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HomeMy WebLinkAbout0701 MAIN STREET (COTUIT) - Health 701 Main Street 'Otuit �— - - - A = 036010 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: 'TI1L 1`�ln vf/ key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. r� Company Name 14 Teaberry Lane Company Address --- Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S14595. 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 2/17/11 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-09/08 Title 5 Official Inspection F41,,1suSewage Disposal System-Page 1 of 17 r , i Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 703 Main Street ` Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: While I have not found any indication of system failure, it should be noted that this system is an old cesspool style system that has been used seasonally for the past several years. An change in use might affect function. It should also be noted that this system is located very near the property boundaries particularly the overflow cesspool. The house has a drywell/cesspool for the kitchen and when system is pumped both the cesspool and the main should be serviced. In addition, the house has a garbage grinder and I recommend it be removed for longer life of the cesspools. 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, wilVpass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-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 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. City(rown 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 wM 703 Main Street Property Address Rives, John Owner Owner's Name information is Cotuit Ma 02635 2/17/11 required for every 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: **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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. } E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 Commonwealth of Massachusetts @ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. CityrFown 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): n/a Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-09/08 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 703 Main Street M Property Address Rives, John Owner Owner's Name information is Cotuit Ma 02635 2/17/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes No Last date of occupancy: Nov.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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 703 Main Street Property Address Rives, John Owner Owner's Name information is Cotuit Ma 02635 2/17/11 required for 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: no reason for pumping cesspools were dry with a small amount of solids on bottom of main cesspool. 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 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form - Not for Voluntary Assessments 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 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: Over 30 years est. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): >20 Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage.Building sewer for cesspool#1(kitchen) is pvc. Building sewer for#2 cesspool(Main) is cast into orengeburg. Septic Tank(locate on site plan): Depth below grade: n/a feet Material of construction: El 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: Sludge depth: t5ins•09/08 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 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. Cityrrown 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 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.): No tank three cesspools in series. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. Cityrrown 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 M 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) s Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert no d-box Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: L t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit. Ma 02635 2/17/11 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 3 ❑ 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.): At time of inspection leaching appeared to be in good shape all three cesspools were dry a small amount of solids in cesspool#1&#2 no sign of carryover in overflow cesspool. A Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): 3 in series Number and configuration Depth —top of liquid to inlet invert dry Depth of solids layer inch or two in#1 &#2 Depth of scum layer no scum Dimensions of cesspool #1=400gal#2=500gal #3=6'x8' Materials of construction Block Indication of groundwaterinflow ❑ Yes ® No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 703 Main Street _Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of pond ing,'condition of vegetation, etc.): At time of inspection all three cesspools were dry a small amount of solids in kitchen and main cesspool but no sign of hydraulic failure. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. CitylTown 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 . 40 A2-= 3r6 13f 132= 2.I1 ' 0VC4lp�J t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 703 Main Street Property Address Rives, John ` Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. Citylrown 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: >20feet 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: pate ® 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins:09/08 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 wM 703 Main Street Property Address Rives, John Owner Owner's Name information is required for every Cotuit Ma 02635 2/17/11 page. CitylTown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE `.- ATI'ON 761 / -loth tU SEWAGE # . t VILLAGE 6Q+t `� �?-135�q t ASSESSOR'S MAP & LOT 036-0/0 INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY 1600 GCd 14 'a�O LEACHING FACILITY: (type) ® GQ I -'-1O (size) �'TA-)r� NO. OF BEDROOMS �( UILDE R OWNER A o aw (a te` `Tn Da, iJS PERMIT DATE: I�� COMPLIANCE DATE: In I©� 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 T A � = vim 64 6NM� TOWN OF BARNSTABLE L::vATION.,7�>1/''I� ,� S SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME PHONE NO. SEPTIC-TANK CAPACITY LEACHING FACILITY:(type)e.p--5 g2,a (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR WNER �� 1 � DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No O � `� G � � � v� 1 M .�,. � .a � � r No. FEE • e COMMONWEALTH OF MASSACHUSETTS V Board of Health, 13q,<A/S7A'�6 MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 70/ 01114/ J Jr, 0072< r Owner's Name Zgiz 4,-Z.4 Map/Parcel# 3& �`� Address 70/ AA ---1 jFr; r jq Lot# /o Telephone# Installer's Name Dv/v A`-�j -ae;4617 AG Designer's Name ,�9 iCjZ�jZ/�LS�/�DG•t.IC/l�iJ �G Address 70$1,Z"L/4 7-04JS /tICGGf, A-W Address y .r-�.g�.✓ 0 7Z'1zd/cis /tl� Telephone# �[--7/1— Y� y f Telephone# Type of Building `y/il/G G� �' Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building / � No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) 7TU gpd Calculated design flow fD Design flow providedS gpd Plan: Date 71.ir/®" Number of sheets / Revision Date Title c5''E.D77c c- YC7-&?v1 f�i�s9z�z Description of Soil(s) /L/&;D! Soil Evaluator Form No. RlOe& 7 Name of Soil Evaluator OGf.�'�1G�r Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 143 ti"O-Lj Q-Ii tmw exld7ir1/G c'S��/'� w/.c% 777Zcr :V� <Si ( The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tA not to place the /system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed vy�K,4 �l r Date L f Inspe i No.A FEE COMMONWEALTH, OF MASSACHUSETTS Board of Health, MA. "4 APPLICATION FOP DISPOSAL SYSTEM[ CONSTRUCTION hRMIT ,y Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 70I X64,,d Jl- C'Q !// T Owner's Name Map/Parcel# �i (o /V Address 7pl A141-/ r/ G07v, Lot# to Telephone# Q�— / 6�Gcn G Installer's Name 0Ov �j Designer's Name Address ;P•v.30X 70�A,,4kcnas ic./<CGf off Address 1, �Ai.J ST Telephone# j� -771 —' 71 y f Telephone# _j0i- 1 Type of Building S/n/G,GG G/ s Lot Size 3 sq.ft.r' a Dwelling-No.of Bedrooms Garbage grinder ( ) •Ot11er-,Type;of Building ��A No.of persons Showers ( ),Cafeteria ( ) .