: ' 4 Site Location: i f /UG d� c15� n Lot No. Owner: /' ``, Address: Contractor: Address:,+ CL Notes; r k! STEP 1 Measure depth to water table to.nearest 1/10 ft .............................................................................. .Date i month/day/year. STEP 2 Using Water-Level'Range Zone and:Index Well Map:locate site and determine: O'Appropriate index well......... ......... ......... ............... OB Water level range zone ............ G STEP 3 Using monthly report "Current Water Resources.Conditions" determine current depth to water level.for index well ........................... �A month/year i STEP 4 Using Table of Water-level Adjustments for index well. (STEP 2A),current depth. to water fever for index well (STEP 3), and yvater=level zone (STEP 26)' determine water-level adjustment ................:.............:......... ............. STEP 5 Estirriate depth to high water 'by subtracting:the:water level adjustment(STEP 4). from measured depth to water :level at site:(STEP Y) .:.... ....:.... Figure 13.-Reproducible compufation form. .15 . . .. , _ , ��_� �y --=�._ . . '. �.. � � . � . - �� L: . . �, `--a' _..._... .. - _ _... - � _� � _ _ � �. ' . � �� _ ' . 1 . � '�, . � � & , � � : . , � �� �� � � �. � � �. �� � �� � � .. . .. ,� �� �► � . , i.__... TOWN OF BARNSTABLE ..L' CAUO' N SEWAGE # l V.JLLAGE ©���•� ASSESSOR'S MAP & LOT®Z�' INSTALLER'S NAME&PHONE NO. � /� � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /n^gf��.� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: Sr"� !f� COMPLIANCE DATE: S ', Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �- w s? L„ S� s� . O n 0 6 �R � � .�, 0 � � � � . �.� .,, � '� �. o .. �l. `.�y.ai `` .F�'� � � y' 4� �� _ � �/ No. r s ,.h Fee �� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatton for Migaal *pgtCm Com5truction VCrmit Application is hereby made for a Permit to Construct( )or Repair(✓)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,A dress and Tel.No. GU tai r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. r1pze1,i Type of Building: Dwelling No.of Bedrooms / Garbage Grinder(✓W Other Type of Building Xe5/ eeee No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ile gallons per day. Calculated daily flow gly'® gallons. Plan Date Number of sheets Revision Date Title 5,W7'V 1✓ A'�i Description of Soil Nature of Repairs orAIterations(Answer when applicable) /S'��'® !