The URL can be used to link to this page

Home My WebLink About0886 MAIN STREET (COTUIT) - Health 886 MAIN STW6-y COTUIT A= 035 087 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. 886 Main Street Property Address Barnaby Owner Owners Name information is COtUIt required for _MA 02635 March 21, 2014 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on theI 6NO computer,use 1. Inspector: S only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use theseturn key. Company Name rab PO Box 1487 Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-776-4186 SI 12855 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 r March 21,.2014 p Inspector's Si nature 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. q t5ins•3l13 Title 5 Official Inspecti n r :Subsurface Sewage Disposal System• ge 1 of 17 I Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 "March 21, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any bnformation 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: Tank was not in need of pumping at time of inspection. Leaching system showed no evidence of saturation or surcharge. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M •'• 886 Main Street Property Address Barnaby Owner Owner's Name information is required for Cotuit MA 02635 March 21, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 7 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address Barnaby Owner Owner's Name information is required for Cotuit MA 02635 March 21, 2014 every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 1:1 ® 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 wafer 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'' 886 Main Street Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every page. Citylrown 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 thy. 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.a ® 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address Barnaby - Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) . ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Currently. Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsun.-ce Sewage Disposal System•Page 7 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 886 Main Street Property Address Barnaby Owner Owners Name information is COtult required for MA 02635 March 21, 2014 every page. CltylTown 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: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped,determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy. ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): E t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every 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: 2001. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 3„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 886 Main Street Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every 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 29" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 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.). Liquid level was at bottom of outlet invert and tees were intact. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance-from bottom of scum to bottom of outlet tee or baffle - Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street �M Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments-(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address P Y Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): No solids or high stains present, liquid level was at bottom of outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-3/13 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 886 Main Street M Property Address Barnaby Owner Owners Name information is it required for Cotu MA q 02635 March 21, 2014 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Three 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No standing water or sidewall stains observed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer f Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 886 Main Street Property Address Barnaby Owner Owners Name information is required rey ou uiredfor MA 02635 March 21, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions - Depth of solids Comments (note condition of soil, signs of hydraulic failure, level.of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of..1.7 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a •' 886 Main Street .......... _ - . _._-.