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1243 MAIN STREET (COTUIT) - Health
1243 A = 018 - 078 COWit a> L i pig - DES Commonwealth of Massachusetts Title 5 Official Inspection Form copy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 19 +21 Nickerson Road Property Address t a 309 Amberley LLC , Owner Owner's Nartyz information is Cotuit ✓ MA 02635 May 28, 2020 required for every page. City/Town State Zip Code Date of Inspection tzl E- A Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. Passes 2. Conditionally Passes 3. B Needs Further Evaluation by the Local Approving Authority 4. Fails May 29, 2020 lnspedYo s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page. Cityrrown C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 1 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: 2) System Conditionally Passes: El one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not deter/ned" (Y, N, ND)for the following statements. If"not determined," please explain. �� i The septic tank is metal and over 20 rs old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltrati rr exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repl ced with a complying septic tank as approved by the Board of Health. i *A metal septic tank will pass i pection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the ank is less than 20 years old is available. Y 0 N /!� ND (Explain below): i i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 +21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28 2020 required for every State Zip Code Date of Inspedion page. Cityrrown C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 0 Observation of sewage backup or reak out or high static water level in the distribution box due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval f Board of Health): broken pipe(s) are re laced 8 Y N 8 ND (Explain below): obstruction is re ved Y N ND(Explain below): distribution b is leveled or replaced Y N L] ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): © broken pipe(s) are replaced © Y © N 8 ND (Explain below): obstruction is removed ' © Y 0 N 8 ND(Explain below): 3) Further Evaluation is Required by the Board of Health: Conditions exist wh require further evaluation by the Board of Health in order to determine if the system is fallifig to protect public health, safety or the environment. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form VA Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address - 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page_ Cityrrown C. Inspection Summary (cont.) Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 eet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Bo d of Health(and Public Water Supplier, if any) determines that the system is fu ctioning in a manner that protects the public health, safety and environment: 8 The system has aseptic to and soil absorption system (SAS)and the SAS is within 100 feet of a surface water su ply or tributary to a surface water supply. 8 The system has a septic nk and SAS and the SAS is within a Zone 1 of a public water supply. 8 The system has a Sept' tank and SAS and the SAS is within 50 feet of a private water supply well. 8 The system has a s tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private wa r supply well**. Method used to dete ine distance: **This system passes f the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria in)/and ates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp , provided that no other failure criteria are triggered. A copy of the analysis must be attached to this orm. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7QW018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page City/Town C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) 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 1h 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 SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] © The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000gpd. 0 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd t/ndic"a7ewe 15000 d. For large systems, you muster yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No the syn 400 feet of a surface drinking water supply 8 8 the syn 200 feet of a tributary to a surface drinking water supply the syed in a nitrogen sensitive area(Interim Wellhead Protection Area mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road J Property Address 309 Ambedey LLC Owner Owners Name information is required for every Cotuit MA 02635 May 28 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? 8 Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 8 Was the facility owner(and occup@nts if dif runt from ewn@r) pFevided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 19 +21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is required for every C MA 02635 May 28 2020 D tuit page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 (2+ 1) 335 GPD DESIGN fl@w b@sled on 310 CMR 15203(f®F @x@mPi@: 190 gpd x# € €�fp�► �) Description: 0 Number of current residents: Does residence have a garbage grinder? Yes No Does residence have a water treatment unit? 8 Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) Laundry system inspected? Yes No Seasonal use? Yes 8 No 2018= 85 GPD Water meter readings, if available(last 2 years usage(gpd)): 2019= 102 GPD Detail: Homes used seasonally. Sump pump? Yes ® No Oct. 2019 Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft. etc.): Grease trap present? Yes No Water treatment unit present? �] Yes No If yes, discharges to: Industrial waste holding tank p esent? 8 Yes No Non-sanitary waste dischar d to the Title 5 system? Yes No Water meter readings, if ailable: Last date of occupanc use: Date Other(describe bel w): 3. Pumping Records: Owners records: 5+years Source of information: Was system pumped as part of the inspection? © Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road ` Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool 8 Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other(describe): 2nd septic tank Approximate age of all components, date installed (if known)and source of information: Septic tanks original. D-box and leach field installed December 2012. Certificate of Compliance on file at Health Dept Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: Ll cast iron E 40 PVC other(explain): Distance from private water supply well or suction line: n/afeet Comments(on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 AmberleY LLC Owner Owners Name information is Cotuit MA 02635 May 28, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1 j Depth below grade: feet Material of construction: concrete metal 8 fiberglass polyethylene 8 other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 8 Yes 8 No 8.5' x 4.5'x 5' 1000 gallons Dimensions: 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" 10" at inlet Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Recommend maintenance pumping within 6 months. Shed is 6"from edge of tank. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 +21 Nickerson Road, #19 tank Property Address 309 Amberley LLC Owner Owner's Name information is required for every Cotuit MA 02635 May 28, 2020 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): 2nd septic tank Approximate age of all components, date installed (if known) and source of information: System installed December 2012 Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2.4 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): n/a Distance from private water supply well or suction line. feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts iw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 +21 Nickerson Road, #19 tank Property Address 309 Amberley LLC Owner Owner's Name information is required for every Cotuit MA 02635 May 28, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1.5 Depth belowgrade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 4.5 x 5 1000 gallons 5 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" 12" at inlet Scum thickness 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 11" How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Recommend maintenance pumping within 6 months. t5insp.doc•rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road -' Property Address 309 Amberley LLC Owner Owners Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: concrete 8 metal 0 fiberglass polyethylene 8 other(explain): Dimensions: Scum thickness Distance from top of scum top of outlet tee or baffle Distance from bottom of cum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be umped at time of inspection) (locate on site plan): Depth below grade: Material of construction: concrete 8 metal 8 fiberglass 0 polyethylene 8 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: 8 Yes No Alarm level: Alarm in working order: Yes No Date of last pumping: Date Comments(condition of alarm and float witches, etc.): "Attach copy of current pumping contract(required). Is copy attached? 0 Yes 8 No 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): One inlet, one outlet. H-10 D13-3 4.4' below grade. Light solids carryover. No leakage. No high water staining over outlet invert Riser installed to bring cover within 6"of grade. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 +21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes 8 No* Alarms in working order: 8 Yes No* Comments(note condition of pump hamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 0 leaching pits number: leaching chambers number: 10 Units in trench leaching galleries number: © leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number innovative/alternative system Type/name of technology: t5insp.doc•rev.7r4VX18 Title 5 Mae!Inspection Form:Subsurface Sewage Dispel System'Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC Owner Owners Name information is Cotuit MA 02635 May 28, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Trench with units 62.5'x 2.9'. Camera used to locate and inspect units. No standing liquid at time of inspection No sign of past hydraulic failure Units are vented. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflo/signs 8 Yes No Comments(note condition of sraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC Owner Owners Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of inspection page. City/town D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of ydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 + 21 Nickerson Road Property Address 309 Amberley LLC Owner Owner's Name information is Cotuit MA 02635 May 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t 3 `i C. IO 01 J v ,o A � i � L� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 +21 Nickerson Road Property Address 309 Amberley LLC Owner owner's Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 15. Site Exam: Check Slope 8 Surface water rl Check cellar Q Shallow wells >5 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed. 2012pate Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: maps massgis state ma us/oliver.ph You must describe how you established the high ground water elevation: Test hole in 2012 found no ground water. Base of units 5.6' below grade. No high ground water in area of system. f Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7l2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19+21 Nickerson Road Property Address 309 Amberley LLC - Owner Owners Name information is Cotuit MA 02635 May 28, 2020 required for every State Zip Code Date of Inspectionpage. Cityrrown E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed &Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed D. System Information: For 8: TighVHolding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 rl Commonwealth of Massachusetts /// Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1243 Main Street Property Address I� Cotuit Court Condo Owner Owner's Name �.a.,• information is required for every Cotuit Ma. 02635 09/14/2015 =� page. Cityrrown State Zip Code Date of Inspection 'a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information L�/�7 on the computer, 64 ///T j use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections �y Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t_ 09/17/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. O'� T t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below) ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 117 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >550 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal uses 0 Yes Z No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Apx. 1 year ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy - ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6,. Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard 1500 gallon 3" Sludge depth: t5ins•3/13 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 117 IN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal [],fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 4` t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: M t5ins•3/13 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 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s f t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 9/115/2015 Assessing As-aunt Uaras TOWN OF BARNSTABLE LOCATION/4Z%3 9�C,jam_ SEWAGE# 27-y l 1 VILLAGE �`L ASSESSOR'S MAP&LOTC 7 0' INSTALLER'S NAME& PHONE NO.g" SEPTIC TANK CAPACITY 1,600 .� LEACHING FACILITY:(typo 3 ag&& (efze) f NO.OF BEDROOMS r PRIVATE WEEL/L�OR PUBLIC WATER BUILDER OR OWNER J� n�'� �R/ DATE PERMIT ISSUED:DATE .COMPLIANCE ISSUED; S °�17 ba" � - VARIANCE GRANTED:.:w No d ` ro � F f Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augured a hole at a lower elevation and shot it with a transit to five plus feet of seperation. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form Not for Voluntary Assessments °y 1243 Main Street Property Address Cotuit Court Condo Owner Owner's Name information is required for every Cotuit Ma. 02635 09/14/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I�l Fee-T N0 L v t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Page I of 1 f TOWN OFBARNST"LL q -®a SEWAGE4 VILLAGE.a -L>`t+' -ASSESSOR'S MAP&PARCEL e C 0 7k INSTALLERS:NAMM &PHONE NO. CCU 0 '-' . t;:ke-A:u -90k m 63 SEPTIC TANK CAPACITY LEACHNG FACII ITS`:(rype)' IrG✓it? lS 3 C (size). NO.OF BEDROOMS 3� � OWNER i Wr PERMIT DATE: COyIPLIANCE DATE Separation Distance Between the: Maximum_Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and.'LeachingFacility,(If any wells exist' on-site or within 200 feet of leaching facility) _ Feet Edee of Wetland arid.Leaching:Facility:(If.any wetlands exist within 300 feet of leaching facility) Feed FURNISFIED BY s= ra5b t. .. 