��/®h �`4��� — �`ek 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 b his oar He v Signed Date l / Application Approved bya Application Disapproved for Lea following reasons Permit No. Date Issued No. ®� / Fee v 1 THE COMMONI(►tEAL'TFF'OF MASSACHUSETTS fr PUBLIC HEALTH DIVISION`- TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for MigtJOgal *patent Conmruction Permit F, ':Application is hereby made for a Permit to Construct( )or Repair(1/)an On-site Sewage Disposal System at: s 'Location Address or Lot No. - Owner's Name,Address and Tel.No. GO tG�J ' iG1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: DwellingNo.of Bedrooms - Garbage Grinder g (__11 Other Type of Building No.of Persons Showers'( ) Cafeteria( _ ) Other Fixtures Design Flow //0 gallons per day. Calculated daily flow yyG gallons. Plan Date Number of sheets Revision Date Title � ah Description of Soil Nature of Repairs or Alterations(Answer when applicable) O�J�Of� /5�00,Q4h y`Q11/� �-44,0-e—IPK . N-,o Jry 4:/,roles'.s w/x4 ,s t©4 to x /.5- ,De ea Date last inspected: 7. 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's of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his oar Health. X,_,\ x Sigled Date Application Approved by Application Disapproved forVhl following reasons t 4 Permit No. Z��, Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Certificate of (Compliance - .-i THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or re aired/replaced( on by j?0/'fj'La'&j �D/157`. for /Ut°'�"�'✓`;UX as /y1q H 'S C' J` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - al dated Use of this system is conditioned on compliance with the provisions set fo below: t' 9 J f f No. /V Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �Migogal *p.5tem Construction Permit i Permission is hereby granted o to construct( )repair( an On-site Sewage System located at � I 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. All construction must be completed within two years of the date below. Date: ' �� Approved by , r � ` ix II z� O c� I G i . C 5tJLN f { 7 � t ;J { 1 e � 1 v t"77K' Sf`(..`s-M.a'FXxY=t%-�*s,x�'-a"'..{?�tc`,,,,.�.•9„iy�`-a y-t.,�c�•'?r c�".-..24. $r�YJ.,'+s.x�i:'>Ev `n'1". +fit...w"a.s,,:�`,'.}•4 eY� •`S:M'.w3.tR r nrc*.z.J aez' '.:k...-?,;.5,•srS'+s.'Gr-.r","r , r 1 a� : &xK';u�£>s' .r.cd 4fi-r`?-4n}a{ 4Wi•.ts*,'.,.'b er�" s`stye 3`:,Z..x r^z�''i✓r",3P r{'*�s?x�,-'.:6•d.,`• ;!x.+�•7'.io'-a,u':".r�.a ,p--•. xY� rc -S; "r. 'sr - .:..d r a. i�•9 r + fi c,N rN N .,,. E ::i,+ .k .n d�' r ,wa'�-•' '.' i c,:. ter,4t `3 c-+a';f b< . s a,�i- .•r 3a-o `°,, ;Y`m �. P,S `P h^xt^` r.,��b.;r e+,�$1.. _,a..m.`"i .9 •. �r,. '� S- t ,eAr>a:..r,.jhE.},.E.K`:,!.�i s�$Yar r`y q,'5P..�.,,=�r+-;..r..'`�t-.'g+kJ xt'•.Fzt3,,^,'f•'`,�,,��•Yi�i-4+C.:.i,. i'°gkse•^''�as$�ht,';rC'YS``°'a.°a t4Y',Vi2�`-�>r aa,..;..:�,,v3h;=�L- �'.�q'.i't"a St.,,._,.,.:"".;��''rby£f..S X,'�rC'•"r-§.s.;`?,.r+r�f^`"�L,,`,a,`.Ia_",`,z�.t";.:,r r1'i arx tC�,v".A.