__..--------- -... -------- Property Address Barnaby Owner Owner's Name information is required for Cotuit _ _ — MA 02635 _March_21, 2014, every 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 ❑ drawinq attached separately Front r 23 28 03 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main Street Property Address Barnaby Owner Owners Name information is COtUIt reg uired for MA 02635 March 21, 2014 every page. Cityrrown 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: 20+ 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: Low area of abutting property with no surface water is lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 886 Main Street Property Address Barnaby Owner Owners Name information is required for Cotuit MA 02635 March 21, 2014 every page. Cityrrown State Zip Code Date of Inspection. E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 59r.1,,-0a1)n SEWAGE # �}'ILL,AGE Cy /� `� ASSESSOR'S MAP & LOTO3��Sl7 INSTALLER'S NAME&PHONE NO. Dl'T�� O ��1�5;7— 7Z/'9,�� SEPTIC TANK CAPACITY / -00 LEACHING FACII.ITY:(type),S'OD GaL L r4 C6004, (_-3 (size) /d.x ya 5<P � NO.OF BEDROOMS BUILDER O OWNER PERMITDAT tl�a I COMPLIANCE DATE: Y-z 7 -o l Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /lv a4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o, � s S a R �. k 200 ,,-. tip, ®$7 may, No. �� — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Mi.5pogar *pgtem Construction Permit Application for a Permit to Construct( )Repair(t )Upgrade( )Abandon( ) IF/Complete System ❑Individual Components Location Address or Lot No. gp [ ,yam^j� Owner's Name,Address and —Tekw�y Assessor's Map/Parcel ((JJ /B/(/j/ 401 of! Installer's Name,Addresx;Tel.No./,*L1 �,f Designer's Name,Address and Tel.No. Type of Building: j Dwelling No.of Bedrooms ! Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures !J/� Design Flow //d gallons per day. Calculated daily flow 7!® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ` _010 Type of S.A.S. Description of Soil 3 Nature of Repairs or Alterations(Answer when applicable) Lox/a Z 1-,rk,r."e 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 his o of alth. Signed Date 7 J7 6 Application Approved by Date D__ Application Disapproved for the following reasons Permit No. 7,4v _ ?�� Date Issued } _ �0 i t sy R •No. � Fee + t Entered in com uteri THE COMMONWEALTH OF MASSACHUSETTS P M ;, PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS` ✓ ZIpprication for Miopaal *p!5tem Construction Permit Application for a Permit to Construct( )Repair( /)Upgrade( )Abandon( ) D4/complete System ❑Individual Components Location Address or Lot No. ^j� �� Owner's Name,Address andd►Tel.No. Assessor's Map/Parcel Q O C'l/ 1 ®��/ �r�r1�'" C ,7`�/ T Installer's Name,Address,and Tel.No. Designer's;Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft.- Garbage Grinder Other Type of Building f >°A-,e No.of Persons Showers( ) Cafeteria( ) Other Fixtures J/� Design Flow �� gallons per day. Calculated daily flow 4 %e�) gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15_U`D QW Type of S.A.S. 142 X 4 Description of Soil t Nature of Repairs or Alterations(Answer when applicable) ��`/ (/ �}"d/'�/�,(' 7- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system il in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifit", 1 cate of Compliance has been issued by his or f ealth. / F Signed Date -1761�1 Application Approved by Date . G Application Disapproved for the following reasons Permit No.l Zv d — Z Date Issued , THE COMMONWEALTH OF MASSACHUSETTS 035 D�7 BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance AO" THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( �')Upgraded( ) Abandoned( by r�� Lo / at �� /1�'�lli9 `J�% �Gjl�L// �`" has been constructeq in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.7-08/- 2.Oa dated S' 'Lov Installer Designer The issuance of this ermit hall not be construed as a guarantee that the syste '-I f ti s desig V. Date ��Z 7�� Inspector 66-k ,4 + vi e-j --------------------------------------- No.