Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0021 MARINER CIRCLE - Health
21 Mariner Circle JA�ot it- i F/R `023 042 `r F I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 Evaluatio by the Local Approving Authority 4-11-13 Inspector's Signature Date The system inspector shall submit a copy of this'inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Insp on ,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 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. Cityfrown 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: System is in good working order with no sign of failure. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection . Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: , ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 t5ins•1 7 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form :Not for Voluntary Assessments 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 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 t 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 Y day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Mariner Cir Property Address Barbara iBell Owner Owner's Name information is Cotuit MA 02635 4-11-13 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No , ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion*of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Forth: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 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. CitylTown 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 S SAS on the site has rp System (SAS) 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4-2013 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•11/10 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 M 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name - information isCotuit MA 02635 4-11-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--not pumped since 2004 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-11110 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 , 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24" Depth below grade: 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"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: 1000 gal Sludge depth: 12" t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City(rown 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 20° Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. Cityfrown 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.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leachingfields 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.): Leach chambers in good condition and empty at inspection with stain line at 6"off bottom of chamber. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G 1 M 2 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 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: ® I`and-sketch in the area below ❑ drawing attached separately f rcgc etck jq . o o Dec � �a5 O - • �'. � r Kr�r ,J� •� 19,-? ' , y V v Q•3- 3 97 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments s a' 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit . MA 02635 4-11-13 page. City/Town` 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: 12 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 1' i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Mariner Cir Property Address Barbara Bell Owner Owner's Name information is required for every Cotuit MA 02635 4-11-13 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 t5ins-11/1 J Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS I(.,.. ' " EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS u DEPARTMENT OF ENVIRONMENTAL PROTECTION A,f, ; r ` I ('1 1143 c -- ti +y FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 21 Mariner Circle La Cotuit Owner's Name: Lydia Yaffey Owner's Address: Date of Inspection: 1/5/2005 AP 0 2 3 A-RCE[ .r p 4 2 Name of Inspector: (please print) Patrick T. Sullivan LOT Company Name: Ready Rooter a Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: Passes Conditionally Passes Needs Further Evaluation by the Local Authority __,,-'Fails Inspector's Signature: i��_ 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. Notes and Comments %a N . ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. 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"Condit' nal Pass"section need to be replaced or repaired.The system,upon completion of the replacement or rep�Jr, as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND) in the �or the following statements. If"not determined"please explain. ✓ f 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 exfiltratibn 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:tructurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years odd is available. ND explain: / r Observation of sewage backup of 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 ! obstruction is removed distribution box is leveled or replaced ND explain: % r' The system req.4ired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ' obstruction is removed ND explai Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the B rd 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 determ' es in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which I protect public health,safety and the environment: _Cesspool or privy is within 50 feet of a rface water Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water pplier,if any)determines that the system is functioning in a manner that protects the public health,s ety and environment: i _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 SA,I is within a Zone 1 of a public water supply. i The system has a septic tank and