`,Y4k�t,ht�'x#ti,:..�!.,5,v{�`�s>•,3 e7a.'r°+,a,�`.''r-,-.xti'.44&y•`++y''.'.�tf.7 el�,'i,'y'"ama,'6,.._Fa.u'�rrrx xt'ai f-s,'3,'S.w J.A-x.,.`:.T`.§.t'''t..xJ:,..,�.si,.'afi'�3,,.gswaB•*R-x�t,;:{^,^s�:+E.p..+.a+.t�?'r rt`.x'�`sti.k'y'F�s$#�r''1 k`•%y,k k r`--ta+t:b-V.:.GN+-r"�.x.Jr '3m T1�f:<•r h r� ^ RIN,x � A �' + #! 4ia g+ ��tD2r rt 2,d,.f 'r_M .r C"r a '�•x-� r. c;.r s>LFg't 'r`:.',�r z„ yk,i �ny'"Y' 5 ."'' ,� A - rt "^ 'a z s, r � ��.,'�"! f� �, %. 'A`Y'.�14�t`� di'�`�` 1 ".'�w.v .-i?,�+j' .r.. ,�, r ai,��t p"f `�..e'�' +i toS::et7'x 44•.c r. 'C' 3Y�.�:�� �f%r .� r f`v'�< •vz 'r:..'i+ ,+.. � r' -';z' -r'rz - ' g r ?SY� Jx �s .'� {3` „�i'rrr MSN�:'-rx'rw. >_�Tra'uai a ,�..3 x�' ..J t{_. "` +• r �.. , , . .``'`> -i`ri .n a •f^i sW'£ Y x� .+„ ^,# `� sn tgy.�tf�.s�k..-S'�'�`... �' �s x 'J' s%Y a >w :. ��i xr, a. - t ERTIF �s•"c Y ti x. �+ r,7 ,Y s;:.c}f 5' r {,...wz-.,�w _; s CICATION OF,SKETCR AND APPLICATION FOR A DISPOSAL . WORK3CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI 4 r - ; z& ;l '`.�, 5a i' xs 4A :r ' x _:w ,xi. .5 y..: r 2e ,YJ Crl •_ ..# r x c 5�.t, t� vsr �,5 i 'za' t e s� 5 r x ',` f x `k�-w � `• Y .+ ✓¢ �y " a i-r< 'a .k� +'.rti' r 7 ,z"' �x`'w#1- $ S t .. r }ra g � r � �b i�� r r}# - e .� S. �..'Zllkll x 3 I�i ; hereby certify that the app itcatton fo d T. tsposa]works s > K ��+, G" srn$ 4�„F4;,fi1d7 K�.t"'ya5t '.'.•C c4 S's' �. k " 4 3. 1, gµ �, t '.,� �c�y k- r �'E 4,,s. i'� it q r-,j -_t5 t - . u 5 k 1 4 const u petmtt stgneti by me dated Z�. " `` ruction F l' � CO 8 t + Propertyaocated at meets all of the followtrtg cnteria ., There are no wetlands within 300 feet of the proposed septic system ere are no pnvate'wells within 150 feet of the ro sed. P Po septic system e observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase in flow and/or change in use proposed �There_.are no variances requested or needed. SIGNED '.DATE: _LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system,Also if the licensed installer posesses a certified plot plan, this plan should besubmitted] '��kg�J�,S�, �'r"•rf: iz ,s''�ri-.a?.`f,p :,� •Y �,y�q..e•r�.,y'} `,� '.N t 'tl ra �r."' 'A 3 `Y* .•.,fit f u s ' �,>_ �,a' �r'' k:..: , e» ' s mr„i't' ' r'�: §" St'C`^.a r•:;< s.: ,n, :,r'' -.:t :., 'z , ';i *�S � '+ *X' s }_ ;-.. =•rrt^ ,;.,�. s y>. a � �:' �i'.;,. +:- k� .'' . rv`rss,s" r. Ri -p:,; <*`;_' §, .jTM e4. �#+'.2 �35 �t'.9.a iawr S'�, ""`"ai�` P �,.` 'a'f ¢• •+ y$ - 1,.� 7� �� �*`wfx,'�."•'i,-, :.,..%, r.� .•, �,.,,� `Yrt� �.�, � -�� s"'£�r�S4 tr S- � i Y� �� rtii�e;�'. •�+k�. 4 ,A, 'St zt 'S'' >��,t�� ��.�������'' .., .