—6&e)1— &ao a 5_ F Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizpool *p5tem Construction Permit Permission is hereby granted to Construct,( )Repair( I/)Upgrade( )Abandon( ) System located at 0 $;/O 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. Provided:Construction npst e completed within three years of the date of this Date: Approved by o � . DESIGN/APPLICATION RAC OF BEDROOMS=,equired designed gpd: _ .SIDEWALL: length yP X width Z X no. sides Z t = dtO sq ft. length /P X width z X.no. sides _ � sq.ft. SidewaU area 2p BOTTOM: width_ZV_X length =sq.ft. 'Bottom area total area SOD sq.f�. ®� sq.ft X e / _ deli ed (application rate) gallons/day �00 k 4 ' A" NOTICE: This Form Is To Be'Used For the Repair Of Failed Septic Systems.Only: - CERTIFICATION OF SKETCH AND'APPLICATION FOR A DISPOSAL .WORKS CONSTRUCTION PLRNUT(WITHOUT DESIGNED PLANS) 11�1�iT� Al /&ZAere0y cerffy that the application for disposal works construction permit sued by me dated 0,3101concerniaQ the. property located..at Mi Aallj meets aIl'of tEe following criteria:. V1 ne failed system is conne=eo to a residential awedin;oniv. 1 here are no commercial or business �„ es assocated with the dwelling. I ne soil.s c:zss - e _ o / -rhea as (_�A�� I end ne pemcianon 1t_ is lets .han or to_tiai :o =7 utcs per 'ncz �Xler e are no we•.lands wiinin i o0of rife 7proposed septic sv stem 4ihere are no ore. e wens within.1:0 of he orot:osed se-,,tic s�sem. V/)>her e is no incase in flow and/or change :n-�,ze oropcsed !/ !ne:e are no varances.,e;used or neede'± t LX he bottoa of the rrnoosed leaching faclity will not oe located less- ,��above the P than five.__, ma.-dmum adjusted,-aundaate.-table elevation. (Adjust the groundwater.�abie.tsing the =r ptor /eihod when apoficable]. if S. _S. will be located with 750 fee:of any vegetated wetlands. the bottom of the proposed leaching facility will not be located less Lban fourteen(14)fee;above the rtu=�mum adrt sted groundwater table elevation, Please complete the foflowins A) Top of Ground Surface=Ievation(using GIS infornsation) B) GM.Elevation the MAX High GM. Adjustment D rr EN=- BETWEEN A and B DATE: �J [Sketch Proposed plan. systear on back]. ¢hafth fi)kkr- i � ' TOWN OF"BAR -4STABLE % LOCATION 921& �/1/7 :. SEW 4GE # VILLAGE_ C�%/��1�` ASSESSOR'S MAP & LOT�3S-��7 INSTALLER'S NAME&PHONE NO. ,.r2l L G�/?„5 77i- 3�4 77777-7 9 { SEPTIC TANK CAPACITY - /SOU �( LEACHING FACILITY: (type) s'op GcC L r 4 Cl iy.. � (size) /d �C 5/a X� l NO.OF BEDROOMS ! BUILDER O OWNER I•r/ 7 PERMITDATE: COMPLIANCE z 7 DA �—� TE: Y- Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �"z Feet Private,Water Supply Welland Leaching Facility .(If any wells exist on site or within 200 feet of leaching facility) Feet i Edge of Wetland,and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) " ` Feet Furnished by �CT� {' } ' 1 - Ji G ire y' o 00 i0 \/ qe ,A0C�ATI N SEWAGE` PERMIT . NO. mllLLAGE I =R'S NAME ADDRESS R U L D E R OR OWNER DATE PERM ISSUED DATE COMPLIANCE ISSUED �� .-'i N C \> a " ._� S �C ,' O v O uc . A � tw, s ~� •. �� I v � �" _ - T THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------- -- ....................OF... ,2 ppli ation for 11hipi sal 19ork,5 Taustrudion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ... ` ( _..1►!! :sws •..... .