0 410 ----�6 1 A Ii �}C JASPC http://,issgl2/intranet/propdata/prebuilt.aspx?mappar=0180780OA&seq=1 8/23/2019 TOWN OF BARNSTABLE LOCATIONIM M pjvi Sf—' 8145 A SEWAGE#p261 VILLAGE CQ4-(—)(-- ASSESSOR'S MAP^&PARCEL ' PA 01& e_�7 INSTALLERS NAME&PHONE NO. 1C DC:i `j C Kt l� i .50& 7.6 q qG 3 SEPTIC TANK CAPACITY D✓rc �+ LEACHING FACILITY:(type) I,P-Si t41Ckt (size) 5 NO.OF BEDROOMS OWNER `�l 1 PERMIT DATE: )J� /� COMPLIANCE DATE: �. l 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) L Feet FURNISHED BY ikILJ , 1� c GArA a IDS �i p , R 1O V WI 1$ �'�� J, '65 3 c CA 0 � � pub �®x ' No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARMSTABLE, MASSACHUSETTS Yes 2ppYication for Nsposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(' Jpgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. _ .� ��i�►�f �Bla s a.3 h,4 Assessor's Map/Parcel 10d A-)9JI TCf'dJ Installer's Name,Address,and Tel.No.�l &// / Designer's Name,Ad/dress,/and Tel.No. c%G/C � 6►QZ/j/1 � Type of Building: 6 �Z�p3 Dwelling No.of Bedrooms 3 Lot Size 15 f 9V- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date /L- Number of sheets p2_ Revision Date Title /J 1/1 C-1 Size of Septic Tank e k.,, S i. f 100e, Type of S.A.S. cS�ele53_41.,a C6r,Prug 17_/ Description of Soil /Y►Q��N,,, Nature of Repairs or Alterations(Answer when applicable)c ¢ �Q.U g�.p Jn is p a,JO" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b his Board e Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. -k- 00 Date Issued oe No. ( 3 ', Fee ! f�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN S OF BARN' T�4ILE, MASSACHUSETTS 4 01pplication for DispopAY *_ pgtrm Construction 3permit +, Application for a Permit to Construct( ) Repair( 48rad ( A�'radon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. j /d 1/3 ®�]�fii��vsf lB���js. •�J�� .��1 _ - Assessor's Map/Parcel �fl�rGC J J�A)5-1 Installer's Name,Address,and Tel.No. 7 7.F, Designer's Name,Address,and Tel.No. �JaH y R`C G�a ��✓ Type of Building: 79C ( %3 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ' ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) I Other Fixtures Design Flow(min.required) 3 ,o gpd Design flow provided r i G gpd Plan Date /Z /Y- /L. Number of sheets Revision Date - { 7 Title ; •1 eil L Size of Septic Tank o oo E T_ype of S.A.S. Ce;r4 1,ru.r eC FlL J _ J Description of Soil /1 ed, 4,4, h1c ti c L Or IY. •. Nature of Repairs or Alterations(Answer when applicable)� j�G G,n-r &�r J/� r r' Date last inspected: • Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in .accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of�Hea th.` ` Signet Date Application Approved by Date G Application Disapproved by Date for the following reasons Permit No. / 00 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at ��1,. /3 /y6 Ly�ajoV�,( C/+Rs�u# t— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.00/3 Cd r dated / )3 f Installer Designer #bedrooms Approved design flow gpd The issuance of this permit sh i not V construed as a guarantee that the system ill functio de i ed. Date �Q Inspector No. a O) -3 Oo Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair( .1 Upgrade( ) Abandon( ) System located at � l ) 1 s-� ��7' c� t)) and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co blete, within three years of the date of this permit. f Date Approved I F r t ` •` t Town of Barnstable �Isms, Regulatory Services Thomas F. Geiler,Director Public Health Division � q. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 568-790-6304 Date: 113 Sew"age Permit#—,2 3 00/ Assessor's Map/Parcel Installer&Designer Certification Form j�e�-erT, T1c-En+2e f E. . Designer: E✓r, ; n�,a r•�,�� lnio r 1�s, lnc . Installer: cove`SX Address: )2 W, C.rxr S s :e led 1z4. Address:30 T1htc_k 1e+-rUVk c-e �M A- e z,6 y y S ikvJJ W«Lt YA lk 25 63 On CCMCA S C•XCy was issued a permit to install a ;(date) (installer) r3i� 2 3 septic system at 17-'13 Mur',l based on a design drawn by (address) I � \n-" eLr_ . dated -2 1 +2— (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. . I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations., Plan revision or certified as-built by designer to follow. Stripout.(if required) was ' cted and the soils were found satisfactory. ZH 0#&,A s9 ptallees RETERT. GNMcENTEE ignature) CIVIL W 9 No.35109 O 0 �GISTE�� 'fis (Designer's Signature) (Affix Design re) PLEASE.RETURN TO BARNSTABLE.PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffrce formsWesignercertification form.doc TOWN OF BARNSTABLE LOCATION SEWAGE#.,-01;L VILLAGE C,,,!>7ntL7- ASSESSOR'S MAP&PARCELA Pal INSTALLER'S NAME&PHONE NO. �i4v SEPTIC TANK CAPACITY LEACHING FACILITY.(type) 0'Ata—Tsize) NO. OF BEDROOMS . OWNER 11-9 W;11 10® PERMIT DATE: �*-Il f jz— COMPLIANCE DATE: Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility.' -Q4 feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) 0e/A4- feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). ydId feet A FURNISHED BY z I � 3' CA- AC.— i OIL � C 8 5' LL f. �► D 42— 6...D _ t-,ac r �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS apphration for Vspo8aY bpsirm ConstCurtioll Vertu Application for a Permit to Construct( ) Repair(4411u,"pgrade( Abandon( ) omplete System ❑Individual Components Location Address -�or Lot No.!� z� 3 t--,JA11-( '3'7" Owner's Name,Address,and Tel.No. Assessor s'�Nra 1P'arc�I M A` W4 �l 11 r&A Installer's Name,Address,and Tel: o. Designer's Name Address and Tel.No .� &A 11 Z v/.c4cu rE,P 11 AD. RTM f.0 4 6 kvlA- Type of Building: Dwelling No.of Bedrooms Lot Size 19• sq.ft. Garbage Grinder( ) Other Type of Building,YJ M646 BgMth( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided �-J43, 3 gpd Plan Date (4:!gb`L Number of sheets - Revision Date Titlen a&&P',6A 3 XO T G 5 V.M i ()P -Ck6 Size of Septic Tank 1 b b 0 <fr E' "( Type of S.A.S.,J-2 t36 ALEA*0O K ve p Description of Soil Af-MACA15b 1?)Ar,) Nature of Repairs or Alterations(Answer when applicable) ZA0774-1 l 6J&_\ S.04S, y AQWS 6 r- 6—Ab3 A-9c 204 p" W Wcmo 5,"6q2p4T'I6,N Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date b Application Disapproved by Date for the following reasons Permit No. - Date Issued Fee ! THE COMMONWEALTH;OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE;-MASSACHUSETTS 4plication for,.Misposal *pslem Construction 3permit Application for a Permit to Construct( ) Repair(grade(,e.�Abandon( ) Ej omplete System ❑Individual Components Location Address or Lot No. Y3 IV;p -I r( 3 Owner's Name,Address,and Tel.No. �IVf TJ T� M/� TN �c.11 1 I r42P Assesso s ap/Parcel 'AP J —t5-] oX - f--o 4-65,7 44I rv"► . Installer's Name,Address,and Tel"No. 