SAS and th./SAS is within 50 feet of a private water supply well. _The system has a septic tank and SAS a. the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used,to determine distance i' "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen andpitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy/df the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2.005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or sy tem comfit 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 and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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 well. Any portion of a cesspool or privy is 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma Y- (Yes/No)The system fails. I have determined that one or more of the above 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 de si flow of 10,000 gpd to 15,000 gPd• i You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria a ove) 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 — — r 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 coat;ct the appropriate regional office of the Department. f f i i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 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 -xZ 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) _Z _ Was the facility or dwelling inspected for signs of sewage back up? _,Z_ 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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No -, _ 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):__QL DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Z) Number of current residents:7— Does residence have a garbage grinder(yes or no): ti.x�-- Is laundry on a separate sewage system(yes or no):,—[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):(n Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no):_fxj<D Last date of occupancy: , COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,et97: Grease trap present(yes or no):_ Industrial waste holding tank present es or no): Non-sanitary waste discharged to th itle 5 system(yes or no):_ Water meter readings, if available- Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): Y If yes,volume pumped: dcz�<Dcogallons--How was quantity pumped determined? Reason for pumping: ,-�� TYPE OF SYSTEM �eptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 BUILDING SEWER(locate on site plan) Depth below grade: i ' (&' Materials of construction:_cast iron t,40 PVC_other(explain): Distance from private water supply well or suction line: sv� Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: t/ (locate on site plan) Depth below grade:\` �1" Material of construction: ncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 5 C(-5- - q- 6- Sludge depth: V Distance from the top of sludge to bottom of outlet tee or baffle: ' Scum thickness: ?*' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: p" How were dimensions determined: \,,y.0 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:— Material of construction:_concrete_metal_fiberglass /1yethylene_other (explain): %p 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 g baffle: Date of last pumping: Comments(on pumping recommendations, inlet apdoutlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, c.): l Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 TIGHT or HOLDING TANK: (tank must be pumped a*e of inspection)(locate on site plan) Depth below grade: / Material of construction: oncrete_metal._fiber glass_polyethylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day// Alarm present(y or no): f Alarm level: Alarm in workin 6rder(yes or no): Date of last mping: Comment (condition of alarm and at switches,etc.): t DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Zes x PUMP CHAMBER: (locate on site plan) / Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump cha er,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type �:Xileaching pits,number: leaching chambers, number: 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�s 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,%(yes or no): 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 9,f hydraulic failure, level of ponding,condition of vegetation,etc.): f f i i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. a r 53 y I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Mariner Circle Cotuit Owner: Lydia Yaffey Date of Inspection: 1/5/2005 SITE EXAM Slope Surface water Check cellar-" Shallow wells Estimated depth to ground water?1 feet Please indicate(check)all methods used to determine the high ground water elevation: t,/'Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) --_L'Accessed USGS database-explain: You must describe how you established the high ground water elevation: 4 . TOWN OF BARNSTABLE LOCATION �� +M��►�n�c ��rc1 P_ SEWAGE # VILLAG ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. ��$�®� �'-�t;,$�v h'l1©ti — SEPTIC TANK CAPACITY IX 7- LEACHING FACILITY: (type) %_ � n ize NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 10 te Lo a Leck � � ' Town of Barnstable a Regulatory Services $ Thomas F.Geiler,Director Public Health Division ve ° Thomas McKean,Director 200 Main Street,Hyannis,!VIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# Assessor's Map\Parcel 23 +z Designer: an q Wa'r"Q, Installer: CfS�Plre �C�Atir.� c/t., Address: &'usJ'Af el led Address: �CJ . f3v 5e- 18 Z9 On_ was issued a permit to install a (date) M (installer)_ septic s m at 2 / cQ C k` r C&�Ul ,�'based on a design drawn by M C.FA (address) 1t�_o_U j dated I/zd <3 1-- . {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 andi'or septic tank. 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. n C p�(H OF,ygsIP . 