� :1' .:...................... ................................" .................................................... Location-Address or Lot No. C1411 /f `Ownery s Address ............... Installer Address UType of Building L Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a Other—Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---------------------------------------- W Design Flow.......... ...................gallons per person per day. Total daily flow........................................... WSeptic Tank—Liquid'capacity.....__.....gallons Length................ Width.......:_....... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per'inch Depth of Test Pit.................... Depth to ground water........................ Q+' ---------------------------------- ------------------------ -------------------------- -... -------- .--- ------- •--------------•---------•-----•-------- •---- -••-- 0 Description of Soil........................................................................................................................................................................ U --•-----•--••-••---•-----------••--•-----•---•------•--•--•-•---------•--•----.....•------•-•----••-----•-••-•------•---------•---------•------••••-•--••••-----•-•••-••---------------••--••---•-•----- x ••-••••••••-----------------•••--------••-------••--•---•-••--------•----•--•---••-•---...•-------••-•----•---•------------•------------••--•--••••-•--•----••--•-•----•---•--•---••------.........--•-- V Nature of Repairs or Alterations—Answer when applicable-------1......\5.dq.... .......1._T-C,y ........................................ ......S.-Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b _2=LLissued by the b� �igned . --•--•-------•...-•------.--• ��. .__ Application Approved ... ••.. •-•---...-•-----•-•-----•••------••.................................. L 1 " --' Date Application Disapprove or a following reasons----------------------------------•----------------------------------------------•-•--•----• --•--••-----------. --...-•----•---•-••---•-••-----•-•-•-••••-------------•-•••--...--••--•-•--•------------.....•-----•-----••.._.._..------------. •--•--•-•-•••----••••-•----••--------•-------•-•---•--•-•-•-•----•-•--- Date PermitNo..................................................._.... Issued....................................................... Date :; C/ Flmx ..............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................-.......... Appliration for Disposal Works Tonstrnrtion rani# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --•......................._...--•--•------.................----•-----------------•..._......•.... ••-•--....-----•---------..........---••--•------•----•--...-•----------•--•-----.....-•---....... Location-Address or Lot No. ......................_.......................................................................... ..........--................................. ............................................... W Owner Address Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures -- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_______---.____. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �.' Percolation Test Results Performed by.......................................................................... Date........................................ ►4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil........................................................................................................................................................................ W --------------•--------•------...-------------•----.....-••-•-.....--•---------------........-•-----•-----•----•-•------•......--------------•------------•...--•-----•---......-----•.•---•-•-•-----•- W ------------------------------------------------------------------------------------•-------...--------------------------------•------•--------------------•---------------••-•--•------------------• U Nature of Repairs or Alterations—Answer when applicable.......:........................................................................................ ----------------------------•---•------------------------------...