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HomeMy WebLinkAbout1106 MAIN STREET (COTUIT) - Health F1106 MAIN STREET; COTUIT 1 A= 034 053:002 - ,I t' t TOWN OF BARNSTABLE LOCATION ®� at` C—,rr, s VILLAGE ttvt`� ASSESSOR'S MAP&PARCEL _ - NAME&PHONE NO.' , SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) (size) 1000 NO.OF BEDROOMS OWNER `(\CA r � PERMIT DATE: CRff=D=E DATE:_ �P 3I ►g �� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet "`^'FURNISHED BY Y Y Y Y 4 • ♦ \'\ 4 \ \ \'+ I r r r-F ! r ! . \ 4 \ \f ♦ 4 Y Y 28 G(J Y Y • •! r J f r f` •. 4f 4JY Jkf ♦ J Y `kf4 1 8 f J f l f f f f f f f 'Z7 4 4 Y Y Y Y 4 4 Y 4 \ `. 4 \ \ ♦ ..- f \ \ 4 4 Y \ Y \ 4 4 \ \ \ \ 4 4 + f f f f \ 4 \ Y 4 k Y Y 4 \ \ ♦ Y Y ♦ Y k '. f + ff + f 13 Patio! f f f !y!y! ! ell 'k 4 \ ♦ 4. k \ 4 4 f f f ? ? ? ! J f f ! f ` ! !` ` ` ` ` Right side of house ? :• r r f \ k ♦ ♦ ♦ 4 4 \ \ k Y 4 4 k r r J ! ! ! 4•Y 4 4 k \ 4 TOWN OF BARNSTABLE LOCATION 1/0(0 ! cV n-- 5;1 SEWAGE # VILLAGE ASSESSOR'S MAP&LOIA/39 INSTALLER'S NAME&PHONE NO. `�' ��' — � SEPTIC TANK CAPACITY 16 O LEACHING FACILITY: (type) (size) NO.OF BEDROOMS r BUILDER OR OWNER `�►� �� Cv -�L�� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �4� �, 3 j Commonwealth of;Massachusetts Title 5 Official Inspection Form Subsurface Sewage D sposal System Form - Not for Voluntary Assessments i wM 1106 Main Street — Property Address Paul Pinard I - -- Owner Owner's Name information is MA _ 02635 March 18, 2011 required for COtUIt I -- State Zip Code Date of Inspection every page. City/Town Inspection results mu�t be submitted on this form. Inspection forms may not be altered in any way. Please see complieteness checklist at the end of the form. Important: A. General Information When filling out forms the r _ computer, r,use 1. Inspector: j IlX(1 "I only the tab key I to move your Patrick M. O'Connell — cursor-do not Name of Inspector i use the return key. Septic Inspection S'lervices Co. — Company Name rQ 189 Cammett Road Company Address Marstons Mills MA _ ____ _ —__ 02648 — emm City/Town State Zip Code - 508.428.1779 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 ofthe inspection. The inspection was performed based Qn 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 i ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority March18, 2011 Job# 11-39 VInsector"s Signature Date The system inspetitor shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)iwithin 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 rase at that time. Thisl inspection does not address how the system will perform in the future under the same or different conditions of use. I Title 5 Official Ins ectlon Form Subsurface Sewage Disp at System•• age t�f 11 (Sins•09/OB P i I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1106 Main Street — Property Address Paul Pinard _—_ --- — Owner Owner's Name information is Cotuit _ MA_ 02635 — March 18, 2011 required for State Zip Code Date of Inspection every page. City/Town I B. Certification (cont.) Inspection Summa : Check 'A,B,C,D or E/always complete all of Section D A) System Passes: I have not fount an information which indicates that any of the failure criteria described ® Y I in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need',of pumping at this time, leacihng pit had 8-9" of effective leaching. I I� B) System Conditionally Passes: ❑ One or more s�, stem components as described in the"Conditional Pass" section need to b 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 +`IIyes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is fetal and over 20 years old* or the septic tank (whether metal or not) is structurally unsourid, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspectioi 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 indica�ing that the tank is less than 20 years old is available. ❑ Y ❑ N, ❑ ND (Explain below): I I i i Title S Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 l5ins•09/08 i I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dllisposal System Form - Not for Voluntary Assessments 1106 Main Street _ Property Address Paul Pinard I Owner Owner's Name information is Cotuit j MA — _02635 _ March 18, 2011 — required for I — State Zip Code Date of Inspection every page. Cityfrown i B. Certification l(cont.) B) System Conditionally Passes (cont.): i ❑ 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): i j ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstrul tion is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distrib i tion box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i i ❑ 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): (Explain:below): ❑ broke pipe(s) are replaced ❑ Y ❑ N ❑ ND p ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i I 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. I 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 i I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt mars Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 t5ins•09108 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 1106 Main Street — Property Address Paul Pinard — Owner Owner's Name I information is Cotuit i MA 02635 March 18, 2011 — required for City/Town State Zip Code Date of Inspection every page. B. Certification i(cont.) 2. System will ifail 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 supplywell. ❑ 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 coliforrn bacteria indicates Absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, p�ovided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i I I 'I I i I i i D) System Failure 6iteria Applicable to All Systems: - I You must indicat� "Yes" or"No" to each of the following for all inspections: Yes No I ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 El than_day flow t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page a of 17 i I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage D'sposal System Form - Not for Voluntary Assessments 1106 Main Street ! — Property Address Paul Pinard I — Owner Owner's Name information is Cotuit MA 02635 March 18, 2011 required for - --- ---------- --- ----- ------- every page. CityrTown I State Zip Code Date of Inspection — B. Certification j(cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® I Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface 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 j and chain of custody must be attached to this form.] ® i The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. I E) Large Systems: to be considered a large system the system must serve a facility with a design flow of 10, 00 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 i ❑ ❑ the system is within 400 feet of a surface drinking water supply i ❑ ❑ i 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 ❑ El j Area— IWPA) or a mapped Zone II of a public water supply well i 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. posal System•Page 5�I 17 l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Dis Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1106 Main Street — Property Address ; Paul Pinard — Owner Owner's Name information is MA 02635 March 18, 2011 COtuit required for A every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been.done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ if Pumping information was provided by the owner, occupant, or Board of Health i ❑ ® 1 Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® j 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 I available note as N/A) ® ❑ ! Was the facility or dwelling inspected for signs of sewage back up? i t ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? I ® ❑ 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 I 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: I ® ❑ Existing information. For example, a plan at the Board of Health. ® ElDetermined in the field (if any of the failure criteria related to Part C is at issue 1 approximation of distance is unacceptable) [310 CMR 15.302(5)] i D. System Information Residential Flow 6onditions: 3 Number of bedrooms (design): :3 --- Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): ---- -- I t5ins-,09/08 Tille 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1106 Main Street Property Address Paul Pinard Owner Owner's Name information is Cotuit MA 02635 March 18, 2011 required for ----- -.— - -- - — every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: I I I i i Number of current r'iesidents: 2 I i Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a sep rate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system ins�ected? ❑ ,Yes ❑ No Seasonal use? ❑ Yes ® No j Water meter readings, if available (last 2 years usage (gpd)): N/A irrigationsystem. — Detail: i i Sump pump? i Yes ® No - Currently Last date of occupancy: Occu led. Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: ---------- -- Design flow (based Ion 310 CM 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No i Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins•09/08 1 ille 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1106 Main Street I Property Address Paul Pinard Owner Owner's Name information is Cotuit _MA 02635 March 18, 2011 required for ---- every page. City/Town State Zip Code Date of Inspection — D. System Information (cont.) Last date of occupgri use: Date Other(describe bellow): i i i General Information Pumping Recordsi: j Tank pumped one year ago. Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons i How was quantity pumped determined? - -— -- --------------- --- Reason for pumping: —----—-------- --- — I Type of System: ® Septic tank, distribution box, soil absorption system I ❑ Single cesspool ❑ Overflow cesspool ❑ Prvy i ❑ Shred 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 I ❑ Tight tank. Attach a copy of the DEP approval. i ❑ Other(describe): l5ins•09/08 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 I 1106 Main Street — Property Address Paul Pinard -- Owner Owner's Name information is Cotuit j MA 02635 March 18, 2011 required for -- - every page. City/Town State Zip Code Date of Inspection D. System Inforimation (cont.) Approximate age of all components, date installed (if known) and source of information: 1980's — — Were sewage odors )I detected when arriving at the site? ❑ Yes ® No Building Sewer (loi ate on site plan): 3' Depth below grade i — feet I Material of construdtion: ❑ cast iron ® 40 PVC ❑ other(explain): - — I Distance from private water supply well or suction line; feet I Comments (on condition of joints, venting, evidence of leakage, etc.): i I Septic Tank (locate on site plan): 2' — Depth below grade:] feet Material of constru8tion: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i ;I If tank is metal, list age: years` Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5' long x 5.2'wide- 1000 gal. — Dimensions: ; I 2" Sludge depth: — 15ins•09/08 TAle 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Diisposal System Form - Not for Voluntary Assessments i 1106 Main Street — Property Address Paul Pinard Owner Owner's Name information is Cotuit i _MA 02635 March 18, 2011 required for — — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 — i Scum thickness i -- — 6 Distance from top of scum to top of outlet tee or baffle — 13,E Distance from bottolm of scum to bottom of outlet tee or baffle — Measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in needlof pumping at this time. Liquid level was found at bottom of outlet invert and tees were intact and clear. — i I — i i i l - i Grease Trap (locatle on site plan): i Depth below grade 1 feet Material of construction: I i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene Elother(explain): i — h Dimensions: — — i Scum thickness — I i Distance from top oaf scum to top of outlet tee or baffle ----- — Distance from bott om of scum to bottom of outlet tee or baffle --- Date of last pumping: Date l5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page to of 17 i Commonwealth of Massachusetts Title 5 Off cial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 'w 1106 Main Street a Property Address Paul Pinard Owner Owner's Name information is required for Cotuit MA 02635 March 18, 2011 _ - every page. CitylTown State Zip Code Date of Inspection D. System Inforjmation (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.): y I Tight or Holding Tank (tank.must be pumped at time of inspection) (locate on site plan): Depth below grade l Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ .No 'Alarm level: --- Alarm in working order: ❑, Yes ❑ No Date of last pumping: Date ------ -------- Comments (condition of alarm and float switches;etc.): i *Attach.copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 tt . i Commonwealth o� Massachusetts Title 5 Official Inspection Form Subsurface Sewage disposal System Form - Not for Voluntary Assessments 1106 Main Street — Property Address Paul Pinard _ Owner Owner's Name information is Cotuit MA 02635 March 18, 2011 required for -- ------- - -----Zip Code Date of Inspection City/Town /T'own State p p e. Y —every page. , D. System Info mation (cont.) I Distribution Box (If present must be opened) (locate on site plan): oil Depth of liquid level above outlet invert - ----- Comments (note if box is level and distribution to outlets equal„any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present, liquid level at bottom of single outlet pipe. — i I — I _ — Pump Chamber(locate on site plan): i Pumps in working order. ❑ Yes ❑ No Alarms in working Order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): i If SAS not located, explain why: i t5ins-09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1106 Main Street i - Property Address Paul Pinard Owner Owner's Name information is MA 02635 March 18, 2011 required for Cotult ____ _ __._ _— every page. Cityrrown State Zip Code Date of Inspection D. System Inforlmation (cont.) Type: i ® leaching pits