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HomeMy WebLinkAbout0226 MAIN STREET (COTUIT) - Health 226 Main Street (Cotuit) Cotuit P % A 209 190 1 MAP COMMONWEALTH OF MASSACHUSETTS PARCEL, f,..,�. ..,....... EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR8T , Z DEPARTMENT OF ENVIRONMENTAL PROTECTION 1.1 y (Op, d ti W V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner's Name: NORM AR�ENAULT Owner's Address: 226 MAIN ST. COTUIT,MA 02635 ED Date of Inspection: 6/2/03 RECEw Name of Inspector: (please print) JOHN GRACI,INC. Jul p 1 M3 Company Name: SEPTIC INSPECTIONS TABLE Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 To\NN OF BARNS HEALTH Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Nses _ Needs Furthe aluation by the Local Approving Authority Fails Inspector's Signature: t Date: 6/2/03 The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Titl in nrrlinn Pnrm r..,i 511 nn Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 226 MAIN ST. COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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 i e(s)are replaced Pp P _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 226 MAIN ST. COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks 9. X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] � 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): � —���® Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a 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: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1988 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 226 MAIN ST. COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 226 MAIN ST. COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PITS, THEY APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. w A f�ec� Do AA A At48 l in Page 1.1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 226 MAIN ST.COTUIT,MA 02635 Owner: NORM ARSENAULT Date of Inspection: 6/2/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole withir. 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. �f Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street'Boston,Ma. 02108 Jolui Gii Ad D.E.P. Title V Septic Inspector kip P.O. Box 2119 Teaticket, MA 02536 WILLIAM KWELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM M ! � PART A - a CERTIFICATION Property Address: 226 Main St.Cotuit Address of Owner: 1`99 1 Date of Inspection: 5/13/98 (if different) B Name of Inspector: John Graci Mrs.Shultz I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: F. s ;ems 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 dented inTRle V code 310 CMR 16203.My findings are of how the system is Conditionally Passes In at the time of the Inspection. Inspectiondoes - performing P MY P g — Needs rt r Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Falls septic eystem and any of its components useful life. Inspector's Signature: , ,I Date: 5120198 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. I 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. COMMENTS: 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or. the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfillralion, of lank 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 007197) One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 225 Main St Cotult Owner: Mrs.Shultz Date of Inspection:5113ms _ Sewage backup or.breakout.or hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: 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 watersupply 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 the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: 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. Yes No 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. .4 Qevhed W127187) _ . e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Maln SL cotuit Owner: Mrs.Shultz Date of Inspection:5113199 D]SYSTEM FAILS(continued) Yes No 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: You must Indicate either"Yes"or"No"as to each of the following: 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: 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) 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. (revleed 0427187) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 220 Main SL Cotult Owner: Mrs.Shultz Date of Inspection:5113198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _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 normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x 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. _t_ 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 — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)] (reyhed 0427)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 226 Main St cotuit Owner: Mrs.Shultz Date of Inspection:5113199 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: sm g p Number of bedrooms: 6 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): Na Sump Pump(yes or no): No Last date of occupancy: rda 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: rde Last date of occupancy: nfa OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: pumped 1 112 yra.ago System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: Na TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)and source Information: ®yrs. Sewage odors detected when arriving at the site:(yes or no) No (revised 0412V97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 22S Maln St cotuit Owner: Mrs.Shultz Date of Inspection:$113199 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L10V'H57-W6V' Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:B" Distance form bottom of scum to bottom of outlet tee or baffle: is" How dimensions were determined: measured 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.) Septic tank and all components ere structuragy sound and functioning properly.Recommend pumping every one to two years. GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:Ma Distance from bottom of scum to bottom of outlet tee or baffle:Ma Date of last pumping,,. 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.) We BUILDING SEWER: (Locate on site plan) Depth below grade: 2V' Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction lin0o- Diameter: V i,mments:(conditions of joints,venting,evidence of leakage,etc.) (revised 04r1A97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 22B Main St Cotuit Owner: Mrs.Shultz Date of Inspection:5113199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene other(explain) Dimensions: We Capacity: We gallons Design flow: Na gallons/day Alarm level:_Na Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: equid level vAthboBomofpipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox is structuraiy sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yea Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rda (revlsed e497J87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 228 Maln St Cotult Owner: Mrs.Shultz Date of Inspection:5113199 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: We Type: leaching pits,number: two 1000 gallon leach pits leaching chambers,number:roa leaching galleries, number: We leaching trenches,number,length: rda leaching fields,number,dimensions:roa overflow cesspool,number:We Alternate system: roe Name of Technology: We Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) SAS appears to be funcdoning properly.Old not expose teach pits. CESSPOOLS: (locate on site plan) Number and configuration: roa Depth-top of liquid to inlet invert: roa Depth of solids layer: roa Depth of scum layer: roa Dimensions of cesspool: We Materials of construction: roa Indication of groundwater: roa inflow(cesspool