-Other Fixtures -Design-Flow (min.required) 7 4lU gpd Calculated design flow y Design flow provided Jul s~ gpd Plan: Date Number of sheets Revision Date X Title Description of Soil(s) Name of Soil Evaluator� "`/ GL/f Date of Evaluation Soil Evaluator Form No. RlOe o 7 DESCRIPTION OF REPAIRS OR ALTERATIONS /I���b� /� �cGhly✓G'� G�`l /�✓� �rcST��J y The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and f^ther a �ees/s�/tQ not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed l> /J i f/5���s Il Date Z �-2/ -- - _ lam} I No.AV 04,4't- FEE41* COMMONWEALTH OF MASSACHUSETTS, Board of Health,M ! / , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) `Complete System The undersigned hereby certifyy that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated ,ev Approved Design Flow (gpd) / Installer t V— Designer: Inspector: Date: f? The issuance of this permit shall not be construed as a guarantee that the system will function as designed. s NoApq ` FEE =. cl COMMONWEALT14 ®F MASSACHUSETTS Board ofHealthlIgAge¢��+ MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to 'Construct(,,�"Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at /1� 9, _,r' , rv. " r ea r.. as described in the application for Disposal System Construction Permit No. a /%ated �f ry Via. Provided: Construction shall be completed within three years of the date of thP-J s permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date U 6 ✓e Board of Health /P• '" TOWN OF BARNSTABLE f LOCATION 701 /"`ot(Iy �'. SEWAGE # v�Od t—645 VILLAGE 6CE it/bQ905�C4 1 . ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. 60?+53 k(Al,� C© , SEPTIC TANK CAPACITY 1600 Cd 14 'OLP LEACHING FACILITY: (type) C.". (size) NO.OF BEDROOMS c UII.DE R OWNER PERMITDATE: C _/n COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by T Ai = v � MiLtA s� A ��= 3C) 3 - i i I i �ATfi pots - l-IviNL7 '-#>d1�f��2 - s'I A8 NMVUQ - - -SNOISIA3lr mil 6ll 133rOdd IA7Z.'1201z 31V0 Lr NItiva d .1 �nl�rtilc J. iRa- �a � cn ZCO er cry v tron ca It- LID M. l IT i IF?* MA AC, J -44PQ uj 72 AA 41 O Q _I w --- -- -71 O dl -- --- — --- 4 �� i' Iz 1 ,�• r �z. - - '.,0.�47- �rl`��'1 s)Gi�jl •UPJ/',O•Ils.f - •- c a COASTAL KITCHEN CABINETS 5085645137 P. 01 s � J 1• Gommonweort of Mossoclw im ExecutNe OMCe of ErMforrmintol Affcfrs John Grad D.E.P. Ti lei-V Septic I •pector I al (Department of /.�O.`Box 2119 Environmental Protection ��zcke4 M 02536 (508) JAN z 4 1997 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION UNIX Property Address: 701.Main St.Cotuit Address of Owner: �� 9 i; t°i,r• Date of Inspection:111547 (If different) Name of Inspector:John Grad omyClaim Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I ceriily 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 inspection. The inspection was performed based on my training and experience In the proper function and maintenance of orrsite sewage disposal systems. The system X Passes This Inspection Is based on criteria defined In TWe v Conditionally Passes code 310 CHAR 13.303.My Mdirm are of hoe,the system Is Needs Fu er valuation B the Local proving Authority p�o�np at the time of the Inspection.MV,nspection does Y AP nol Itopty any warranty or quarentee of Me Ioncewty or me Falls septic system and airy of Its components useN are. Inspector's Signature: Date: U2im The System Inspecux shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the A r-lem 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 spp�oprlate regional office of the Department of Environmental Prolectlon. The original should b3 sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION 31JE1110,tRY: Check A,B.C.or D: A]• SYSTEM PASSES: X I have not found any Information which Indicates that the system violates any of the failure criteria defined as In 310 CMIR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more `em components need to be replaced or repaired. The system,upon completion of the repiaceninni or repair,passes inspection. Indicate yes,no,or not,delermined(Y,N,or ND). Describe basis of determination in all instances. If "not determined',explain why not.) _ TN'septic tank Is metal,cracked,structuratly unsound,shows substantial infiltration or oxf 1"tion,or tank failure is Imminent.The system will pass Inspection If the existing septic tank is replaced with a conforming septic lank as approved by:Cte Board of Health. (revised 1111dW) One Winger Street a Boston,Massachusefts 02108 a FAX(617)556.10d9 a Telephone(617)292-5500 _ 1 COASTAL KITCHEN CABINETS 5085645137 P. 02 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B cHECLIST S Property Address: 701 Main SC COO Owner: earyalalttl Date of lnspection:'In5119t Check it the following have been done: X pumping Information was requested of the owner,occupant,and Board of Health. %None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection, _ !al As built plans have been obtained and examined. Note If they are not available with