number: One 6x6 pit. — i ❑ leaching chambers number: ❑ leaching galleries number: — I ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: I ❑ innovative/alternative system i Type/name of technology: — Comments (note cgndition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): j Liquid level was found 8-9" below inlet pipe with no high stains or signs of surcharge. I , I i i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): I Number and configuration I Depth—top of liquid to inlet invert — i i I _ Depth of solids layer i Depth of scum layer -- Dimensions of cesspool — i Materials of constr fiction m Indication of groundwater inflow ❑ Yes ❑ No 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Y Commonwealth 0 Massachusetts W Title 5 Official Inspection Form Subsurface SewageDisposal System Form - Not for Voluntary Assessments 1106 Main Street Property Address j Paul Pinard Owner Owner's Name i information is required for Cotuit MA _ 02635 March 18, 2011 every page. Cityfrown State Zip Code Date of Inspection — D. System Info mation (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I I _ I I i Privy (locate on site plan): I i Materials of constr l ction: - — I Dimensions -- — - i Depth of solids Comments (note c�ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i I i i I I i i i i I I i I j j I I l5ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts - Title 5 Of"I cial Inspection Form Su!bsuifac'e Sewage Disposal System Form Not for Voluntary Assessments i _ 1106 Main Street -- — -- Property Address Paul Pinard -- Owner Owner's Name information is Gotuit _ _ MA 02635 March 18, 2011 required for __ _-...... 0263_ .-_. - --- -- ----- - ------._.. State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewag� Disposal System: Provide a view of the sewage disposal system, including ties to at least two perm�nent 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 i4 the area below ❑ drawing attached separately 28 I JJ , 18 \ \ \ \ \ ♦ \ \ r 9 tyn / / F ! u i iiF'I , / / ? / ! / F13 Patio / ' / /\ Right side of house • / f J J / t 1 j ♦ � e • r i I I j j I 7 1 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Official System Form - Not for Voluntary Assessments M 1106 Main Street Property Address Paul Pinard Owner Owner's Name information is required for Cotuit _MA 02635 March 18, 2011 - every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) I Site Exam: i ® Check Slope ® Surface water i ® Check cellar j i j ® Shallow wells 20+ Estimated depth to high ground water: feet Please indicate allmethods used to determine the high ground water elevation: i ❑ Obtained from system design plans on record i If checked, date of design plan reviewed: pate i ® Observed site (abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health -explain: I i ❑ Checked with local excavators, installers - (attach documentation) i ® Accessed USGS database -explain: USGS topo map. i You must describe how you established the high ground water elevation: Low area of abutting property with no surface water is considerably lower than SAS. i I i . i I I i i i Before filing this!inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 . Commonwealth of Massachusetts u Title 5 Oficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1106 Main Street Property Address i Paul Pinard Owner Owner's Name information is required for Cotuit } MA 02635 March 18, 2011 ----- --- 2 - every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Sur4tmary: in, B, C. D, or E checked ® Inspection Sure mary D (System Failure Criteria Applicable to All Systems) completed 'i ® System Information — Estimated depth to high groundwater ® Sketch of Se age Disposal System either drawn on page 15 or attached in separate file i it I i I i i I i i i I i I I I i i i I I I I i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Secretary,EOEA —.._. David B.Struhs NIX;.�� Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARCELNk JO_jr-3 ®'402? PART A CERTIFICATION. Property Address: 1167(, Mv+ t' CDTv' f Address of Owner:, v 0j,- Date of Inspection: /6 " (If different) Name of Inspector: 6-).5 Company Name, Address and Telephone Num"ber: c� 6A 26T r— 1W Wyr,s''4tls 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: /�sses ,/ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signa Date: r' --tom le9 �U IJ The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The origina! should oe sen; tc :ne system owner and copies sent to the buyer, if applicable and the approv ing authorit-. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYST CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone.(611)292-5500 w `i Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O(Q cc—, V.,1 Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled 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: L� 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: �\k�twv, Ge�Pao1—*1 ou i1041 :M�,r,�. + ! . P ty^'-r( �Oqc\ Nez6v,�,�� the system has a septic lank ana Soil absorpUOn system anu is withiii 00 fCCi to a su iccc 'V�czci supp:j Gr tributar)- to a surface water supply. The system has a septic tanl, and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tans, and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria 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• , D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into 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 SAS or cesspool. (revised 6/15/95) 2 G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �'(�p 44q, v 5—F CO 1 0 7— Date of Inspection: D] SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apple to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water suppiy 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. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10(o tit 1 w 5/ O7U 1 1 Date of Inspection: Check if the following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the 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. As built plans have been obtained and examined. Note if they are not available with N/A. :� � The facility or dwelling was inspected for signs of sewage back-up. e system does not receive non-sanitary or industrial waste flow , The site was inspected for signs of breakout. ✓ All system components, excluding the Soil Absorption System, have been located on the site. 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. .ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b\ non-intrusive methods. I c facility o•'...i' ; . ' o;: pa-a, i c'f ov,ne.7 were prop ided with information on the proper maintenance of Sub Surface Disposal System. r (revised 8/15/9511 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �IQ�p It irti S� GU?v-I Owner.`--,Dr,.-,-r�D C ��w Date of Inspection: �O_') pV FLOW CONDITIONS RESIDENTIAL: Design flow:- v Qallons Number of bedrooms: 3 Number of current residents: Garbage grinder(yes or no):4-- Laundry connected to systee (yes or no): Seasonal use (yes or no): /`� J Water meter readings, if available: Last date of occupancy: t -e�t COMMERCIAUINDUSTRIAL: /' j Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume primped: gallons 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: �6i y Sewage odors detected when arriving at the site: (yes or no)!C (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: fa Q(Q tit A,, Owner:'.^ Y Date of Inspection: 16 _' o0- SEPTIC TANK: L, (locate on site plan) Gt Depth below grader Material of construction: concrete_metal _FRP—other(explain) Dimensions: Sludge depth: 3# Distance from top of sludge to bottom of outlet tee or baffle: 7 Scum thickness:_ ��t� Distance from top of scum to top of outlet tee or baffle:? / u Distance from bottom of scum to bottom of outlet tee or baffle: 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.) o -e, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle: DictanCo from bottom ni crt,— to hnttnm of outlet tee o• battie- 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.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: W Aa Cd-V') - Owner: — Date of Inspection: �a © C7 TIGHT OR HOLDING TANK: (locate on site plan) r Depth below grade: Material of construction: _concrete_metal _FRP--Other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments (note ii ievei anti distribut ry a:, e� uence of,oGd: ca,r)o,e;, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `Q(p j tj ST C :pW-t� Date of Inspection: 16;)10 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods). If not determined to be present, explain: Type. � - leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site pla ) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of ground%%atc-. inflow (cesspool must be pumped as part of inspection) 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5T Owner:�A�;t p Cir�wfCw�(� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent,references landmarks or benchmarks locate all wells within 100' 1-0 t (' 3� DEPTH TO GROUNDWATER fA-r NQ(,v f'srv- Depth to groundwater: feet t>—V o t'c method of determination or approximation: (revised 8/15/95) 9 05 o� _ z�� E E ®ow In�N I wa�cc e I j a Q(Za� NEW MASTER Ib� r4 L. BEDRROOM_ W N 1 I ..M " IIN �' E ',�p e I a IN NG_ '� ° II SCREENED% aC9 v _ 1 I 1 nAn.W.NOI 1 o iiI PO CN I a. U V' SIX RMN PDR. NEW �-_ _ i".'