'Designers Name Address and Tel No C p(� ty1 J .N71~ Type of Building: Dwelling No.of Bedrooms Lot Size y sq.ft. Garbage Grinder( ) f Other Type of Building S�til(„1 ryt i 1 No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 143, 3 gpd Plan Date y�20�J 2 Number of sheets Z Revision Date Title Size of Septic Tank / b 00 Ci4 Type of S.A.S.!M &c l4 Q{{ }70 N p Description of Soil_gF,6 Nature of Repairs or Alterations(Answer when applicable)j AJS7-A/ j M&W S'a4s 4-1 A0%^/S D Date last inspected: s s Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of -ter Compliance has been issued by this Board of Health. Signed Date $/ 2 �� / !a), Application Approved by � Date , Application Disapproved by ,1. Date for the following reasons Permit No. /�-- -/// Date Issued --------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(t_<� Abandoned( )by ` F 4 /�,G�,Q 4 M at 12 t..J 3 P' A I L'7" C= ,i,bA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N&/k.. /) (9 dated Installers )eS' 6,49A I A M Designer PcF MCA N'T7>-E CF,m G1 u 2/niG-IrJe2 f<S� #bedrooms Approved design flloow & gpd The issuance of this perm funcit shall not be construed as a guarantee that the system will ' do t'designed. Date Inspector �U •' t` r -. ----/--------------------- --------------- --- - No:;--�%�t� � � �i' Fee T� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION .BARNSTABLE,MASSACHUSETTS Misposai *pstem Construction ermit ' rtw Permission is hereby granted to Construct( ) Repair( ) Upgrade( Abandon( ) System located at 4_/ (�!j�Q j S 77 C y T?-i7l &1 A, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co/ pleted within three years of the date of this permit. Date ,r c` / / / Approved TOWN OF BARNSTABLE LOCATION f 0- Y3 SEWAGE # 97— 3 VILLAGE ASSESSOR'S MAP & 1.0T01 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY i LEACHING FACILITY:(type) 3 (size) Y+ �_ V — NO. OF BEDROOMS .S� PRIVATE WELL OR PUBLIC WATER Jll BUILDER OR OWNER DATE PERMIT ISSUED: DATE ,COMPLIANCE ISSUED: � `� VARIANCE GRANTED: No l\` r a: 4 _ ASSESSORS MAP NO: f PARCEL NO: FEE.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ------- ------------------ ----------_0F.................. Appliratiou for 1ligposa1 Works Totutrnrtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . , . ... . ---- ------------------------ -- - 9� L ti ess or Lot No. ......... ......_ -• ..............._......._.... ............._.. ......• ......... ...._... --- y��jyA Owner Q[4 W ... .._... •..........................^---.. .....rC.. C% ress.. �- -�- _--- Installer Address Type of Building Size Lot 0_'0 V'0----_--Sq. feet DwellingdZNo. of Bedrooms...�.......................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ...-•---•---......-•----•-----------•-•••--••--•----•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity&PP.gallons Length................ Width................ Diameter------.......... Depth....----.--..--. x Disposal Trench—No..................... Width.................... Total Length...........--------- Total leaching area--------- _sq. ft. 3 Seepage Pit No....I----_-------- Diameter._61--.V� Depth below inlet._Y............. Total leaching are Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..............................•_.._...__.__._...__.______...-....__.._____ Date....�1'�� Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water.----------------------. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-----.........--.. R,' 0 Description of Soil-- U ---•••-••-••-•-----••-••-•----•-•-••--•-----••--•------• ..................................................-•----------•••--•--•-•---••------•-••-•••--------•--•••---••-•--•......•-•------•-•... UW ------ ----- -- -------- - ------- --------- ---•-•-•- ----------- - -•••. --....... ------••• - Nature of pal sPo Iterations—Answer when applicable.. ..�Q Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLIT-LE 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 liealth. Signed -----•--•-• . ............................ ` - ......................... Application Approved BY �_ Date --•-------------------•-- Date Application Disapproved for the following reasons:............................................................................................................... --•-•-•-•-•---••-----•------••--------•--...-•-•---•---••----•---------------•-•--•--••••----••----•...----••-•-•-...-•••--••-•••--•----•--------•----••••---•-•-•------•-•-•------••--•--••---•-....... ADate Permit No..... -------•-•-•----------. Issued. -"�1.' '{ Date — No. a. FEs... •. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------- - ------- -- -----------OF.................... Applira#iun for Di-spacial Works Tomitrurtion ramit � Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1 ��, 6 �................. .....•--•-----.-••••--•----...-•--•---...... ..__...----•••-•-••.--._...............--- •. x L-at• - ress or Lot No. Owner /� A dress -- -•............................................•---• ..... •. nstallerAddress �} UType of Building Size Loth_ --------Sq. feet U DwellinglL No. of Bedrooms__S....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ....-•--•---•----•-----•---••----•---•----••-•------•-•---.....--•--•--••----•----------------------•-•------------------------- W Design Flow............................................gallons per person per day. Total daily flow.........0.............................:.....gallons. Septic Tank—Liquid capacity.I.K�42__gallons Length................ Width................ Diameter..............-- Depth_._..__......... �QlW Disposal Trench—No. .................... Width............._...... Total Length.._................. Total leaching area....................sq. ft. Seepage Pit No...I---.--.--_. -- Diameter:1:6_`f....�. Depth below inlet. ............... Total leaching area- Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..�..._ .J__` I;2 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........................................................................................................ 0 Description of Soil._:-.r ........................................................................................................................................................................ V -•-•---•---•••------------•-••--------....•--•------...--••••--•••-••-•-•-----•......----•---------•--------••-••---------------------------••-•-......-•---•---••--•-•-•----•------•---••------------:. UW ------------------------------- -••-•------------••-•--•--•---•-•-----------•--....------=----•--•-•----•----•--------------------•-•-• -•;�... ............ Nature of epa'rs o Iterations—Answer when applicable. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i-T�L ; 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. Application Approved B Hate Date Application Disapproved for the following reasons:.............................................................................................................. Date Permit No---- ------------- -- Issued-W Date THE COMMONWEALTH OF MASSACHUSETTS ^� BOARD OF HEALTH . .............1.fit.......OF..... / _.' :+� � r...................•.....,............ Tiertifiratr of (�om�rli nrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } by................ = -.A.J . .. ...------. •----- ---------------- ------ Installer at -, - dAt, .,.... •------------- •--•-•--------------------- .rzt�t�.' ;; - has been installed in accordance with the provisions of T i l E j of The State Sanitary Code as described in the application for Disposal Works Construction Permit ............ dated....................:........................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT.THE SYSTEM WILL FUNCTION SATISFACTORY. F„ DATE-•-------••-....�-.'..._ - __' 7-•---• Inspector _.Ac,.,i�...Z--- --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 5,-.......... ��t��o��l ork� �on�#.rion rrmi� Permission is hereby granted............ ----- ------------------------------•-•-•-••------------...--•----••------...............-•----. to Construct ( ) or Repair-!�e) an Individual Sewage Disposal System at Street 7 as shown on the application for Disposal Works Construction Permit No J .>f .._. Dated.......................................... (" Board of health DATE. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 1 TOWN OF BAR,,NSTABLR -(iCAT16N ,�. �3 �- __- SEWAGE #_ 'S-.-Z VILLAGE �c ASSESSOR'S 11AP & LOT ;I INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY Uc;, LEACHING FACILITY:(type) ) (size) '..-NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 l —_ 1 is �' —'"- ]` �. ,C ,r .. � - � THE COMMONWEALTH OFASSACHUSEETTS � E&�Hej ................ ..1/. OF... ... .. WH Appliration for Dhipoii al Mork.5 Towitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: /2 "3 �6e64Sa� RD Ir .3X0 a iwr) •-----••---.�---.._..-=•--•------•-•---•-•----••-----••--•-� ........:.....• -•------•---•-•••-----�---�-•••-----••-•----•• -•--•----•-•-----•....------••---------••. Locati n- ddress t N I r /LL ,� 6/4OFA/�iVW&V Arm &&7ft1�, ---------- --- -- -- -_. ..._...----._....-••-••-•....__-•--•• ..........----•---------------------•------•-•-- A<W �') ----•-••--------------- ess �.Y. ner Ad r--- �W1 ----- ............. I staller Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms____.____l_____________________ Expansion Attic ( ) Garbage Grinder ( ) ------•- '04 4 Other—T e of Building _ No. of persons-------1.................. Showers / Cafeteria Otherfixtures -----.?AN/Pr ••-••--••---•-•-•-•••••-•---•--••-------•----....--•--...•••••-•••-•••••_.... •--•-•-•-•-•........_•••_.. W Design Flow___________________________________________gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._-___________ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date......................_................. ►4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 _._.-••--•••----------------••••=-•-•-•••-•-•-•--••-•-••-••.....----••-•--•.........•-------•--•-••---..__..._....._._..._..•---•-••--•--•--•-•---•---•----•- 0 Description of Soil........................................................................................................................................................................ x U •-•••••--•--•••-•------•---•-•••---•---•-----•••-••---•-••-•••-•-••••---•••-•••••••----•-----------•-•----••-••-•••••--•••----•------•-----•--•-••-•-----------•-•--•-............................... w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------------------------------------------------•-•________••---...----•---•----••-•----•---•-----•••-••••-••--•-•---•-•----------••------••--••--------•---••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with �•1 T�•1 S.-. the provisions of .: ::.a. 5 of the State Sanitary Code— he undersigned fu titer agrees not to place the system in operation until a Certificate of Compliance has been issued e of h th. ��jj�S Signed-••--• - ----•--_- •--- ---•--- -----•- ---_� C?. Dat Application Approved BY -•-- •-•-- ---•• •- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•••-•---•------•--•---•--_-•••-- --......----••---------------•---------------------------•-•----- •-- ---- ------------ ------------- •---------------------------------------- •---------------------------•------------ Date Permit No._�_______: Issued..................................---------------------- Datti THE COMMONWEALTH OF ASSACHUSETTS BOfAeRD � HE H� ...............%.L'.�.L iV....OF....... ..? ... �. P. 1 Appl ration for Bitipaaii al Vorkg Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..... __ _.................. •-• .......... ...•---•--- Location-Address or Lot No. ......................—.......................................................................... -----.._.....•------•---------•--------•----••-------•---•...-----............_..__.....-----•---- W Address .......... .... ._\t_.... -- ._ ......................................... staller Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building _____.. No. of persons............................ Showers Other—Type g --------------------- P ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------•----------.•---•-•---•---•-•-•----•-•-•-•--•-•-•-•••-----------•-------•------••-•---------••------.------ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------.__--_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_____-._--.._-__-___. P4 --••---•-•---••-------•-•-•-----•---••---•-------•--•••--------•--••.............................•-•......................................................... 0 Description of Soil........................................................................................................................................................................ x U ..............................................•---•-•••-••••••------...•-•----------------------•-••-••-----------••---•.....•-••----•--•---•---------•••-•--•--........................................ w VNature 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 TT T LE ;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. Signed .�., Date Application Approved By !}/�i�l_��.._ ...... .r %?. ,e Date Application Disapproved for the following reasons:..................................... ....................................................................... .....................................................--......-----------•-•--•-------......-------•-----•----------•......•••------------••--------•-•--------•--•••----•-•--•••--•-••-•----_.... Date M ...—. PermitNo :_ ` ..................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HE LT ............. '...... `......OF.,�..: �� '; .. 1.. .�' ............. �...... y�'.-. y q �.`... T.Waertifiratr of ToutpliFattrae THIS 4,TO. C RT Y, Ta e Individual Sewage Disposal System constructed ( ) or RepairedX) by `�, f.-: - ---------•-•-------- -- -- ...;d;�.. �rd.taller at-------/ Il -�: �i✓r-4f-u-------------------------•- has been installed in accordance with the provisions of T° TLC: rj ofjhe�tate Sanitary o e a x ed in the application for Disposal Works Construction Permit No...._6..�_"' dated--- _ __/ __� .. ....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... -•----•--------••--•-••------ Inspector------......�y .................................................... THE COMMONWEALTH OF MASSACHUSETTS BQARDfF�HEAL H � r,)a)l) , ... 6 � ... •r FEE ��....... i �rwil a/1�'/ r�/ g_ go litrudiaatt unfit Permiss' is hereby granted .... u s t�r'•L, - ---------------•--------...---...--------------•-•-----------......---.........---.....---- to Construc ) Repa' ( ) an Jjndividu Sey�ag >spo System b n at No..-•I •,co ' ' �� `. /� _1� Screet y? � as shown on the application for Disposal Works Constructio mit No ?