must be pumped as part of inspection) roa Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) roa PRIVY: (locate on site plan) Materials of construction: Na Dimensions: roa Depth of solids: roa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) roa (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 220 Main St Cotult Mrs.Shultz 5113198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) ti, •s •s DeC�. I � — Q o DI I . c ill �1 x (revIesd04WN7) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 225 Main St.Catult Mrs.Shultz 5113199 I Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS mope and charts (nvbed04W)P?) 1�qd IO o[ 30 l' gnsff- /D GE� ,ov �t r � ,(� LSj LocUS Z 0 ea CA LOCUS PLAN al 1 0 I C� J rcP^sE i a�.,53s 00 I CO. 0 J „ rs V J $N ao I s,a�1z'V�j J Fo I �N 2 I 4pT: sP IP V) D _� -u THl% PLAN AND SURVEY WHRe aG a�SG 1 11 �. PREPPMM6 IN AC—et,&—M WITH T116 PRO C�OU RAL AND TH CHNKAL ST ANWROS < I) I I FOR TtH'PRACT IG6 OP LAND SVRVHY1wfCv G.G9. BD'FO N lot SI-06'. �'FD ESY INdX�f• lY{Lt .— R.L.S. SANTUIT- NEWTO\//N p IB34 Go'Co.L.O. i BA2N STi�BLE PLANNI4-1 C� B�A^�O APPRovAL UNDE@TMB.Su9nlvlslowl PLAN OF LAND IN BARN STABLE,MA. lL A o -eacaureao GEOR6E BLAKELY CUMMAQUID, MA. Hos EN62.ASSOC.=IJG. GZZ WCl MAIN S.T. RAYIJFIAM,MA. b In canforml a Mth one th. the Aaelalan of-Dee&o 0 . 'DATE seta evd reaultl I 8O SG ALE 1"�40 MAY 29�1984 of F 4brsuu�M1p• O YA 4OET 100 lha Comoro—hh of Moy O 10 7A 90 - METER6 - .. .............. „. 390-59 ` TOWN C BARNSTABLE LC.:CATION� `cc _SEWAGE # j - *-- 1 YILLAGi�� lam: ASSESSOR'S MAP C, La , _-ALI-1 TI INSTALLFR'S NAME. 11% P.i:?�'b_.�U �(�(`��'b%J_1_ . �1•��1���K��_� 1:��� SEPTIC TANK CAPACITY_�� LEAC:IIING FACILITY:(tyl:e)_____ __ L j—p (size)_J'�(� NO. OF BEDROOMS_,__l —PRIVATE WELL OR PUBLIC WATER___ _ BUILDER OR OWN;ER_!ae.o DATE PIMMI.T ISSUED: DATE COLIPLIANCI, ISSUED� V.A IAN E GIRAIlTM: Yes __No c6 N ...::_._!11 Fizz f THE COMMONWEALTH OF MASSAtHUSETTS ~ BOARD OF HEALTH -.-4.................OF.. rzm- 7MV. 54LC. Appliration for Disposal Works Construction rrrmi# Application is hereby made for a Permit to Construct (V11"or Repair ( ) an Individual Sewage Disposal S stein at: �.N..I T. . � _........... .......................................... •-----------••------.........-------- __. _ ____ - Location-Address - - . or Lot No. W Owner Address .................... Installer Address Type of Building AA Size Lot.41,_Z!.5_..Sq. feet Dwelling—No. of Bedrooms..........`T.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons...._...&............... Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------ -•- --------------------------------------------------------------------------------------------------- W Design Flow.......... . ........................gallons per person per day. Total daily flow....'_4 Q......._.........__.•.•..gallons. WSeptic Tank—Liquid capacity0Q9.gallons Length.1l_'0".. Widthl0 'I.. Diameter................ Depth�u.R�`` x Disposal Trench—No..................... Width.-........�_._____ Total Length.k.:............�.. Total leaching area.............. sq. ft. Seepage Pit No -L__.____._-- Diameter...`®:'�... Depth below inlet---�. �....... Total leaching area.59.4....sq. ft. Z Other Distribution box (� Dosing tank ( )a Percolation Test Results Performed by-G .. ..� � !c L?`✓=. .RVEV Date--t U..qe-+(.9b(0.•.._. Test Pit No. 1......Z.....minutes per inch Depth of Test Pit... _..____ Depth to ground water.... .......... 44 Test Pit No. 2-------Z......minutes per inch Depth of Test Pit._j_r.�_..."_...... Depth to ground water..-�`.'...--...•...... fYi -----•----�-.......... :... O Description of Soil.... ► Z? _ 41. 8 W U Nature of Repairs or Alterations—Answer when applicable...................................................•..................._................__..... ----------------------------•-----------------•------...........