N/A. x The facility or dwelling was Inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. x The site was Inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected for condition of baffles or lees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing Information or approximated by non-Intrusive methods, x The facility owner(and occupants,If different from owner)were provided with Information on the proper maintenance of Sub- surface Disposal System. f (revised 11115195) 4 , COASTAL KITCHEN CABINETS 5085645137 P. 03 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 701 Mein St cow t Owner: 0aryc1801 . Date of Inspection:111115197 FLOW CONDITIONS RESIDENTIAL Design flow:o gallons Number of bedrooms:? Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: Na Last dale of occupancy:Na COMMERCIAUINDUSIHIAL: Type of establishment*. Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no)No Water meter readings,if available: Na Last dale of occupancy: nla OTHER:.(Describe) r1� Last dale of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: tam was taut ptamped i years ago. _ System pumped as pert of Inspection:(yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping' Maintenance. TYPE OP SYSTEM Septic tank/distribution box/soll absorptions system X Single cesspool Overflow cesspool Privy Shared system(yes or no) (If yes,attach previous Inspection records if any) Other(explain) APPROXIMATE AGE of all components.date installed(If known)and source information: ' Approndm �9 years — . Sewage odors detected.when arriving at the site:(yes or no) No (revised 0A51" y 5 r, - COASTAL KITCHEN CABINETS 5085645.137 P. 04 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Y01Meinetcotaa Owner: • Gary t ledd Date of inspection:1110191 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,It possible;excavation not required,but may be approximated by non-Intrusive methods) If not determined to be present,explain: Ne Type: leaching pits,number: me leaching chambers,number. leaching galleries,number: rya leeching trenches,number,length: nia leaching fields,number,dimensions:roe overflow cesspool,number:0'xO'black Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) overflow cesspool was Sid full of the time of the Inspection Recommend pumping everY year. r CESSPOOLS:X (locate on site plan) Number and.configuration: one Depth-top of liquid to inlet invert; s' Depth of solids layer: 1. Depth of scum layer: t' Dimensions of cesspool: 8."' - Materiels of construction: block Indication of groundwater: none Inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Recommend pumping system every year. PRIVY:,_ (locale on sfte plan) Materiels of construction, nia Dimensions: nia Depth of solids: Ne Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na (noised 11l1iiY5) ' , _ 13 $-. COASTAL KITCHEN CABINETS 5085645137 P. 05 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 791 Main s<Cotult Owner: oaryat4lki Date of Inspection:VW97 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A N AAA DEPTH TO GROUNDWATER Depth to groundwater.12 feel method of determination or approximation: USGB Maps NW Charts (revised 11/15M) r CommonweoWi of Mos=husetts ,John Grad Executive Office of Environmental Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 Environmental Protection Teaticket,MA 02536 (508) 564-6813 j- _ . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � ?— � PART A CERTIFICATION Cs Property Address: 701 Main St.Cotuit Address of Owner: Date of Inspection:1115197 (If different) f( 199J Name of Inspector:John Gracl Gary Glatki Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.MV findings are of how the system is _ Needs Fu her Evaluation B the Local Approving Authority performing at the time of the Inspection. e l Inspection does Y PP 9 Y not imply any warranty or guarantee of the longevity of the Fails septic system and any of its components useful life. Inspector's Signature: ;// 4^ Date: 1121197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to.the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 701 Main St.Cotult Owner: GaryGlatkl Date of Inspection:1115197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 701 Main 6t.Cotutt Owner: GaryGlatkl Date of Inspection:1115197 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. • r (revised 11/15/95) . 