` •, ,t;+wt�: �� ,n,,,.r ',-:��✓,�- �:: t ���.,,,.:,• r tXf�� a'atik`",'i'aJ S���J,7"'Y.,�,r. � z=�� r.: �.y.. �' .. ��. �• ,, ..:n�`" s,i�.�`!^74<;F- .��.n 'y rhn.. y„ S.ti c,.'i'iY. g a�i•-�,,A�t u.S,i. F :�43 u•" .r-*:x�L ,s�;..:a n/. 'mod` < r.'' �v{r�� � �.§T�!{ :..x � � r j � � � �- 'T'�s �'S �`iz• � cs" � -�� s` w ^,��� �4i #`�. � � '`r ,fit,�' �d} Fjr'K�' 1`h� „a "'3 # � � ..• y't��+Xa` EF � �n� J� ��r::�' ` 'F+fi' `�,�" `�,d 'S �,s•., ,�t•� - ,�� x+...�2s'x`1 tz�.,k+ra+�'4i U E i� �"1 �. � �,a '3r�y .r» `����'x, a°� � F�lt.� � � » ^"+�•�e��� � _ r �`%r+x.� ., {y�.A.v._c. i... {?�.. ,a4rw hb y �x..r�u a, S� >.;.,.. �rz� ix r •4:� �•. _-- .'1'i.x`;{. �•.,- r,Ka;,� `'.�:.' ... ,..;:s���,zb�K;t~; {7 -..�':,, , �... COTUIT PLAN REF: 375/43 \\po TITLE REF: 26112/326 \ Z$. PARCEL ID: MAP 22 PAR. 26 \ I/ ZONING: "RF" SETBACKS: 30'F-15'R-15'S { �Ov � ' MAX. BUILDING HEIGHT: 30' S ZONE 11:"WP": WELLHEAD PROTECTION ZONE SP�P�O O FLOOD ZONE: RIND ZONE: EXPOS. "B" PARCEL A2/271D: $PEEVE e COMMUNITY PANEL: 25001Cb7525 DATED:07/16/14 THE wnTER LINE �'� .Z1 LOCUS 391 =, UP Q VARIANCE REQUESTED: TOF=60.9 W (o ) p�0 Jfi PER 310 CMR 15.405(1)(B): •TO ALLOW S.A.S. COMPONENTS To BE INSTALLED BnwooNo°° pis sj Q Q 5.5' BELOW GROUND, VENTED AS MITIGATION PER TITLE FIVE 9\� PROPOSED 1500 GAL. TANK e , p ►: ° O N 60 /OCUST (off co LOCUS MAP ,O�w _-= OP��' // Y Dc ° �/ / FLAGPOLE p�h' NOTE: Doh - L�6, DB ,� OO NO PLUMBING OR s h �G� -- sss 0' / ° #1 /:\F't' HABITABLE SPACE c�j. O ° h 9.3 / b�. �O IN PROPOSED GARAGE S ,�`e, ��. rr o• Q TP#z Q 03r, / �� �� 59.4 h O F / �o �oo- CEDAR CD TW/MAP. . PARCEL2 61D: N 46.1' �. ��C'�+ /� ' 1wV NT B�o—CONC. �p�1•�`1 6�, \so• R:QQ O CEDAR 2 Q �G 59.3 /F� TRI-oAK PROPOSED SITE PLAN WooDED o * NEW LEACH FIELD — 4.. AREA �R��E *. NEW•POOL 56g OO G�Rp;Ftp ,CPRwP�E� * NEW- GARAGE . E `.5 �0 LOCATED AT: . PARCEL 61D: f PARCEL ID: 391 MAIN_ 'STREET- AREA=5.4,712t S.F: 22/25-1 CO IT U I IT, MA. PREPARED FOR ' OODO a5.�� �oE �No DEIRDRE L. NICKERSON -< PARCEL ID: d SEPTEMBER 19, 2017 N —2 22/25 AFC as REV: SEPT.. 28, 2017 m 0) .1 70 0 R o �P yoTAIRV o MacDougall Surveying PARCEL ID: �� S 8c Associates �N, O F yq SqP y� P. O. Box 2428 GRAPHIC SCALE _ EDWARD � srA. Mashpee, Ma. 02649 o zo ao so Aso t No.2898 PH. (508)419-1086 E�° CELL: 774—327—0617 �i s NA email: ( IN FEET ) � macdou gall survey©comcast.net 1 inch = 40 ft. SHEET 1 OF 2 J#1920B c ti 2" LAYER OF REQU. 1/8" - STONE . .... i/2" VENT HOUSE DOUBLE ORLF FILTER FABRIC TOF=60.9 C • LEAN SAND- FILL PER 310 CMR 1�5.255 • 59.8 5 , 59.3 59.3 59.3 iezeee11.10 ­111 ����������������� 59.49 i.1eee i11 eeee ' iiiiiii""'iiiii i iiiiiiiiiiiii iiiiiiiiiiiiiiiii iiiiiiii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiiii iiiiiii .iiiiiiiiiiiii i�iiiiiii iiiiiii : -:::���� 4° SCHEDULE 40-P.V.C. EXIST, MIN: PITCH i/B" PER FOOT RISER RISER RISER RISER 53.8 �0' 0 S=.o7. LEVEL 4' 4, 4' _ FOR 2' 14' m S=.01 4 ., 58.5 ton LIQUID LEVEL a 5g24. r: ® .