------.......---....-----•-•--...........--------•---------------......------------------------- ------------------•-•----- Agreement: The undersigned agrees to install the aforedescribed Individual kewage Disposal stem in accordance w'th the provisions of TITLE 5 of the State Sanitary e he undersign d fur Ter agrees of to place t e syste i operation until a Certificate of Compliance_has b en s e y t e board' he (�� D Application Approved By.......................... . ............................................. ....... ..... ' ....... ate ' Application Disapproved for the following reasons---------------------•--•---•-•--....---------------------------------------......--•....._......._......_....._ -----------------------------------------------•-------------•-------•----•-----•-----------_-•------------------------------ ---------•--------Date PermitNo.---.----- --------�......... Issued....................................................... Date Fim THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH < y F .........©W.�.................OF... �-�'`i�h?.�7,4..a.-�--------..._............----------- Appliration for Disposal Works Tonstrur#ii n Frrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Stem at:s : 22h ................ ... ................o T ...........................••--------------............... .................................................... ( Lq ty .Add or LotNo tso� krI, Aj •--•---...---•----•---_-..............•---....--•---•-••-•---•--- Owner -.......--- Address W Installer Address 2 UType of Building �I Size Lot______ _______ _ _...Sq. feet Dwelling—No. of Bedrooms..........................................................................Expansion�ttic ( ) Garbage Grinder ( ) Other—T e of BuildingNo. of persons............................ Showers — Cafeteria d Othe fixtures --------••--•---••---------•-•------------------------....---------IV ---------------- •---•--- .. o------•---••-------------••----- W Design Flow...........................................gallons per person pe day. Total c)ail ,flow.._.'�_.'_�'�'.._....-_._......-.._..........jzallons. WSeptic Tank—Liquid capacity�SpUgallons Length................. Width_(_�_'.._.�..._. Diameter................ Depth�'-_0.�.. Disposal Trench— Wit __._..._..,. Total Length Total leaching area x P � --------- ----- - _U -----• g r g j sq. ft. �- Seepage Pit No................ Diameter.................... Depth below inlet...................... Total leaching area..d'� a ......sq. ft. Z Other Distribution box ( ) Dosin ank( ) -51 a Percolation Test Result Performed by..............................................7....-------------........Date ?:....I.. v ---•- 04 Test Pit No. I................minutes per inch Depth of Test Pit.--1_5(o....... Depth to ground water______________.......... 44 Test Pit No. 2_...._G....._minutes per inch Depth of Test Pit---- ........ Depth to ground water_,"._................. w' ._.�_... :., _..�' Description of Soil ---•---- -------------------- x W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .--••............................................... Agreement: The undersigned agrees to install the aforede r ibed Individual Sfwage Disposal S�i tem in accordance w•th the provisions of TITIE 5 of the State Sanitarye The undersig furt er agrees not to place t e syste operation until a Certificate of Compliance has b n s ed the board f hea h �^ C� Signed............ •--•.......................' '....----------....... _.._.__ Date A 'Application A roved B -------------•--------•--..._... ........ ...................... Application Disapproved for the following reasons:.............................................................................. -......... Date Permit No. t:3 = 4t------------ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .................OF......... . .... ............................... Cprrtifiratr of f��ant� p TH S S TO CERTIFY, That the Individual Sewage Disposal System construct"—("I or Repaired ( ) by--------- --------------------------•--•------•-----••-----•----------..-----------•------•-•--•-------•---•---------------------•-•----...-----•---•-•------•-•---••- Installer at.. �p � � f� t-- -- - --------•--•---•-----_-_:,•------------- ------------- -�, has been installed in accordance with the provisions of TIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ._.._. dated - -- ------- --------•---.•-_-----. p _ : //- '// THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT�B1 �NSTRUE® AS A 4U'4 THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................5..::1C ----AA.................... Inspector...................... .................................... V Z Q�tOESd THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH jQ c�4:itJ...........................0 F.......... oY fL1 .. ................ Disposal Works QTnns rudi an rrmi# Permission is hereby granted............ .. . .. to Construct V--- or Repair ( ) an Individual Sewa a Disposal System atNo _ t`-- w..._/.�7 �n. --''_-- ��_�L� c....---.----- ------------ -•---•--------•---......-•-------------•---•------------.....----...... !r Street as shown on the application for Disposal Works Construction PermiCcN ________ Dat-d: C=v---------------------------- F� DATE---- /�% .................................................. Board of ealth •.- . FORM 1255 HOBBS & WARREN, INC., PUBLISHERS \, y No.(3.6..—.._ 5 , ! �� Fmz .7...�..�....... _ ! . ti THE COMMONWEALTH OF MASSACHUSETTS z BOARD OF HEALTH --------------------- ----------------OF............:-...............-..........------------......---------------....._.._-....._. Apptiration for Di-sposal Works Tonitrttrtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal Syst at: - .---•• ee -- ...._.- �� a o� • -- Locati n Add or Lot No. ner7 Address Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........j______________ Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons________________ ( ) ( )____._______ Showers — Cafeteria W Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow----------1 WW.____.__ ns. Width___________.____ Diameter 9 Septic Tank—Liquid capacity/ __ allons Length D th ..... Disposal Trench—No_____________________ Width.................... Total Length............�_.__._ Total leaching area... -sq. ft. Seepage Pit No-------`2....... Diameter........6..._..__ Depth below inlet...... ........... Total leaching area... :�_.sq. ft. Z Other Distribution`box ( ) Dosing tank '~ Percolation Test Results Performed by--------------_M..(..R p:' N_.__....._._.....___-__-_____-__ Date........ /_4_��!$_-_-_____... Test Pit No. 1..... _ __.minutes per inch Depth of Test Pit_._._�_�..1______ Depth to ground water_._._.MA_9_..._-. j Gz, Test Pit No. 2.....L __.minutes per inch Depth of Test Pit......1-1........ Depth to ground water.......................' -----------------------------•----•-----••------•--•-----............---••------•----._...-----••---....-------•----• - ------------••----•---.... 0 Description of Soil_•_____________'f--I_-________-S bso: Z -� C®A .-------- ---$_ -----0..-------J.-':�.-........ x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... f , Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TIE _E: p 5 of the State Sanitary Code— The undersigned • ther agrees not to puce the system in operation until a Certificate of Compliance has n issued the and f It ` r alp Signed- =••-- -•------ - ---•--.. . ---- ---- -----,--•------•--- -•�-- ------- ----•-------- Dat Application Approved By.............................. -------.... ..- )1 )u.