3 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 701 Main St.Cotult Owner: GaryGlatkl Date of Inspection:1115197 Check if the following have been done: X Pumping information was requested of the owner,occupant,and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving norrnal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. NaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. x The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/15195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 701 Main St.Cotult Owner: GaryGlatkl Date of Inspection:V15197 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 gallons Number of bedrooms: 3 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: rda Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped 4 years ago. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance. TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool x Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: Approximately 30 years - Sewage odors detected when arriving at the site: (yes or no) No (revised 11/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 701 Main St.Cotuft Owner: GaryGlatkl Date of Inspection:1115197 SEPTIC TANK:_ (locate on site plan) Depth below grade: Na Material of construction:_concreate_metai_FRP_other(explain) Dimensions: n1a Sludge depth:n1a Distance from top of sludge to bottom of outlet tee or baffle: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance form bottom of scum to bottom of outlet tee or baffle: nla Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n1a GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle:n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n1a (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 701 Main St.Cotult Owner: GaryGlatkl Date of Inspection:1115197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete_Inetal_FRP_other(explain) Dimensions: nla Capacity: nla gallons Design flow: n/a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 701 Main St.cotuH Owner: IGaryGlatki Date of Inspection:1115197 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: n1a Type: leaching pits,number: n1a leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: n1a leaching fields,number, dimensions:n1a overflow cesspool, number:6'x6'block Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Overflow cesspool was 314 full at the time of the inspection.Recommend pumping every year. CESSPOOL$:x (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: 5' Depth of solids layer: 7' Depth of scum layer: 1' Dimensions of cesspool: 6'x6' Materials of construction: block Indication of groundwater: none inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure, level of.ponding, condition of vegetation, etc.) Recommend pumping system every year. PRIVY:_ (locate on site plan) Materials of construction: nla Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 701 Main St Cotuit Owner: GaryGlatkl Date of Inspection:1115197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �rN )1 f+ lq 0 A f,"A DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 TOWN OF BARNSTABLE LOCATION'7l�J `'I A i �� S7`. SEWAGE # VILLAGEC�t/-// ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. SEPTIC .TANK CAPACITY 1,6W19 LEACHING FACILITY:(type)�-P-5-5��� (size) i NO. OF BEDROOMS ,% PRIVATE WELL OR PUBLIC WATER ✓ BUILDER OR(OWNER) DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED. VARIANCE GRANTED: Yes No no,H j 3 Design Schedule ELEVATION Leaching Area Requirements Q 2 9 FINISHED FIRST FLOOR 100.7' 4 BEDROOMS AT 110 GPD/BEDROOM = 440 GPD v TOP OF FOUNDATION 99.7' FINISHED BASEMENT FLOOR 92.5' ADDITIONAL 50% FOR GARBAGE DISPOSAL = N/A SEWER INVERT AT FOUNDATION 96.4' SEWER INVERT INTO SEPTIC TANK 96.0' PERC RATE = <2 MIN. / INCH (CLASS 1 �Q �O SEWER INVERT OUT OF SEPTIC TANK 95.8' SEWER INVERT INTO DISTRIBUTION BOX 95.2' LIAR = 0.74 GPD/S.F. �o W SEWER INVERT OUT OF DISTRIBUTION BOX 95.0' MIN. LEACHING AREA OF S.A.S. SEWER INVERT INTO LEACHING SYSTEM 94.5' LOCUS p� M BOTTOM OF LEACHING TRENCH 92.5' 440 GPD/ 0.74 GPD/S.F.