_!.i. ated........., � Board� of Fiealth•0�v " DATE--------------- ................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOC T ,ON SEWAGE PERMIT NO. v 'VILLAGECxL*l) CP INS l ER'S �A-ME & ADDRESS R UKDE R OR OWNER e DATE PERMIT: ISSUED •r DATE COMPLIANCE ISSUED I �,r No Flia.......1�..: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .... .... ......................OF................................---.. ........................... Appliratiun -fur Uhipo l lVarkii Tonfitrnrtiun Prrntit Application is hereby mar a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: e07 I.rLCC�E Sc�---------�----r--Cc�--------A..----- -...------------ ------------------- Loati . ddress or Lot No. -----�'-...... .. !ce c c,.,..............................5........ w Address .•....•• .........--.- .............. Installer Address UType of Building Size Lot............................Sq..feet Dwelling—No. of Bedrooms.....L.................................Expansion Attic (✓� Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtµres ---------------- W Design Flow............... _: Ions per person per day. Total daily flow......... ... ._..._............gallons. WSeptic "1',tnk/—Liquid capacity_/ .-._--- allons Length................ Width................ Diameter---_--_-.-.---_ Depth................ x Disposal Trench—No. .................... Widtli....__....._./`� vo e th.................... Total leaching area--------------------sq. ft. Seepage Pit No------ Diameter/A tX below inlet.................... Total leaching area..--:_..____.____-sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---------------- .......................................................... Date-------------------------------------- a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-----------------_- LT. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_---_-__-__.-_------_... 9 ..-•------------------------------------------------- •------------•---••• .............--................................................................ G Description of Soil ```�• � ----rr--- --------f`Sl..G/O L-�•-•-----------------------•-•--•-•-------------------- w 6--------- - ----------------------------------------------------------------------------------------------- x ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article NI of the State Sanitary Code he un e * ned f rther agrees not to place the system in operation until a Certificate of Compliance has been is e y / f lth. Signed----•-•------- -- ----------- --- •-•------•---- Yt_-s: ------•.............. ................................ Date Application Approved By- L-- ----------- ��- `r��.7 --------- I�- Date Application Disapproved for the following reasons:-------•------------------------•---------------•-------------.........---•---...-•---•---•-•---•-•-•----------- ------....-•-•----•...------•------••-----•...................•----------•••.....-•----•..-•-----•-------..------------......._........------------•......----------....-•-------------......---------••- Date Issued... .._(_' .1?� . - Permit No......�l�y.o ram/ Date No......................... FEic....... � • �G THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ..................OF.......................................................... .................-...-.. XpV irtttiuu -fur Utsputt1 Works Cnuuutrurtiutt Prruiit Application is hereby made 4or a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: U GT- /jr N(ckf-- sol4i -R-�....,...CU7oi.. W5S-.. Locati n•Address or Lot No. w. w f 7y LU,/'c *ko ----------_---------------------------------------------------------------------------------------- --•--•-•-•---•--•-•---------•-----•--......_..-••-••-----•--••••--•---••--•-•---••-------•---•---- W / .1,80 1;r Address a ....................................................�... _ Installer Address UType of Building Size Lot............................Sq. feet .--I Dwelling—No. of Bedrooms-----z-..................................Expansion Attic (✓) Garbage Grinder ( ) a4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ------------------------ - W Design Flow__ _____________ d-_-_________ - Mons per person per day. Total daily flow......._` __ ��_____._._...-....gallons. WSeptic Tank Liquid capacity.//_"__'gallons Length---------------- Width................ Diameter---.-----.------ Depth-.---------•---. x Disposal Trench—No- ---------------- --- Width___.___..._.j. �__. ,o�Len th__..._.......___._.. Total leaching area...............-----sq. ft. Seepage Pit No //�' . tk below let____________________ Total leaching Diameter g area-----------------sq. ft. Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.---------- .............................................................. Date--------.---------------------•--.-•--- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water---------.--.-_.--.----- (4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--._-._--_-_.._.--_----- P4 ------- --••------------------------- •--••------------•---•------•--•--.--...-•--•----••-•-•••--•.............................................-----..---- O Description of Soil-------_------- /, `- - /'/Ir /// , U ----------•----•---------------•••-----------------•_----_-----;/ /....•••..Z - x •---•----------------------------------------------------------•-•-•--•-------•---------------•---•--------------•-•----------------•-•-----------------•-----•------------------•- •--•----•----------. U Nature of Repairs or Alterations—Answer when applicable.-.--------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------. ---•-------------------- ----------------- Agreement: The undersigned agrees to install the aforedescribedr Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code The unde,st med fu,.rther agrees not to place the system in operation until a Certificate of Compliance has been is 'e t e o of h lth. Signed............. ---------•------------------•-•- �j Date Application Approved BY -�.-- .�F '' 4 -------------- � ` `7 --------- Date Application Disapproved for the following reasons:----•-------------------••-----•-•---..............-•---------.....-•-------------•-•................--•••-••--- .............•••••••----•-•••............-----------••--------•-•--------••••----•-••-••••--••••••-•--••-------------•-••••-------------------•----..--_------.•----•--------------------------.------- ``!! Date Permit No....... �� Issued....7/ 13. � ................................... Date -„�r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r'�-.t: 0F..... /=. .u:.-:/' './y'..'......................................... Trrtifirate of fITI'uut;ihatt r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by -- ;- ;--------------------------------------------------------- ----------------------------------------------•---------------------------------------------------- Installer.— f at.....---•••••-• --••..............••---------•--...--- ------•------------••--has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.---L----------------------------------------- dated----- -- ..:..!_�.r_..-___A-!.7 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE �-�••...-------•-•--......•--------- Inspector----•• / -----.