- _ ._.. Da e Application Disapproved for the following reasons____........................................................................................................... ---------------------------•-•----•-•-------•---•--•-•-•-•----------------=----------.......-----------•._...••-•--------------------------------------•----•--------••---•--••---------------------.._ Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ABOARD OF HEALTH L ............. r „ ... .. ...OF...... � !1, ............................................. %rrftf irtttr of Toutphatta THIS IS TO CERTIFY, That the Individual Sew a e Di s osal System constructed or Repaired ( ) by........ s P! --------- l ....h..r�..................---....... Installe- i}�l1 �`i 1 t O'TVI� 1 at...................................:64....I..................................................................................................................................................... has been installed in accordance with the provisions of Ti T E 5 of The State Sanitary Codq as described in the application for Disposal Works Construction Permit No----S._�_`j 25_I__-._.___. dated-.-.__.Q-1 a_ ._1�_________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNC ON SAT SFACTORY. 1 � a DATE.......................... { •-.- `'- Inspector No........................ FE$..................._......._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C ........... ...............................OF......................................................................................... Appliration for Disposal Works Tonstrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Y i -- - '/d- ?L // Loca'on-Addr % ' or. Lot No. --. - .:._Ve ._ 1 net� _ Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............-----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ................................. W Design Flow...........................................gallons per person per day. Total daily flow.......... ............_..........gal ons. 04 Septic Tank—Liquid capacity� a�...gallons Length................ Width................ Diameter----� Depth--_'��_.._...... Disposal Trench—No..................... Width.....f_..._.._._._.. Total Length...... Total leaching area..--sq. ft. ............ Total leaching area..4_ ....sq. ft. Seepage Pit No.......Z........ Diameter._....�j_..__._._. Depth below inlet.... Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by...............M.1.�l�'...N.__.............................. Date......8�....... .........._.. aTest Pit No. I....L_2!----minutes per inch Depth of Test Pit---- ------- Depth to ground water----- A_._t........ (T Test Pit No. 2....4o.?.-__..minutes per inch Depth of Test Pit-----13.......... Depth to ground water------ ."g.......___. a •-••-----1---- -------------•--------------••••----•--.....---••---------------•---•--•-•--•---•-••---•...•--.•-----n---_----------------------------------- D Description of Soil--------------- ----------- ' ..h o L•-----� o� --------------C. S c r�L-----..A.. ....---.11.-•----. x v --------•-•-••--•----------••-----------------------------••---••-...._._......-----••---•-•••------••------------------.._.._...---•----- 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 T TiE }of the State Sanitary Code— The undersigned k"rther agrees not to place the system in operation until a Certificate of Compliance has`b en issue9Y the bard o healt Sign :.` ��''Gl� f r .---••- ----- -- ------ ---------•--------- Application Approved BY---------•-----------•--•--•- ---••-.. Iq- _ .... ? ----- D to Application Disapproved for the following reasons:----•---------••-----•-----------------•---------------------------------------------------••---•......-----•--- I' ........... ---------------------------------•---------------..._.......------------------------------•--•------._...