� ® ®, ® ® ® ® ®• 0 ®. ® ® ® am ® .� ® ®` TIE MIN. 14 P 159.0 53.11 , ® ® ® ® ® ® ® ® ® oo° ® ®' ® ® ® ® 00c E A�SE ppFF NDS. (2)INLETS 53.11 MECHANICALLY 4 000 ®. °�• ® ® ® 0 T® oo ® ® ® ,® C3 ® 0 a 0 C2 ® 0' ® ® ® 00 0 93 48" ADD COMPACTED SAND ,, c c 0 GAS4 BAFFLE EXISTING .. PROP. DB-56 52.8 3/4,,.TO 1&1/S2" 1,500 GALLON Y (H-20} DOUBLE WASHED TONE DISTRIBUTION 41.5' z:0 TANK TO REMAIN BOX W/"T"&,BAFFLE: 3-500 GAL. (H-20) CHAMBERS M Q in BARN (5'W X 8'-6"L X '3'-0"H-) 59.8 iiiii iiiiiiiiiiiiii.iii 59 0`: TI CH A SOIL ABSORB ON' (TRENCH FORMATION) NEW'.1,50D' GAL. TANK M "(S.A.S.) 13' X .5' e SCHEDULE`40 P.V.C. 0 c SYSTEM 41 MIN. PITCH.1/4' PER FOOT FROM BARN (H-10) PROFILE Or BOTTOM OF. TEST PIT #2 ELEV:= 45.8 SEWAGE DISPOSAL SYSTEM s' ® s=.10 NUMBER" LIQUID LEVEL ---- -- 10 (NOT To SCALE) DESIGN. OF, BEDROOMS 4 E. S XISTING) 58.o MIN. 14" 5�.75 ;,, GARBAGE DISPOSAL.................--_-NO --- ADD . B TOTAL ESTIMATED FLOW , ;. g p� -DATA;'D A T.A BAFFLE COMPACTED SAND AT (110 GAL./BR./DAY X 4 BR.). __440.__ BOTTOM OF TANK 440GPD X 2.00% 880- GAL CERTIFY THAT.I AM CURRENTLY APPROVED BY THE DEPARTMENT OF GENERAL NOTES ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR-15.017 TO CONOUCT USE EXIST. t500 GAL. TANK ALSO`:NEW (H-10)1500 .GAL. F.OR BARN SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED INSTALL: 3 H-20 5000AL ,CHAMBER-S (W 4' CRUSHED..,STONE 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. ) TITLE 5 AND THE ;TOWN OF BARNSTABLE RULES AND REGULATIONS - BY ME COwsIsTENT wlna THE .REQUIRE1FURTHER o-TRAINING, EXPERTISE, AND EXPERIENCE DESCRIBED IN 310 CMR /5.017. i FURTHER CERTIFY THAT THE RESULTS OF MY ON THE SIDES,- ENDS & IN`-BETWEEN) AND BACKFILL.' FOR SUBSURFACE DISPOSAL OF SEWERAGE: SOIL EVALUATION, AS INDICA D E ACHED SOIL EVALUATION FORM, 2. 'ALL ACCESS PORTS OVER TANK TEES SHALL BE ARE ACCu N Ac D CE 3T0 CMR 15.100 THROUGH 15.107. WITH CLEAN SAND FILL PER 310 CMR 15.255 ACCESSIBLE WITHIN 6" OF.FINISH GRADE. SOIL CLASSIFICATION... ..... .__1____� • 3 ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE EDWARD A. STONE; PLS.,CERTIFIEo SOIL EVALUATOR DESIGN 'PERCOLATION. RATE..... CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER-OR WITHIN 10' OF,DRIVES OR PARKING AREAS nTHEN THEY EFFLUENT LOADING RATE......... __- MusT WITHSTAND H-20 LOADING. REQUIRED LEACHING CAPACITY...; 440_GAIDAY 4. THE EXCAVATION,CONTRACTOR SHALL ;VERIFY THE LOCATION OF. ALL urluT,Es PRIOR To ANY EXCAVATION. 