------•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF. .............................................................................. No........................ FEE........A.-/-.f . Dispu,itt1 Norkii QIumitrurtiutt Prrutit Permission is hereby granted-------------------------------------- •-------------------------------------------------------------- to Construct ( ) or Repair ( ) ai Individual Sewage Disposal System at No-------------=•• - Street as shown on the application for Disposal Works Construction P t No��Eoar Dated------- --- � DATE. f Health - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Town of Barnstable Regulatory Services Sl, Thomas F. Geiler,Director BAMWABMMAW Public Health Division 9. 1. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 1-7 Z- Sewage Permit# -�� Assessor's Map/Parcel Ot a--8 7 Installer&Designer Certification Form �e�-er�'; 1'1 c_.E+,-►-e.� tom.E Designer: 'E,.,y: n�a�r.�, W a r 14 5% Inc . Installer: Address: 1z W. Crb S S ;e ►cl 12�{. Address: YJ 3 C � MA- IVA a ? On Cg J,.e 1'1aeY-?-&v was issued a permit to install a (date) (installer) MA)IV RGvS septic system at l Z V3 �"la'n S>` �a�r.. based on a design drawn by (address) dated 4- (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) was ' cted and the soils were found satisfactory'. OF PETER T. WENTEE -� Installer's Signature) CIVIL ,0 9 No.35109 9 �O STS G� (Designer's Signature) (Affix Design re) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification form.doc oF� Town of Barnstable P# Department of Regulatory Services Public Health Division Hate 3 t MAM t6s�A�e� 200 Main Street,Hyannis MA 02601 MIS ILI,Date Scheduled G" Time =)Pee Pd. Soil Suitability Assessment for S age Disposa 1 Performed By: pc �`e� � ^� _ Witnessed By: LOCATION& GENERAL INFORMATION Location Address Z j Owner's Name�3 �Mt�n S�+- T:'a 1 �—�. W-1'1i ct,r�cl� . 'MA Address �0 I��c. 1 zck 5— ( Ti�-r`2S A-dL,0-e., xAA0, Assessor's Map/Parcel: O 1 � _ 0 7� Engineer's Name NEW CONSTRUCTION REPAIR - Telephone# L 5Sa-9-)..A-7-7—$35 3 Surface Stones -7 Land Use ` nf� Slopes(%) / J / ��_ Distances from: Open Water Body���ft Possible Wet Area ft Drinking Water Well Drainage Way ft Property Line 6Jr— ft Other` ft " SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) a l�9 TOWN 0 �z z BLE 21 2 29 M 4hN S Z1 b=I Parent material(geologic) v ILI Depth to Bedrock .( t Depth to Groundwater. Standing Water in Hole: N� Weeping from Pit Face w�� ri Estimated Seasonal High Groundwater ! ' DETERMINATION FOR SEASONAL HIGH WATER FABLE Method Used: Depth Observed standing in obs,hole: in, Depth to soli mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. lVell# Reading Dude: Index-Weli leveei Aqj:factor Adj.Groundwater Level PERCOLATION TEST bate , Thug— Observation --Z Hole# Time at 9" Depth of Pero - Time at 6" Start Pre-soak Time @ Z C' 1: UP.1 Time(9"-6") End Pre-soak CS w►.=t Rate Min./Inch Site Suitability Assessment: Site Passed Q— Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling '(Structure,Stones,Boulders. Consistency. vl r''l S . 2;.5_Y.V. • DEEP OBSERVATION HOLE LOG Hole# `Y Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) .0--6 LS ►o�►2Y/Z 6�30 pQ-IS DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color "Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. n • n Flood Insurance Rate Man: Above 500 year flood boundary _No_, Yes Within 500 year boundary No 'Yes' Within 100 year flood boundary No— Yes Depth of Naturallv Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -- If not,what is the depth of naturally occurring pervious material? Certification l[ (�Q,S I certify that on (date)I have passed the oil evaluator examination approved by the s Depaitment'of Environmental•Protection and that the above analysis was performed by me consistent with the required trainin expertise and experience/described in 310 CMR 15.017. Date Signature- f Q:\.SEPTIGIPERCFORM.DOC O>LC N � S W10 � AGE PERMIT NO. 07YL - B VI -LAGE INSTA, L,LER'S NA El & ADDRESS ■ B U I'L D E R OR OWN ER DATE PERMIT. ISSUED DATE COMPLIANCE ISSUED tZ � �-�> 3 r a 711 h N EXIS77NG SEPTIC TANK ® Cross St Keelo Rd (Bldg. 3-House#21) •CBdh - O TOP OF TANK, EL.=27.93 30, 30.26 Pine Ridge Rd o INV.(OUT)=26.60f ___---- Nickerson R I 29,10 8of I Sea St + (approx.) z D EXISTING HOUSE(#21) 30.43 O H 30,56 Q LOCUS (BUILDING-3) O.H. / Q O 0r V -01 S-O78 LOCUS MAP NOT TO SCALE 119 64 S.F.t fence'� -x DRI LEGEND i - WAY' 98 -- EXISTING CONTOUR EXISTING LEACH PlT CV' x 100.98 EXISTING =SPOT GRADE TO BE PUMPED, FILLED 30,57 99.6 PROPOSED 'SPOT GRADE W/SAND & ABANDONED t ?�0 30,81 -W EXISTING WATER SERVICE t � 29.31�) x -W (a prox.) W -G EXISTING GAS SERVICE -O:H.•W.- OVERHEAD WIRES TEST PIT BENCHMARK I �\ EXISTING INSTALL CLEANOUT AT MID POINT SET i I HOUSE(#19) TO GRADE I I (BUILDING-2) �� z Q 00 ` J 30.99� -__ 31,28 x 20� • I � N Ln EXIS77NG SEPTIC TANK (Bldg. 2-House#19) ( n TOP OF TANK, EL.=29.47 30.66 INV.(OUT)=28.14t 29.6 30.x9 30.87 O \ 30, 7 STONE.:: 11� DRI VEWA Y GARAGE I (SLAB) P. EXISTING LEACH PIT 21�' � TO BE PUMPED, FILLED W/SAND' & ABANDONED- loi i 5_ 30.4 9 - ' xY 11 I I 30.17 BREEZ 30.4�p- WAY 0 O 30,24 x � x 30,68 D IQI 1EXISTING -1-� 4 Iwo HOUSE(#1243) i�I i i I N i� (BUILDING-1) 'Ln 4 i TP 2 U,I(Al, T.O.F.=30.6± lJ. 1UL3 S . x lal 11 ��/7 i ►tn�z� I EXIS77NG SEPTIC SYSTEM- 29.95 tU , NO CELLAR 1 - � o (BUILDING-1) 30 30.05 NO CRAWL SP. 1 t x TP-1 m t-I I -T j-1 m I. t-------27' u r-1 I LJ_1-�-�. 30.64 DIAM. . \ NO CRAWL SPACE 30.17 I o CELLAR ) 29.92 SAME GRADE AS THE W W OUTSIDE EXIST. GRADE. T = .6 OG �\\\ � 29;76- �\ M 29.97 GS- 1. x 30.11 R. WALK 29. 3 FLAG❑L1f x 29.90 30,00 L� �° tK 30,2 • r � � � �i`LC �. 30.33 CBdh ( 77't '� 29.78 P i fence CB/ E 1 30.09 29,53 SIDEWALK PK SEY 30.00 p 29,52 edge of pavement 29.76 29,94 MAIN ' STREET Benchmark Set a�����°F�'�ss�, TOP OF CONCRETE BOUND s�PETER PROPOSED SEPTIC SYSTEM UPGRADE PLAN �'. ca, EL.=30.21 (Assumed datum) o McENTEE C. CIVIL 1243 MAIN STREET Bld s. 2&3 , COTUIT, MA � ' NO.3511)9 �q Prepared for: Faith Willard, P.O. Box 1295, Forestdale, MA;02644 Engineering by: SCALE DRAWN JOB. N0. Engineering Works, Inc. 1 A 1"=20' P.T.M. 293-12 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. 2 (508) 477-5313 12/14/12 P.T.M. 1 Of 2 t ` NOTE: TO PREVENT BREAKOUT, THE PROPOSED ` FINISH GRADE SHALL NOT BE < EL.25.7 PROPOSED D-BOX FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PERIMETER OF THE S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT PROPOSED S.A.S. OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE INSTALL .INSPECTION PORT OVER END UNIT T.O.F. CHARCOAL 11 EXISTING F.G.. EL.=27.9t BLDG.-3 F.G. 30.7(MAX.) VENT F.G. EL.=30.4±(BLDG.-2� /- F.G. EL: 30.0t / i MAINTAIN 2% GRADE (MIN.) OVER SA.S. L=106'(BLDG.3) INSPECTION L=23'( LDG.2 L = 2'- PORT .® S=1% (MIN.) @ S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC s" to"I 14" s 10.75" TO EXISTING 48" LIQUID INVERT LEVEL ADD I GAS ADD INV.=25.52 PROPOSED INV.=25.35 1 TRENCH W/12 ADS Arc 36HC UNITS 0 5'/UNIT = 60' • D-BOX INV.=25.30 ` SOIL ABSORPTION SYSTEM (PROFILE) INV.=26.60t BUILDING-3 t, EXISTING SEPTIC TANK ) UNITS MUST .BE STAMPED H-20 INV.=28.14t BUILDING-2 ESTABLISH VEGETATIVE COVER BACKFILL WITH CLEAN NATIVE OR PERC SAND TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP ELEV.=25.73 INVERTS, PRIOR TO INSTALLATION. INV. ELEV.