---•-------------------------•------------------------------------------------------ Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................I.........1......OF...................................................................................... Trrtifirate of Tomplianrr THIS IS TO CERTIFY, That the Individrual Sewage Disposal System constructed -or Repaired ( } by.......................................... c7 'P •---•-•--- ... r-....Q....... .i 1.r?.. ---------•----......................---.....------------------....... ler at 1 ......... `'... --� , InstalC.. O has been installed in accordance with the provisions of T T T� 5 of The State Sanitary Co as described in the application for Disposal Works Construction Permit No._ ....._...... dated-_..QIRANTEE _1W__I/__b�------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... SiGiVtidCi Eiv iNEE'R N1UST SU5't-RVIS THE COMMONWEALTH OF.MM•ASst',HSpET CERTIFY IN WRITINf., H BOARD OF `EkLFF M WAS INSTALLED IN STR�iG� `�•.. P C,30RDANCE TO PLAN.OF ' ^ `/.�� 7 r No..... ------ FEE....................... Disposal Works Tontrnrtion �rmit Permission is hereby granted 0 .'�P --------••-----.-.-•' ... i � to Construct (� or Repair ( an Individual Sew=age Disposal Systemt atNo..................-•--•-------•-----•---•-•-•--•--------•-----•-•--------•-••--•--•---------•......--------•-••... ........................................... Stree as shown on the application for Disposal Works Construction Permit tNo�........1151 ...i Z-5/Dated------- , ......i��j .. DATE---------� ��- --s..6......---•-••--•............................ Board of Health -�-- FORM 1255 HOBBS & WARREN. ,INC.. PUBLISHERS • S YS TEM PROFILE , NOT TO SCALE TOP FDN. FINISH GRADE-2 0 O FINISH GRADE OVER FINISH GRADE OVER •,... DIST. BOX r{ . C, FINISH GRADE OVER , Q.°•:ee SEPTIC TANK . LEACHING PIT -t-( q..5 *,Z 4 4.0 , o e VARIES ' " :.e•.o ;. :.• •°...,:•� .;.:; . ,¢:;. , °:. \ASHED JIB 1/2" 12• MAX 'e.:.rt . ::..b:..:•: .. .o: :.. .: i. a.°:.:. o '! PRECAST CONC OR 'PEA STONE •u:o,,::e ., ., :d'o•: 3 ''-' T BRICK 6 MORTAR OUTLET PIPE LEVEL I TO 12" BELOW GRADE o'C:•o a MIN. e e..p . °: •D:u:9:: :4;..b;e°.o, .«: o�i FOR 2 FT � R, •6' � � .� �-� ',o �O' Li•L � c '•°•s:.: :••i,. ...� 'c:o'::0:' 'is':o: :e` �' ..a•'��;:•!'a.°' 5, 45,4 C. I. OR PVC TEES5.2� o o, ,., # I '• ',�: p•. ; 1 0::0az ' SSMT. FLR. I J GALLON EL . 44.00. DISTRIBUTION BOX INSTALL ON LEVEL BASE 3/4" T0 . 1-1/2 a PRECAS T CONCRETE p� PRECAST I e WASHED ! :°:a .a.:o.:o..• A H— /0 REINFORCED a ° cRusHEo a CONCRETE' t I e � .°;o• .e•,Q•.Q•..e:a:•:o-•o�.o,e.o.,.Q. .e,o.Q..:•,;•.,...a .p , e�Q..o. . STONE :b, 'o:•o.b.o.e°.o:0 0 .o.d o c a e.b' .e•4 0..°:°: ;o: c 4 0: I,. ° 0:. a H— 0 R N 1 : EI F. SEPTIC TANK �:° ° °•I 0. INSTALL ON LEVEL BASE a NOTE: EXCA VA TE TO ELEV. 3.2 -, OR ° °_o° a ;. ,o:o• LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEA TH THE LEACHING AREA ' ' r . N 4 ! 4 ` E REPLACE EXCA VA TED. MA TERIAL W.�TTH� , -- - : 7- \4 CLEA CLAY REE SAND N F (0,_ o„ EFFECTIVE. DIAMETER 46 LEACHING PIT GENERAL NOTESGINSTALL ON LEVEL BASE 1. AL L ELEVA TIONS SHOWN ARE BASED ON A ,5-5 U M E-D 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON __ - ! �+ ,';�; •, , .. . I - '. _ __ _ _ ,,.:: _ _ ,-.. OR SCHEDULE 40 PVG. , . I OBSERVA TION : PrT- t 3. THE BOARD OF HEALTH MUST ;BE NOT, PRECAST CON RETE `• , , l- -fir uC� 'i { LEACHrryc Ps WHEN CONSTRUCTION IS COMPLETE PRIOR .�, F L. 4 I. 0 l2 REG 10) TO BA CKFIL L ING PERCOL A TION .R.l TE: r { MIN • y > / 4. ANY CHANGES"IN THIS PLAN MUST BE APPROVED TE /T i- BY THE BOARD OF HEALTH AND CAPE C ISLANDS WITNESSED B!• l� lam' ' ! �i 1 SURVEYING CO., INC. . \ i " 5. MATERIALS AND INSTALLATION SHALL BE IN r. � C�� •. , (�(- BRO. Of HEAL TH s i , COMPL IANCE WI TH THE STA TE SA NI TARY DESIGN DA TA k ft r CODE — TITLE `V — AND LOCAL APPLICABLE '• RULES AND REGULATIONS o� NUMBER OF UL REGUL � � .. , • ,,. ;!,-' �� C , .. I E L 4 I . 2 _(_. �-3.D BEDROOMS 4.