�nm f:) MASTER 1 C If BATH P II; coo•nm 41 , NEW m• pLIBRARY I muneea.a Ce NEYY'•..} �.L_a ',8 k ,w ke BREAKFAST(- II MUONALL ;I mo.rd rwm. II I� I Pam�./Oe I i.00«rxa t1 F- LIVI DELEO KRCNEN •,I G L_L!_J_t_L1 p - x,.rb 11 w .rs 31.� NF I. ® 'I a NANipp �; L 11 NEW (�' w ' ,�. I �c' t~ GARAGE F rF:mww. i.- y 0 '1 �aIKW t'.' O M r' u °I a I PNOE CN A .1 I• p W STUD GED 1�W aW 1 av L UNDRY dz W (�'� FIRST FLOOR PLAN GENERAL NOTES: LEGEND: s w EKIST.Pinar PLOoa .tole B.P. `I„ ,�'nTM� ,Kn v"iDev C7 EXISTING WALLS ®BMOKeoErEGTOR WSW SECOND •Tee B.F. ,I mq,oa�.p L"'7 CONSTRUCTKN!TOBEREMOVED l NEW FIRSTFLOOR •11e19.F. .aorworAewmo p0o°�8ors.wenu. NEWSCREENEO PORCH.220 S.P. „ µ n,>,mw,rHmme.w,ona SEWNEWCONSTRUCTION SCALE NEW RAG GAE •e70 B.F. t/4" o 1,—D. WINDOW SCHEDULE WINDOW SCHEDULE PATE TYPEMANUFACTURERS UNIT ROUGH OPENING REMARKS MANUFACTURERS UNIT ROUGH OPENING REMARKS A ANDERSEN WOH P42 T-7 VV.4•e IW GOUBL UNG J N 2C7f0 T-0 1fa'.P-1 1/P OOU LE UNO 12/3/2005 B 2N 70 1IB'.Y9 Iw COUBLEHUNG K AW St 7.47la•.Td T8 AWNNG C A251 74 iAl'.7-0fir AWMNp L • AN2/ 7.0 Sir./tP AWNING JOB NO. O C !-O U7 1e'.Yd 2 CASEMENT M On TA 519.T.0/? CASEMENT PINARD E e2 7-0 1/9•.e'-0 1IP OOUSLEMMG N WDH teu 1110 IW.Td iM• OOUBLEtKiNG F R1110 T-e tle'.1101R' DOUSLEHUNG TRANSOM P WOHU42 7 NC.1'-0lie OOUBLERNG G win 110f0 s'•0 1/B'.1'-0 tT DOUBLEHUNGTRAMMM O 1•-0 11r.7.0 ela CASEMENT ,„,11tl1O1MD.,,, DWG. N0. o AN 11 T-0 t .If AVMW a.cvmRwo2.IUFm1 WINYNOTEI.CONTMCTOUFATURERO VERIFY PRIOR TOOWBNITNOYYNERAHGRWGN OPEMNCI9 •,�,p, Al WIN NiNDOW MANUFACTURER PRIOR TO ORDERING OF WNDOW9Ime w� �- _ REVISED: 12/5/2005 M ;s I Ch06N BEDROOM BELOW N I I I t^ O I ,�aanw w.0 OC'� yOj �... � I f � BOH ry� 7ER I + g i BELOW I BATH ;LIBRARY ` EXPANDED I@ELOW g I I � p I •�q B OFFICE :=a Q rT—i Z E+ ° 1 DROOM w P-I rW a � SECOND FLOOR PLAN „;;;,„;,,., -= w co Z � o SCALE ; 1/4" a V-O" DATE 12/3/2005 ®® ® a®e PINS ARD DWG. N0, FRONT ELEVATION A2 REVISED: 12 5 2005 S / � •tea.., �_ - _ t � 1l�11 111 I I IUI 111 111� I I o LI,J I I"II `1t x `t4 ISv .I= 4. � I..�,�� _ ....,: i... •". —_ �_ __� _.Ir LII ��'�i III ..:� - - Ic^� - - "' 9I11,111lyiI' I ` �_— IIIl111111111111=1 �—, �_� III I�I� IIIIIIIIIIIIIIII — -____— IIIIIIl11111111 -"----IIIIIIIIIIIIIIII_=� Nn_ =ls- logo I.ol I••. 1 —_ ... _ 1111 __- _ WE -MIN I Ins):: man v ='-_ • MOM v Mein I 1111M III] 11 FIVIVISIS loss !igloos` —rL • • _—_—__--__ i��—__ �a.��dl — --- __ _ ..... ,.__—..,—.oor.-IiI i—'I Ii—— —e—I@—Ii Ii—Ii—Ii—— xem..:.gi•.«p°n—y — -IiI-'m&°-:sm•,°-xe.;=.xx=�u�°.mtw-xc w-xt w- m, .eiwsaow.m a°xW.`wm nk ggg GVALL iWECJUn„ sggt�wsi C0cV FURL BASEMENT —NEW LLFU NEWASEM NEW — =__ CCMT.DINING r `� � m� r kj a I' i II I ROOM .■. A p I i 1 II I I II I ,1°xeuur°"nxr°i.w w"inmm.:`x°' S nr. I 1 `:rmo,iwa,oacmur EXISTING i �I 1 NEW CO": 1 --- _—_-- FULL I I r, FULL x,ro.a.wu t .1__ ---------- 1 —t BASEMENT li I BASEMENT j.l I $ qqI �I I .Dore w rosawo j @i mvmroonxax I I 1 a SECTION @ NEW DINING 5 1 � Ii--• f 1 tll � --_-i jl I 1.1 NEW GwwAGE - w ro —-—-— �__ _--__I E- re.s xm..me.xu NEW ROOF CONS7, O Q 1•I I ( I n a.mwnwrm.ox... V.,2omrwm°mxovww.m I1 1 _____________________�. .xmemxxxmmmmrmu 'I I I m■e°.'w.°'.e I w.mrww z mmrrm°rrmx I I I I' L-- I I owiw° 1 ixx°Orr meoaxmxa4m ~' w Wi ll' I — ---------- — ---------- — ..,.. Q x.r,„ow emmmm.. r. -------------------------- xr1.96 ,NEW WALL CONjr— SCREENED W Q nwowwuo :�rm1O+maox°oaxiwxe FOUNDATION PLAN gg °�° EXPANDED z : •w°tN°xxo%.°��uBEDS "-I �■ _ ` �ewa� SCALE ,....u.w 1/4 I—O. ■ r°°'anwr� DATE .coxFw PORCH DRY ES�DYOED 12/3/2005 ..r.■•.. ;�<.... JOB NO. ���■° PINARD RWG, N0. A4^SECTION @NEW SCREENED PORCH c SECTION(a3 NEW LAUNDRY/ENLARGED STUDY REVISED: 12 6 2005 wx co „�— ter(— � d� �• F W Go NEW 0 3TOR�GE O NEW y .a.wwwe""' a„awwi. Ge : • Ud' .�.. OFFICE ,%i�.urn.,wM1O°0 .unw. rr w.m c wu,.,°a'axo.o KM iw• .aw.s �wiw""".o.m""``"" w� 4 NEW NEW WALL CONST. NEW REMODELED "°''°°"�' •� ^^� GARAGE :nn>Mao.T7 n MVOHALL CH LMNO waaw.wamwo �n.�•� " °° EAVE DETAIL :�rcmmim�`Vt°rw a.eru.eww .0 ' rain .as R— NEW WL EXIST. FULFULL BASEMENT BASEMENT w.a.anwu nSECTION @ NEW GARAGE/REMODELED LIVING E-� p O NEW ROOF CONST. z E m..•wwr.a. �a TYP.ROOF CONST, � z NEW �8 NEWWALC.ONST. "•'f�'�,`wq wuon.wR"Yi.�e (Zir,] MASTER NEW BEDROOM W.I.C. cm°Y°�bwm'aw"a"a�w.r. COVERED C0N�ST. y PORCH COVERED +..+.ow•.. .www°.°" !8`.'�.}. w.. MUPHALL PORCH SCALE NEW a.n.�,... 1/4" - 1._0" BASEMENT FULL ....w.ecaAnw. DATE e FUEL. .•a.. '""° 12/3/2005 BASEMENT JOB N0. s PINARD � ". DWG. NO. SECTION Q NEW MASTER BEDROOM SECTION(81 COVERED PORCHES/MUGHALL °°°"' A5 REVISED: 12 5 2005 In �ago� � 1 [s7 I I d Owx...wvrwwlwR xwvw l i ' ---------- i l x i 1 0 1 . 