= 595 S.F. MIN. NO GROUNDWATER OBSERVED ® 85.8 PROPOSED SYSTEM RU LN v 440 GPD W/LEACHING AREA OF 608 SF p I LEWIS POND \ c°I \\ \� / / I Z LOCUS NTS / / c, ► N ' `'_:A_1.5" WASHED STONE;. ' ( ?I I I N ZONING DISTRICT: RF N OVERLAY DISTRICT. WP BUILDING SETBACK REQUIREMENTS � to rn FRONT= I = =N I I 30 S DE 15 REAR 15 cn CB/DH c 1 rn . FOUND 35 — — PLAN OF LEACH CHAMBERS LOCUS PROPERTY IS COMPRISED OF: 6 _ I ASSESSORS MAP: 36 LOT: 10 a I I I I I NO SCALE DEED REFERENCE: DEED BOOK 10,699 PAGE 223 PLAN REFERENCES: PI Bk 511 Pg 4 & LCPI 7034 C I \ N/F I -� N/F I RICHARD & PHYLLIS ' I I \ \ \ BUELL 1 I o I COMMUNITY PANEL NUMBER 250001 0018D KEVIN CHASE \ \ ( 1 \ \ N 89'07'35" E 12' F.LR.M. MAP ZONE C \ I S 89'07'43' W — — �_ — #-0— — — — — _ 165.24' 1477� _ — ( = FINISHED GRADE ,I � CB/DH o — — — — � — — — I — —" � �' I 36"MAX.- 9"MIN. \ A-" HEM COMPACTED FILLFOUND \ existing dirt road C �--� I \ GENERAL NOTES \ \ \ I W z I 2- PEASTONE ............... : 98 _ � , r _ —� - - - -` : .• •' n ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE 1 \ SB/DH N 89'41'36 E I r' I I 30.5" 6 + ° •'.; . •' 3/4 TO 1 1/2 WITH TITLE V OF THE STATE SANITARY CODE DATED MARCH 31, N 8T 17'S2" E 288.29' _ \ \ I — — _ � � N � '� I s•• •• • •• DOUBLE 1995 & ANY LOCAL RULES APPLICABLE. 98.67' 1 1 SB/DH FND o o1 - r' ! WASHED STONE I H-20 DB , 52 7 0 t1j ( '°� ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING BY j CB/DH 1 1 1 EL = 97.20' I FOUND , 1 ASSUMED DATUM THE DESIGNING ENGINEER. 1 11 1 9e _ I fi I Q I SECTION 2' EFFECTIVE DEPTH 1 1 1 ° GARAGE 10' min I I WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING, 1 1 ' TH #2I _ — i _ _ _ -- NO SCALE NOTIFY THE ENGINEER & BOARD OF HEALTH AGENT FOR 1 1 I garden / 25.1 q EXISTING LEAC N ° 13.5' PROP05m � ! I INSPECTION. PIT TO BE PUMPED 1 T r r raj 1 IA/F II / // ; %4�.-& E REMOVED i No. 701 52.6 I I PLASTIC LEACHING GALLEY ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4" PVC, SCH. 1 N 0. FIBANK IMANN & / ' ., I J EXISTING SINGLE FAMILY DWELLING KATRIN BIDDLE ' R90 — �/ 19,838 SF t i I w I ALL PIPES TO BE SCHEDULE 40 PVC EXCAVATE AND REPLACE ALL UNSUITABLE MATERIAL I 1 w 0.46 ACRES t _ _ -� 2-"foot wide concrete walkway I SURROUNDING SURROUNDING THE LEACHING FIELD FOR A 1 I DISTANCE OF 5', PER 310 CMR 15.255. ' ^ STAKE SET LEACHING CHAMBERS `� allI PRIMARY BENCHMARK ASSUMED o _ / PROJECT BENCHMARK SEE PLAN Z // � CB/ FND _ s s847'96" w EL = 100.00` LOCATION OF UNDERGROUND UTILITIES ARE APPROXIMATE AND N 89.50'54" W \ ASSUMED DATUM I SHOULD BE VERIFIED IN THE FIELD BY THE APPROPRIATE UTILITY ' — — 21�.83' ^� PROPERTY CORNER TO ANGLE POINT � .: 51.59' CB/CL 83.60' STAKE FOUND \ 212.45' CB/DH TO ANGLE POINT ,j ' TOP I �'�I_ ' �u R>A t2.a�f�1= �~''�'� COMPANY PRIOR TO ANY CONSTRUCTION. \ I n EXISTING CESSPOOLS TO BE PUMPED AND REMOVED. Z N/F \ I 2oa I - o Ca Qc Se►'tSAcfc R�iQ6M�-+T5 I o \ GUY L. & CHRISTOPHER \ w I LOCATION OF EXISTING SEPTIC COMPONENTS IS APPROXIMATE \ JACKSON o AND ARE BASED ON INSTALLER TIES. �Irn U \ \\ I cB/cL NOTICE: THE CONSTRUCTION OF THIS SEPTIC SYSTEM \ \ o I TOP MAY REQUIRE CHANGING THE PLUMBING IN THE EXISTING HOUSE. o ` I 701 Alain Street \ I I Cotuit Massachusetts I PREPARED FOR ' Barbara Kern BAXTER, NYE & HOLMGREN, INC. TITLE SOIL LOG P#10,067 DATE: 9/25/01 .Septic System Repair BOARD OF FINISHED GRADE 99.4' TYPICAL SYSTEM PROFILE SOIL EVALUATOR: HEALTH AGENT F.F. EL = 100.7' D ►�*�D p �-rD� �T�^+ JOHN ELLIS LEE McCONNELL �'`�J yo BAX1ER� NYE & HOLMGREN� INC. TOP OF NOT To SCALE TEST PIT 2 �' Registered Professional FOUND. = 99.7' • EL = 95.8' t Engineers and Land Surveyors F AA-�a '`� '�fCls FINISHED GRADE OVER TANK = 98't FINISHED GRADE OVER D. BOX = 98'1 812 Main Street OStervllle MA 02655 FINISHED GRADE OVER LEACHING SYSTEM = 97'f 0, 0 AIL , , 8"MIN• ) Phone - (508)428-9131 Fax - (508)428-3750 3" min. 10" 4" SCH. 40 PVC FIRST 2' (TO BE LEVEL) (TYPICAL) 4' SCH. 40 PVC 9" (min) Cover E s-(m'"•) 0L2 min 36" (max) Cover MEDIUM SAND PVC or 24" 10 YR 3 1 0' 20' 40' 60' 10" Cl TEES GAS BAFFLE 6" SUMP .. FINISHED CONSTRUCT ACCESS 4" SCH. 40 PVC 2"Layer 1/8"to 1/2" BASEMENT MANHOLE OVER INLET Peastone FLOOR TO TANK TO AT LEAST LEACHING CHAMBERS B WITHIN 6" FINISH GRA 6" CRUSHED Slope = 0.005 min MEDIUM SAND �H OF tilgssq REINFORCED CONCRET STONE BA 33" 3' TEP cy SCALE 1 " 20' = D /2 /2001 _ 10 YR 6/8 HEN _ FOOTING 4" PVC C � AL � .N ATE. 9 5 o.s0216 REV. DATE: REMARKS MEDIUM SAND 9 `I`X-- Q 120" 10 YR 6/7 o,�F FGISTER� SS�ONAL E ' 0 1500 GALLON SEPTIC TANK (H-20) DISTRIBUTION BOX (H-20) 5' MIN TO BE INSTALLED ON A LEVEL STABLE BASE TO BE INSTALLED ON A LEVEL STABLE BASE DRAWING NUMBER No Groundwater Observed ® EL 85:8' NO WATER ENCOUNTERED H: 2000 2000-043 SUrVe worsht 200043se .dw PLASTIC LEACHING GALLEY RATE= <2 MIN/IN Job # 2000-043