=25.30 q..` 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=24.40 GRADE ON A MECHANICALLY COMPACTED SIX 2.83' INCH CRUSHED STONE BASE, AS SPECIFIED IN" 5' MIN. ABOVE BOTTOM OF 310 CMR 15.221(2). T.P. EXCAVATION OR G.W. 3) INSTALL INLET & OUTLET TEES AS REQUIRED. EXISTING SUITABLE 4) GAS BAFFLE TO BE INSTALLED ON OUTLET-TEE BOTTOM OF TP, EL=20.2 - MATERIAL AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. EST. GROUNDWATER EL.=5.0f ADS Arc 36HC UNITS TO BE INSTALLED IN TRENCH CONFIGURATION WITH NO STONE . SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. GENERAL NOTES: SOIL LOG i 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. DATE: APRIL 4, 2012 (REF#13,594 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL EVALUATOR: PETER McENTEE (SE#1542) OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE WITNESS: DAVID STANTON R.S. LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: HEALTH AGENT -310 CMR 15.405(1)(b): ELEV. TP-1 DEPTH ELEV. - TP-2 DEPTH 1) A 3' variance to the 3' maximum cover requirement, for up to 6' max. cover. S.A.S. shall be H-20 and vented. 30.2 0 30.2 A LOAMY SAND 0 11 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR LOAM FILL 10YR 4/2 TO INSPECTION AND APPROVAL. BY-THE..BOARD OF-HEALTH,AND THE - - 29.7 6" 29.7 " DESIGN ENGINEER. C1 B LOAMY SAND ~ 4- ANY CONDITIONS ENCOUNTERED DURING•CONSTRUCTION DIFFERING MED. SAND 10YR 5/8 ' FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 2.5Y 6/4 ENGINEER BEFORE CONSTRUCTION CONTINUES. SOME FILL 27.7 30" DEBRIS � C1 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. ENCOUNTERED PERC 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 26.0 48 36"/48" THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF C2 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. MED. SAND MED. SAND 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. 2.5Y 6/4 2.5Y 6/4 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 20.2, 120" 20.2 120" THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO'BEGINNING ' PERC RATE <2 MIN/IN.("C" HORIZON) , CONSTRUCTION. ESTIMATED DEPTH TO GROUNDWATER 25'f BELOW GRADE 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS SOILS,TO BE VERIFIED PRIOR TO INSTALLATION IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND ` REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE - .INSPECTED .BY DESIGN ENGINEER PRIOR TO BACKFILL. ` 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 63.25" IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED PIPES OR SEPTIC SYSTEM COMPONENTS NOT SHOWN ON THIS-PLAN. 16" 34.5" DESIGN CRITERIA " NUMBER OF BEDROOMS:` 2 (Bldg:2) + 1' (BIdg.3) = 3 TOP VIEW so" SOIL TEXTURAL CLASS: CLASS I END CAP END CAP DESIGN PERCOLATION RATE: <2 MIN/IN. FRONT VIEW SIDE VIEW DAILY FLOW: 330 GPD END CAP REAR/TOP VIEW. DESIGN FLOW: 330 GPD . NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW GARBAGE GRINDER: NO - TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL'MAY r ' LEACHING AREA REQUIRED: .(330) = 445.9 SF DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. 4640 TRUEMAN BLVD .74 EMUS HILLIARD, OHIO 43026 Arc, 36HC DETAIL d EXISTING SEPTIC TANKS: 1000 GALLON CAPACITY (Bldgs. 2 & -3) ADVANCED DRAINAGE SYSTEMS,INC. UNITS MUST BE STAMPED H-20 PROPOSED D-BOX: 1 INLET, 3 OUTLET.- (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN SOIL ABSORPTION SYSTEM 1243 MAIN ' STREET Bld s.- 2&3 , COTUIT, MA USE ADS Are 36HC UNITS IN STONELESS TRENCH CONFIGURATION ' (GENERAL USE APPROVAL FOR 7.88 SF/LF IN TRENCH Prepared for: Faith Willard, P.O. Box 1295, Forestdale, MA 02644 CONFIGURATION) Engineering by: SCALE DRAWN JOB. NO. 1 TRENCH WITH 12 UNITS @ 5.0' PER UNIT = 60.0'• Engineering W64cS', Inc. N.T.S. P.T.M. 293-12 60.0' x 7.79 SF/LF = 467.4 SF 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(467.4 SF) = 345.8 GPD (508) 477-5313 12/14/12 P.T.M. 2 of 2 . I - I I I . - I I ,, -1 -- - -___ , I I I I � I I I I I I " . � I . — 11 i -I-''- - I I � I . . I , I i I I �_________ - I � I I I I � I � .1�. � : � I I I � I ), I . I � I : I . . I - . I I I;� I"I I ,�l _ . \ � I I I I � � i 1 4 1 � ,"., __-,-------, . I I I I 1. . I I I - _1. 11 . : ' ' ' I I -----, � I � . . I I I I 1� I I I I I 11 TYPICAL SYSTEM PROFILE . I I . I I I . I AREA PLAN I I I I r I I FDN TOP . FINISH GRADE= 4 cJ.0 8--. I NOT TO SCALE I . � I I . . I I I I I . . . I I I � . I I It- to' I . I I . I I , I �I � ,� . � 150-001 1 � I I FINiSH I _� I - , . . � ,SCALE : I - I I � " , 11 . 0 I I .� . � 11 FINISH GRADE OVER TANK- 4q.co' "I I � I I ' , I I I , I I ,, 1111.11111W I I I - I. . � 'i� � , I I I I I I - ll� I � , 11 I I� I I 17i � : I -� .1 ",If".. � 1. 11 � 11111111111�1 1-11111--7 GRADE OVER PIT= 49.po - . , ' i I � I I I � I I I � � � I I I I I I I - I I I I I'll", I I I � I I I I , m rl I I 11 � I I I I � I . L OT a r I I '.1 I I I I I I 1 3 1 1 ',�-- ........�,�1. � V:.j'-..:,�-..'-_' ltjl r I � I �l I I 1, I I I I I I I I I I .. ...... I .... r I . I � I. � r � I � , I I � I I I I � � I , _ � - I _ I � 11 - I I I � - _ - . _ I . ,.,,*'.-'."1".*,,.'."�::,_�- r I . I I -_ -n ,, ft �, � I I 1. I � , � � I� . 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I I� : I r I I I 11 � " �� , � , 1� � 1,� I I I I'� -I I � , , I � , I � " 'TOTAL DAILY ,EFFLUENT I 02 GALS. r _r I I r � I _� - I :� -1 . I : 'EST. � I Irl . I . � I � �� I I I I- I r I I � I I'' I 1. I" I r' . .' I I � 'I I , I� �1.r' 'r 4, � 1. I �l I I � I I I LEACHING I P I T 'NOTES:, - � , �, I I I , I i I � I I I I I., � I I � I I I - I , I I I I 11 I 0 , �r, I n I � I , � - . I L .1 I I � 1. r I � , I I r .i I C�� I I � I I . r 1. I r ,_, , , , � " ,L Ir , � - I-L- : r I i ��: 1 " � 1. I I I 'll I � ,� ''r I _�I I, I ' , ' � . "I I I -:�0- I I r r , . � I � r, 1. I r tr , r I I I " I I I i I � I -. r I I r I I I � I , � I I I � r I � I . r I � I I - ", I L: r - I,,r I � � I I . ,� , I . CONC.70 BE 4000 P.S.1 - �a � 28 DAYS. , 1 . SEPTIC 'TANK ' 1000 , GAL. ' , I I I . L I r - . I L - I I I -, I I � I I I I r 11 r ,� I I " r' , I I . I I 11 Ir" I I I I I L, I r I I 1, . I � � I N I r I 1,1. I 'V�6SV _ r � r I " I I I -1 �� �,r' I � I � I I ; I , I � I I I .�! , I ''I . 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I r � �l - � % 1L : � - I I � ,� I 11 r I 11 . , 3 2 A4D� 4 ' S' ECTIONS .ARE AVAILABLE FOR : 1; , , I " �,� r � . I I ,' 4 Ir ,� S r� - 11 I I . I L I 1, I I � � .� 1, I'll .-T-TA04 I lzl� 0 1 .1 I r I �, ., I 11, I , , � 1 I . r,' I � �. 1,�, r. I, , I � I I I �_,__"' I � I ': ! . , � , , � ' 'r I .1 I I 'I ": ,� '': L , , I � I � 100 I r I I � I � I I I I I �, �r.' �� 6.10 'C.0 r . I I' ll r . ' ��' ' � � I I _ ,1, I I� :11 , I - �" I 11 r � ' I I � I r, ''I I �l � ", , I GENERAL � NOTE � rr I I I �� , 44 ; I _ , ,� . , � I . I , I , I _ r I I I _ 11 I , � - , . I - _r I " " r, :�r,f I I � . � GREATER DEPTH REOUIREMENTS � I I , ; I I , I r r� 11 I . .. A I I . r I I I I r 11 r I I � L. . I I . j L:. L I ,,I , I � � � I I 11 ! 1, I I I -1 , . 1. . � I - I . I I 1, I I I �' , .� - � I I I � �� , I r I I I .. I ., " I I I I. I I I � %I I � I . I I � I I . , � I I � � I :: + 4 e-6" r ,� I ,, rr, �l I � I �,�" �. . 1, . � I � ll I r I . I I � I. - ,.,- r � - I I . 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