1 Oo 1 Itl II I k I 111 I 11 I II nn II � II H 1 • m V 1 wacn� w W o E- CE!] I FM I AN I x � z W o z -� SECOND FLOOR FRAMING PLAN SCALE 1/4" - 1'-0" DATE : 12/3/2005 ,JOB NO, PINARD DWG, NONO. : A6 REVISED: 12 5 2005 maw �m o x " as As, im e . aCf) d Wry,cli ,m x 0o .M _On n LO i e 2AN AN Q �� b6 •.I1NiN•N • T ^r' E- Q E- ME EM3 s z p _ if C;d rx c° z Arm Am SCALE ROOF FRAMING PLAN 1 /4" - '•-O" DATE : t.lALL ROOF RAFIERB TO BE].10e 12/3/2005 01SE98 PSON HU9E LnMC 7J AT s ERS Hm'9�`""E CUPS - JOB NO. 3.)VEOFE�TYPEMYOUT PINARD • nA� REVISED: 12 5 2005 LQCATI SEWAGE PE MIT NO. VIL-1LACE {I INST ,LER'S NA HIE i ADDRESS . OR OWNER DATE PERMIT ISSUED _ � ��� DATE COMPLIANCE ISSUED - - � 1 '� __�_�, < b � ° �'� .9� i� � � q r.� _., Y� �"/1 „` �� �� �` _. r.'�' ,*" -.. � i NO.A.7-e Fim.............................. THE COMMONWEALTH OF fRASSACHUSETTS BOARD F !-i_E A I�T Gar, ........OF........ .. _.................�............_........ Appliration for Disposal Worko Tonsturtinn Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 11©� ..x►�,a�ai as.r..................C..o..r..y%7__......... ......... ------oT-�-:.............. Location-Address or Lot No. .N.c,✓n f1 . !� ---•-•-•------------------------------ ..........--.........................................-............................................ / p Address W + 1 .............................. ........... ................................•---•--•--------- Installer Address QType of Buildin Size Lot............................Sq. feet Dwelling o. of Bedrooms._......._a.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ................................. . W Design Flow....... .........................gallons per person per day. Total daily flow..........lk 47._......................gallons. WSeptic Tank--Liquid capacity_.10.4to.gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------/.---------- Diameter-----14'...__.___ Depth below i et......G.......... Total leaching area.Q? 7......sq. ft. Z Other Distribution box (✓j Dosing tank /`/.7% 0-' Percolation Test Results Performed b .......................... _.....__ ._5.=._ Date.._. ...'_��!`7_. ,`�a Test Pit No. I........ it per inch Depth of Test it.................... Depth to ground water.....r.!:._....... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------... J' = O Description of Soil - ° '� . .�_: .�_.._':5'��%_. /= cnG -....-•-•-•----- x . ...... 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'LITTI - 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Misby e board f healt . ..' Dates Application Approved By....... = A � / ................ .............. 4 Date Application Disapproved for the following reasons:-............................................................................................................. --------••-•-•--•-------------•--....----•------------------•----'---.•.....-----------------•---------------..........-------------•----...- --•---------. Date PermitNo.......................................................- Issued_....................................................... Date Q.-.. No.. - ----A4 X Yuim .................._ -- THE COMMONWEALTH O.F.MASSACHUSETTS BOARD H ALT App irFatioaa for Disposal Works Tonstru.rtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ... C?.€:-�` t k ----- --------- "; � � �" � - .. ---------------- Location-Address or Lot No. --!- y. .......... ...............................................__................................................. ei Address �--- ----------------•-------------- -------------------------------------------------- •........ ____---------- _..................... Y,- Installer Address Type of Building. Size Lot............................Sq. feet °' Dwellings No. of Bedrooms..............._............................Expansion Attic ( ) Garbage Grinder ( ) a'k Other—Type"of Building ______________ No. of persons............................ Showers YP � g -------•------ ---------------------•P--'-• ( ) — Cafeteria ( ) Otherfixtures --•••••------••-•--•----- ------------------------------------------------ ------- W Design Flow____.__ . _ ______________........____gallons per person per day. Total daily flow________ ? .:_________"_..............gallons. Septic Tank�--Liquid capaeity_s �-�2_.gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No_ ____________________ Width................... Total Length.................... Total leaching area___.................sq. ft. Seepage Pit No.........0----------- Diameter. /P.......... Depth below i let ........ Total leaching areaP .� ......sq. ft. Z Other Distribution box -") Dosing tank ( ) jJ, �, G +- 4l 7�,. Percolation Test Results Performed by t r_._ .. . .