___ , s x _ 6. NORTH ARROW IS FROM RECORD PLANS AND o GARBAGE DISPOSAL IS NO T TO BE USED FOR SOL AR PURPOSES . I' C� 0 GALLON N 7. FL ODD HAZARD ZONE TC P50IL �.wTO� IL DAILY FLOW � :.` GAL . RECAST CONCRETE lI� 8. WATER SUPPLY TO; U t�/ia 7F-- � �UC�S�iE � �:�:�,�I�. sEprrc rANx�'' SEPTIC TANK REG D. GAL . , �, 46 GAL y yr• .• E ....SEPTIC TANK PRONTO D �:� s LEACHING. `REGUIRED 0 Q 4, a \ -• \�`' ter"" ' ) .. .<� , _ �ti? 5kf���J S. F. , EWALLAE z+Y : .,� '��- •-___ .. -- ti,,�.� , r--"'r` . s` Sz��. �'-A G/S.F. • ,,,�2.�GPO BOTTOM AREA 15 S.F. LEGEND IL-as.F.X ��201S. F. - r GPo 1 - EJQ t�l,� 1�C) r t ED r , IleE RING PRDVI PD . L II ,� PROPOSED EL EVA TION 8 Q U' �c —— EXISTING CON TOUR .INGL E FA MIL Y RESIDENCE 6 F OBSERVATION PI T ❑ DISTRIBUTION BOX b PROF�SED SEWAGE DISPOSAL SYSTEM _� O LEACHING PIT ' "'-` PREPARED FOR o o sEPrrc TANKR C R CONSTRUCTION lRP l RESERVE „•,1� :1 MASTREET :, " •' .. _ .,.., ." 't ` ' • }Ar° 4'`Y'l CtF 17~`Asti,. f , . IN L O T 1 B.�RNS TABL E — CO TUI T -- NA SS. PIPE' INVERT ELEVATION ' r DAT �E�: � I _ ING, INC. 1 k PLOT PLAN b� APE 6. ISLANDS SURVEY SCALE, AS NOT•.D r I5 . 4 . P. O. BOX 334 SCALE: I "— 3Ca• , � � �. ,,., . :7 TEA TICKET MASS.'• MAP SEC PCc LOT HSE �'- ,r•'�s'r',� R ' .. PLAN NO, .. ... '.raf<"�;'ce, ,,. ,..... ..:,.•a...,<,*��.,t -.fit , ..,,.... .w..,,.,' ,. ,_ ,•, ...,.., .. .:r. .a w ,r+<,.,.. , , , ' .a law,. A E S va STEM T SCA E ,�;l 0 ORA DE 0 VER TOP FDN. FINISH GRADE_40�10` EL ADE ,OVER ' �"-- FINISH GRADE 0 VER L�5._0 FINISH'GR DIST� ,� 80X_� 4­ 57 ' SEP TIC TA AIK LEACHING PIT�41- Z777\wl� \X IA\NIIA\\\ V 18N ARIES 7 . if Id r - I I .. I 'OF , /8 . 12 ; MAX PRECA 3 STo_ 5TON SHED PEA. E `BRICK� R , -:-A -"moPT A GRAD 12 OUTL' T PIPE L E VEL BEL ON ; E_ TO FOR 2 FT. MIN. r4 v., 7- t6 00 c.'i. �OR Pvc TEES 0 ,LGALLON SMT. FLR. DISTRIBUTION. BOX EL 4100, S:T INS T4 L L ON L E VEL, BA SE PRECA S T CONCRE:TE 314" TO .I ASHE 'A CRUSHED H-7-:1 o S TONE b N *QEI :'6 SEP TIC A W T 46. :A INS TA L L 0N 1EVEL BASE NO TE. EXCA VA TE TO ELEV 1WER L O)VER TO REMO VE ALL " vious MA TERA L*: BENEA TH THE L EA CHING A REA REPL A CE EXCA VA TED �MA 7ERIA L NI TH v SAND CL EA N, CL A Y FREE ........................ FFECTIVE -DIAMETE 0 46 PI L EA CHING NO TES GENERA L INSTALL ON LEVEL BASE 1. ALL EL EVA TIONS ,SHOPIN ARE BASED ON ' 615 0 M BE CA S T IRON �i 44 2. , ALL , PIPES IN THE SYSTEM MUST OR 'SCHEDULE 40 :PVC PI 7' OBSER VA TION., 3. THE BOARD OF HEALTH MUST BE NO TIFIED PRECA S� CON�RETE WH N ILEACH1*9 PI .:CONS TRUC TION, IS COMPLETE PRIOR E LC WO RA PERCOL A TION TE.` TO BA CKFIL L ING EL 4 (-0 -REG�p) A N Y CHA NGES IN THIS :PLAN MUST.BE ,APPROVED MIN, I7AtSSED B Y, DS BY ,rHE BOARD OF -HEALTH AND CAPE & rSLAN SURVEYING -CO., INC.- r'l V_E�m� MA TERIA L S AND NS TA L L A TION SHA L L BE IN OF, HEA L SIGN, HE S TA TE SANI TAR Y 7 DA TA ,­ COMPL IA NCE NI TH, T .2Q CODE - TI TL E V - AND LOCAL APPLICABLE bA TE IZF DE �' NU BEDPOOMS:'r,' MBEP . OF '6.�:� NORTH .,ARRON 'IS FROM' RECORD PLANS AND RULES AND4 REGULA TIONS I EL I GAPBAGE:, L V' IS NO T TO �BE USEDFOR SOL A R, PURPOSES y GAL ANK,ILRE AT E R SU P PL L' )?TIC ''T GAL o '01v FL 000 HA ZA AD ZONE L "TO 0 6ALL o ONO ECAST CO�N7*E` 5 U L Y TO!V-/Q /A7 C72- V _StP7*.rC TA 46 SEP TIC TA NK PPO VIDEAb > ACHING LE 40 ALL A S.F_, srDEhf ARE x j5G 2.GPD 1 REA BOTTOM A GR I�s x D F. L WO_WATE"q : ,LEGEND LEA CHING' PRO GPD ' VDEO ­m PROPOSED EL EVA TION 4, FAMIL )��' 'RESIDENCE EXISTING CONTOUR —50 SINGLE O&SER VA TION PIT DISTRIBUTION-BOX 0 SYSTEM SENA GE ', DISPOSA PROPOSED LEACHING D FOP PPEPARE R OIVS:Tpuc TION ,SEPTIC T4NK,- ro o �5 lz RE -SERVE E T RP1 .1 MA IN,' s T � L 0 T ,:.1 CO TU., MA 55. "BA��TA BLE: PIPE INVERT.. ELEVA TION 46.00 7VAR AX F6 4 5'm [pb, DA TE: TSL A NDS ''SU VE,YINO, &;7 PLOT PLAN 0 BoXr WO �.SCALE::AS, ED "E4,TICKET WA 5 CALE. MAP, SEC' PCL LOPJ Hc A A/ N0