-------------------------------------•--•------------•......--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned----------------•---------.....-••------------•---•------....--------•--•-- Date Application Approved .`....-- ---------------•-•---------•---------------•--•-----------.....--•------ --- --_--._ `�..----- PP PP - ,. e Date Application Disapprove ,.for y�he following reasons---------------------•---------------•-- ---------------------------------- ------- ........•.................................•-----.....•--•--------------......••-----•--••---...------•---.......-•-------•---------•-----•--------•-.................................................... Date PermitNo.----......-•-----------------------------------------. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................................I.........OF........................... Trrtif irate of Tontphatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at ---------------------------------------------------------•-----------•-•---------•--•----•--------------- has been installed in accordance with the provisions of TITLE 5 of Th State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ _=, --------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM W L F N � CTION SATISFACTORY. DATE. ..Z Inspector. .. THE COMMONWEALTH OF ASSACHUSETTS BOARD OF HEALTH ,� ..........................OF....................... No......._.�?.. ... FEE Z,,�.................. Disposal '=-rk��onstr iort amit Permissionis hereby granted------ :!T! -----------•--.-------------------•--------•---•--•-------•----------...---- •-----......................... to Construct ( r epair -- �ndfvilealI/ - Sewage Disposal System at No................ ------ �., .................... ...... Street as shown on the application for Disposal Works Construction Permit . .................. Dated .-_a__ � .•--_.._---_-.... ............... .. -v-•-------------------------------------------------•-••----.......•---.... Board of Health DATE... .................... FORM 1255 A. M. SULKIN, INC., BOSTON r +f F m ° n o ° c 8 g 8 8 g S a= F co o \\~ ° S a D Foo 3 \\~ g X Z Z m �\ $ ziq ° o 3 `\~ 0 m m b 0 o o EVE- 1801 g D m (fin A 0 now d °' F., o QY D$ l' y2 fo T.a �'S' ii at Z F" 30 Po -o S _. n z x.m S Ile n E o O o o n�a a n o 0 �^o Oac 6 G � p .�.Z y o �a iwr0 a .1 iON'� Z� F n O� ZZ�tA _ O~ P VIP $nro��an-np to N az o� A ° oo� p un�A nzP p�� e�� y�om 21-R ph p G do ah 0 o� yy> r Um y ________ 2�J r o I existlng BAY abwe I ;Ig A t—gdn "g n Nay o z Rng£ -o N P �I fro a-0 �g� G �I o� NAB . r-1 a r-------1 9; <I y > tANDING.5TEF TO GRADE ABOVE O.i I II o f----� I - _ & iisfa I I I I I C T Fm I I I b C 0 m � m E� _ ..nfl 1e idst Z Ag m §I� — y omg F O o _ "0: Z m 0 M t 5 j ( 'w 8'O' -I ' I n � d Imi° �I I _ �(9I3toO1RT '. N I D z 7 n 11J�y �I Z I m A Z ��; EM5T.5Wa 5 TO KEMNN 09 I W I Fong g I m o g g I N n D nE I ---0---- Z ppy _-J A m � A m c�z W OO I - w o� 0 '1 arl9ing 21aflarjdst z — — — — — — — J I I � „�A I I I o F 4 b 8'-G• S psug I I I = oc'Oc+_ I I I o i m-S`9 I I I io w °S5 z NI�z �� I I I I IG'-4'+/- EXI571NG - pOZ ��c A=oz n== ` EXIST.WALK OUT A 9jnaN O _mAry z�gF > y PROPOSED ADDITIONo-�� F o EXISTING HOUSE (to match e 20 G EXIST.FOUNDATION TO REMAIN REMOVEfMiRE EMISTINGREAKONEWOKIWING yopain ��v Fm� ro� 0 �O 3 n}i o `" g PROJECT: REVISIONS: ? (tom)428 427g D m m additions&renovatlons at FAX(NO)428-4M Z . D g GARDNER RESIDENCE _ y ?� N 886 MAIN STREET,COTUIT,MA o TITIE: ARCHITECTURAL INNOVATIONS m A aMSM OF FOUNDATION PLAN/SECTION r.o.Box BOX 2M, t s"�D. crnulr,nu aM5 ' o00000000< 000000 � 0 •; o m m m a ao Q >< m ci v ? z m z Z_ O L7 a e � ? Z 0 = O Z m S b o L. m a $ v 3 9° m 0 m m : mm ° � m 8 ° O 5 $ O ;00 v o g g A p 8 8 m m o f mcl) eggo � m mm p fo o m MST.DORMER m 8 2 000ao $o $000 � � � � � s a a n > 3 J m F 0 ' ll I• I 2 L 4 4 s s s II ao _5�'3' I O 0 cf) b n 0 1 O!t CLo86 O z =OLOSETI Oo -------� /L7 z---- __ Z m ''I I I I I I I �s O� I I 0 �_z 2 0 O 1 O = \ SNRrA55EE ns 5HOWlu' \ oo nya F O 0 I O - , ��c Q g b 8 d m I N 3-2° - mz 40 n i t I I 1 I D I 01•o > I I t----� r------ F II __❑ I E ° OJ -----� n $ o > I O G ;0 O I 0 I r I I I I I I I • - I I -------------- L-------------f . PROP. EXISTING HOUSE ADDITION EXISTING ROOF FRAMING TO REMNN 12' N ONO °F in II �QfB�=N I BO�zd—O I 3 O' 4 4° O Z I I o O o I O A -� D n O II N 0 0 G I II I Ip N = O 2'-0' � I l y � �-�Ild N Z,_y. r•- r e , O \ O L ad --- c� ° -� I 6 IO I I (9 A PANrR. 