'LEACHING CAPACITY 'PROVIDED.:::.560 GA_DAY" TEST PIT RfiESU LTS: 5.. ANY MASONRY UNITS USED TO BRING COVERS'TO GRADE SIDEWALL:(13'' .+ 41..5 )x2x(2 SIDES)(.74) 161 GAL/DAY OR WITHIN' 6" OF GRADE SHALL BE MORTARED IN PLACE. 6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE SOIL,'TEST DATE: SEPTEMBER 18,. 2017 -BOTTOM; (13 x 41.5 )(.74)= 399 GAL/DAY OVER THE S.A.S.-AND `DISTRIBUTION BOX: B.O.H. AGENT: DON ,DESMARAIS TOTAL= 5s0 GAL/DAY 7. SEPTIC TANK SANITARY TEES SHALL.`BE CONSTRUCTED OF ' SCHEDULE 40 PVC AND SHALL EXTEND A'MINIMUM OF 6" ABOVE SOIL- EVALUATOR: ED:WARD. A. STONE 560 GPD PROVIDED_ 440 .GPD REQUIRED = 120 `GPD RESERVE THE FLOW UNE AND SHALL BE ON THE CENTERUNE AND LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. B'ACKHOE:. BRET ELLIS q 8. THE INLET PIPE INVERT ELEVATION SHALL BE:NO LESS THAN SEPTIC SYSTEM-STEM DETAIL PAGE 2 INCHES NOR MORE THAN 3,INCHES ABOVE THE INVERT f1 �� ELEVATION OF THE OUTLET-PIPE. TH�f 1 EL.- _59.3 1 MAIN STREET 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. ELEV. DEPTH IN. HORIZON TEXTURE COLOR MOTTLING OTHER 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS ( ) COfiUIT, MA. BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC;' 58.5 0"-10" A � LOAMY `SAND 10YR4/2 N/A, 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND;. 57.0 10"-28 B LOAMY SAND 7.5YR5/4 N/A SEPTEM.BER 28, 2017 FIRST TWO FEET OUT OF'THE DISTRIBUTION BOX SHALL BE LEVEL. 53.3 28"-72" C1 'SANDY LOAM` 15Y6/3 N/A 1.2. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION 49.3 " C2 MED. COARSE . 2.5Y7/4' N/A ` TO MACOOUGALL SURVEYING FOR B.O.H. 'AN0 DESIGN ENGINEERS REVIEW 72 .120 M a c D O U gall,I 1, S U r Ve yi n g AND APPROVAL. G �M NO MOTTLES, NO GROUNDWATER ,s. PROPERTY WITHIN ZONE II TH 2 E L = 5 9.3 P E R C ® 7 8 <2 M P I) • � .: Associate' s* . �� . w CONSTRUCTION NOTES: P.0. .. Box 2428 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER t A A A A ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 58.5 0"-8" A LOAMY SAND 10YR4/2 N/A 70 M a s h p e e, M a . 02649 WORK ON THE SITE. 9 ° PH. /50811419,-1.086 57.1 LOAMY SAND :5YR5/4 N/A t� t� \ ) 2.-N0 DETERMINATION HAS BEEN MADE AS TO COMPLIANCE ,8 -26 B � G'1S'TE � , WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 53.8 26"-66" C1 SANDY LOAM 2.5Y6/3. N/A "9�i/I I-A�\ CELL: 774•-327-0617 IS TO'OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. CY1ocdoUC3GIISUCV6yC comcdst.net 6 3. 'ALL.SYSTEM COMPONENTS SHALL BE MARKED NfITH MAGNETIC MARKING 45:8 6"-162" C2 MED. COARSE SAN 2.5Y7/4 N/A_ TAPE oR`A COMPARABLE MEANS. NO MOTTLES, NO GROUNDWATER SHEET 2 OF 2. J#1920B