__ Date____`_j ' 7 .......... ,tea Test Pit No L__ ___minutes per inch Depth of Test it. _______________ Depth to ground water------------------------ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth-to ground water........................ - �-{� of D Description of Soil .4 q x -- J_ ..P� c 1J . w N r, _ _..» .... __ -- -----...................... ----••-•--••-------•-•••-•---------------••-••-••-•••--••-••--------------•-----•-••--•....---------- ••--•-••••------------------------•-••--•-•------------•-------=--•-••-••••---••------------------ V 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 TITLi, 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. r Signed r: -- ----- ✓/ . Date Application Approved By....... .�` 1 t�'t...�'a� � L . . `- tom` :- .. .......__•-----. Date Application Disapproved for the following reasons___________________________ _:_:.__...__________._____._______.__________:::_________-_-___--.__..--_..--.. ---------••---------------------------- ----------------...---•--•---•------•---------•---------•---•------------•-------•---•---•••••••••--•-----•---••----•---•••--------•--•--••--•------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA-TH t !F1..............OF...... :....... Trrtilirab of TvrmpliFatur THI S I O ER I -'at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....f. fi --•--•---- r - --•--- ----_--•- -- ......... ............................. a Insta ler has been installed in accordance with the provisions of T? r of The State Sanitary C de as described in the application for Disposal Works Construction Permit No - �j_, .._ _____.___. dated..._ �_r _�_t _�'x............ THE ISSUANCE OF THIS CERTIFICATE,SHALL NOT BE CON, ®�,A►S A GUARANTEE THAT THE ' SYSTEM WILL FUNCTION SATISFACTORY. DATE........... 7 -- . ......... .................... Inspector. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL TH L / f rj...... OF.... ... !. . ..... -- ......................... FEE `.................. Disposal Works TaInstraurttion Uvrrmit Perm>ss>on is hereby granted ...-----:.::.•---•----=--•-=---------------------------------•--.......------..................._._.. to `Construct ( ) or Repair' (_ ) an Individual Sewage Disposal System at No ............... _..•................•---.................................. --- =----- ------••-- Street as shown on the application for Disposal Works Construction Perm No..., ......... Dated..____ ........ .�� .. d d , Board of Health - DATE ' ...-- ------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Ci _ TfsTPl k KIP 20 O IF Dirk p �3 THOMAS (JT/V�' (V � E • �ni Po[.ir- 14 0 v " 3 73. 90 0 °STE THOMAS E. KELLEY CO. ENGINEERS—SURVEYORS 346 LONG POND DRIVE SOUTH YARMOUTH,MASS. 02664 CERTIFIED PLOT PLAN H OF Mgssgc LOCATION o GRETE SCALE . ��34 DATE � r�?T.�y M. � BOHANNON PLAN. REFERENCE..J,��' . ,Z:� /J.... No. 26106 7. 4�'G SOV�,v / 00HANIV0N. .1.ANv S02VI-y C'0H,C9wy I CERTIFY THAT THE ... ...... . '99 Plew5ew 5t., ��Esf �3nd9ew�o�rr, l<�7ss. SHOWN ON THIS PLAN IS %X UND AS.SHOWN HEREON S TO THE SETBACK R TOWN OF . . . . . . . WHEN CONSTRUCTED. /✓�_ /y �J PETITIONER: REGISTERED LAND SURVEYOR 1000 TOP OF FGU'3DlFfION ��- ` . CONCRETE COVER CONCRETE COVERS ';a 4' CAST IRON 12"MAX. • � 12"MAX. • PIPE (OR 4"ORANGEBURG(OR EQUIV) . EQUIV.)- MIN. PIPE- MIN. LEACH. PITCH 1/4''PER. PITCH 1/4"PER.FT PIT. „o PRECAST o' INVEU • a LEACHING ` EL. F.,1' ,00. IN T INVERT �. e•; PIT OR ,•o INVER SEPTIC TANK � 810X /w � EQUIV. o; EL ��.. ���' .• GAL. INVERTELc�.3.� INVERT" wCL w :�: 3/4"TO II& • ww � EL-M40 o' �: ;:. WASHED / •" w STONE ho •: 6!D IA-. -+-1 o �, /p"DiA---►-I N� PROFI LE OF ' GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE KRI INAPIRloyff SOIL LOG WITNESSED BY : 4 DATE .1��/�� ._ TIME: .�iD�IYIVA2 BOARD OF HEALTH TEST HOLE I TEST HOLE 2CffP �/• d E N G I N E E R ELEV.4-7, . -. . ELEV. .5?.o.t t_Drc�q 4- DESIGN DATA gvBSot�- A SvBsotc_. _ y NUMBER OF BEDROOMS .���. . 0 32`�t� v TOTAL ESTIMATED FLOW ma�yy.,�• {� (� M6;DIVNI T'a JJ�. : . GALLONSr/DAY I� m Elp I V/y' e IUD SAN BOTTOM LEACH 1 NG AREA / . SQ.FT./PIT c- Tb SIDE LEACHING AREA . �pB.J d SQ.FT./ PIT C►ta�RS� SZ ,; S4Nt� � GARBAGE DISPOSAL /�L�. . .(50% AREA INCREASE) , L)M r� J } -Co A2SES4kA TOTAL LEACHING AREA to/.�. SQ.FT �7b � CIO) CfL/O , PERCOLATION RATE/oi% 7f44 r0. 0 MIN/INCH —— — 132'' �l LEACHING AREA PER PERCOLATION RATE r P. SQ.FT. !VDWATER ENCOUNTERED'. NUMBER OF LEACHING PITS • LL �T4.�S ioc O�VCdj APPROVED . . . . . . . . . . BOARD OF HEALTH. . . DATE AGENT OR INSPECTOR 00 0� THOM � o.212d0 Q THOMAS E.KELLEY CO. ols ENGINEERS-SURVEYORS FSSIpNAL a�\� •{, 346 LONG POND DRIVE PETITIONER SOUTH YARMOUTH,MASS. nw . . . . 02664 2/ /