0 — O - O N I I Z € I s \ 1 1 19, ° I I I �Ji� N o II m � �� II = =8o II b -ter oil ------- �$q €1 z a - - --- m sJ I -- ��4 ° z_ z - - _J F z r `yb i o, o;- O I G z ' Amy ® ® I n A m m A 0 4'3' T-a b Z REPLACE IXIST.Cf5EMENT BOW WINDOW 8 WT N 2 DOUBLE NUNG WINDOWS 16'-4'+/- EX15TING PROPOSED ADDITION EXISTING HOUSE (to match exist foot print) EXIST.2ND FLOOR FRAMINGTO KEM N REMOVE ENNRE M5nNG REAR ONE STORY WING m D PROJECT: REVISIONS: ? 15oe)a2e aria N m additions&renovations at FAX(505)M a2e5 y g GARDNER RESIDENCE _ 0 886 MAIN STREET,COTUIT,MA ` ARCHITECTURAL. INNOVATIONS o TITLE: FLOOR PLANS A°"OM0F" 'W. P.O.BOX 2050,COTUIT,MA OM5 IT LL ASPHALT P,oOP SHINGLES ROOF 1 SOFFIT TRIM DETAIL To MATCH eM5T NG SIDCI e SECOND FLOOR ADDITION -----""---"" _--"" a - ____________ ___ _______ CEILING HT. WINDOW HDR.HT. ROOF DEL&: } 1.4 DECNNG ON SLEEPERS(2x45) CRLUIBB R'COX ROOF O NG OVER SLOPE ON 22 101ELTJC•�GX)ISTSI�GN O.C. T.O.KNEE WALL CUT TO SLOPE TO EACH SIDE _ SECOND FLOOR __ + SECOND FLOOR N WINDOW HO R.HT. WINDOW HDR_FfT. I, CORNER BD. �CA a a O D R A WHTTECEDAR5mNGlFS I I I I I[] M L�s'EXPOSURE-T`.•P. NEW 12'DEEP BAY FIRST FLOOR FIRST FLOOR -- PROPOSED ADDITION EXISTING HOUSE NEW LOCATION FOR EXIST.FRONT DOOR (to metdl E)dst.That pTlnt) REMOVE ENTIRE EXISTING REAR ONE STORY WING LEFT SIDE ELEVATION FRONT ELEVATION z O PROP.ADDITION ' ROOF t SOFM TRIM DETAIL TO MATCH PXISTING TWO STORE BAY(LEFT SIDE SECOND FLOOR ADDITION --------- ENLARGE EXIST.DORMER --"--"-"----" ----"------------------ 'no, /DORRT DETAIL --- ---'--"- ASPHALT ROOF 9HINGlPS H TO EXIST INGING CEILING Hi. WMDDW HDR.HT. WHITE CEDAR SHL S 0W 5'EXPOSURE-TYP TYP, 4X4 P.T.P05T5 CASED IN I..5'5 m m E m e MILlEO WOOD CAP/2.2 BAW 5TER5 z 6'O.0 W TOP a BOTTOM RAIL5 W T_0.KNEE WALL 4 SECOND FLAOR m SCCONDFLOOR YI FELLA ARCHITECT DOUBLE-HUNG ---------------------- - _ W W — WINDOW'W/CASING#WND.CAP TO MATCH EXI5BNG Q WINDOW HOR.H N T. _WIDOW m v/ D D 2 § D D TO MAC ETING W/CASING 0 WND.LAP d Q = B A TY 1 65 L LRNER B0. CA .ws CORNER BD. O w MICAl REPLACE EXI5T.CASEMENT BOW WINDOW 7 J FIRST FLOOR WITH 2 DOUBLE-HLNG WTNDOW W LLI MATCH MDR HT.TO EXIST.ON WINDOWS FIRST FLOOR ADD NEW 12'DAP BAY V WHITE CEDAR SHINGLES WITH 2 PCUA ON WT NDOA'S W c9 S•EtPO5URC-P.'P. PROPD$ED ADDITION MATCH EXIST.HEADER HEIGHT ADJU a (to matdl eXist.WU DHm) SITE LIST ROOF/CEUNG HT. F_ REMOVE ENTIRE IXISBNG REAR ONC STORE WING TO CLEAR ROOF DECK O.H.4 GLITTER WIFFR 6 TRIM DPTAII S TO MATCH EMSTING EXISTING HOUSE ® PROPOSED ADDITION DATE: 04/12/2016 (lo hasten exist foo DHHt) REAR ELEVATION REMOVE ENTIRE EXISTING REAR ONE STORY YANG SCALE: AS NOTED 1/4'-,-0' LEFT SIDE ELEVATION DRAWING#: 1/4�1'4 A3 - 4 1— — —_—J _ I I I I � I I � • x I $ ur I � I Z ---------- O ;0 J _ 0 Oc — b O m oS D 0 z "I > ---------- Z O U) °v oM� sSs Q_ Q m ]c RIDGE BE a m w _ A x � J I .. I I I v O I � r I T I I .I 17_-------------- PROP. EXISTING HOUSE ADDITION W5TING ROOF FRAMING TO REMAIN. O ld m y x A V T . Z Y ,n DN � � L o m j O Ci I7 D D \0/ r O 17 m r K T A uF O N S I j BEARING WALL BEfDW D 3'-2' c c W — � ar�� °n X o I $i4 N_, N o — — - 14> — _ �O A a � R o ZZ. o 0 � o m c F A (n 2x10 CEIUNG/ROOF DECK JOISTS @J 12"O.C. CUT TO FORM SLOPE FOR DRAINAGE PROPOSED.ADDITION EXISTING HOUSE (to match exist.foot print) E%ISF.2ND FLOOR FRAMING TO REMAIN REMOVE ENnRE O(15TING REAR ONE 5TORY WING o D PROJECT: REVISIONS r (5�)42&4218 IT, additions&renovations at FAX(�)42B-42B5 Q GARDNER RESIDENCE ?� 0 886 MAIN STREET,COTUIT,MA o ARCHITECTURAL INNOVATIONS m TITLE: ,W CO FRAMING PLANS A0NOf7Q "°� P.O.I�X 2�8IUR,61A 02835