9 (Installers Signature� PETER McENTEE m CIVIL � NO.35109 y (Designer's Signature) (Affix B404 W, p Here) PLEASE RETURN TO BARNSIABLE PUBLIC HEALTH DIVISION C RTIFICATE OF COMPLIANCE RILL NUT BE ISSUED UNTIL BATH THIS ORM AND AS-BIJIIT CAS ARE UCEIVED By THE BARNSTABLE PUBLIC EIEALTII DIVISION. TUANK YOU, Q:Health/Septic/Designer Certification Form 3-26-04.doc TawN G]F B STABLE -. LOCATION ;lYca�1����.'✓ SEWAGE VIL%AGC 0 7 — A,�"SESSGR'S 1�RA' IN9TR�LLEYt'5 NA bM 'HONE NO. SEF'IlC TANK CA.yPACITX —------• .�... _� 7. C`iG.K' BrS tsixe) SOd S fad.OWNER COWIl;IM . IT Sepnratioet t'.Distaattoe etween t�,e sFeus Maximum AeljusWc!Groundwater'!' kyle to the,Bottorn of Leaching Padlill. I'biva9c Watwr Supply,WcRI a3lcl i.eai.Mltl�1?ticility (I oily.`�;1ells exist t:a t 0A site oe witJhin 200 feet Of IncW118 faxciliv) Ect ()�Wetiand>a.nd Leacius►g Faciliay(Yf any wetlands exist within 300 feet of lesebing faducy) purw5hoc. Y_..�. ..- �r�yC Gc�C Dak r a Deck . Q 0 93 C It 38' B-q- yy' TOWN OF BARNSTABLE LOCATION SEWAGE # ZOOS'— VILLAGE C.01U'ktr ASSESSOR'S MAP & LOTS r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY � LEACHING FACIL=: (type)f��J © gRimcrN c.��+��c';'�ize) �3�Z x Z 3 NO.OF BEDROOMS BUILDER OR OWNER 1=,h&k PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I ® _ ) -t all g- v6 �r FEE COMMONWEALTH Of MASSAC14USETTS Board of Health, ~� S` `��Q?_ MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) UpgradeXAbandon( ) - ❑Complete System/0`Individual Components Location r < Owner's Name Map/Parcel# Address c Lot# Telephone# Installer's Name r �X Designer's Name 4 Address KQ Z ( Address Z W _ Telephone# Telephone# Type of Buildings" �r� l r' � ���/ Lot Size ?/��. ! sq.ft. Dwelling-No.of Bedrooms A& 3 to (ON Garbage grinder ( ) Other-Type of Building A No.of persons Showers ( ),Cafeteria ( ) Other Fixtures �� `) Design Flow (min.required) ` J gpd Calculated design flow Design flow provided ?�3 � d Plan: DateT10 Number of sheets iL Revision Date f� Title �'� � :� i 4 Description of Soil(s) c f Z L �f c l u Ll - 5o�ci Soil Evaluator Form No. Name of Soil Evaluator m Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersi ed a es t stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr es to n to ace a syst in operation until a Certificate of Compliance has been issued by the Board of Health. Signed - Date Inspections Noy t/ FEE y 40. e GOMMONWEAL114 ®F MASSACHUSETTS � Board of Health; APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT t Application for a Permit to Construct( ) Repair( UpgradeX_ Abandon( ❑Complete System- Individual Components f Location 1XI M q�r t.A_ ,- Cl rc Owner's Name Map/Parcel# 0. 'l 196trceC Z Address SCAN"^Q Lot# - Telephone# Installer's Name G. S .(It E x 'D.V 0%' "C C/-1 Designer's Name rvt "✓� �z �� Wov L U rr Address PiU' '7�X OZo, Cie t_ Address Z LAJ_ Comas T�-C( �Zv� r--0P--5( Telephone# �rtJtJ A- C) Telephone# l ��_ 1' ��7, 0Z4 Lr Type of Building l4-5` t`4�A, "" /`y �-t.yVt���/ Lot Size 2 / Z' sq.ft. Dwelling.-No.of Bedrooms " 1�'� �Q Garbage grinder ( ) Other-Type of Building /� A No.of persons Showers ( ) Cafeteria ( ) Other Fixtures w /Design Flow (min.required) V gpd Calculated design flow _ Design flow provided 2✓3 gpd Plan: Date' U Number of s eets 1—Z_ M Revision Date Title �'( +ic s �5 �-$J`'* � Ol r ✓ f7wC1l C , Z( Y ►�+l Description of Soil(s) O ^(p 6 L 30 tG .k L O((—I Soil Evaluator Form No. Name of Soil Evaluator 14k/"BC Date of Evaluation �L DESCRIPTION OF REPAIRS OR ALTERATIONS .M P The undersi ed a ees i install a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to ,t to lace ,e syst m in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Ins ectionsdA�W 'VZ `I f �y p 7 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, CERTIFICATE Of COMPLIANCE Description of Work: In 'vieual Component(s) ❑Complete System The undersigned1h_ereby certify that the Sewage Disposal System; Constructed ( ),Repaired,;Upgraded �.,Abandoned ( ) by: S4 aq ..r has been installed in accordance with the r vis'o s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. c S'0 dated � G 4 . Approved Design Flow 3� (gpd) Installer Designer:, Inspect r: Date: U The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, `'1 S ��Y, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissi n is he eby ggrranted to;/jC�onstruc ( ) Repair( Up rade( ) Abandon( )an individual sewage disposal system at / //,'�ifC � 60 Le t as described in the application for Disposal System Construction.Permit No Ar',0 dated Provided: Construction shall be completed within three years of the date o fhi p loc/aditions must be met. �41,j Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health v < No.............A.. -Fizi,........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.... ............................................ Appliration for Disposal Works Tvustrurtion ramit Application is hereby made for a Permit to Construct Y\ ) or Repair an Individual Sewage Disposal SyS......at. _ .1:�L�J ���` .�.�....C ................. ..........& ............................................................... L3 AOo6,q4s s ........................w ................ > or W N ............Lot 6;ner Address ... ............. . .............................. ................... .................................................................................................. Installer Address Type of Building Size Lot..Q3;,._W_Y' .....Sq. feet Dwelling—No. of Bedrooms_ ......... .......... ...............Expansion Attic . Garbage Grinder Other—Type of Building No. of persons..........(?.............. Showers — Cafeteria Other fixtures ....................................................................... ........ ------------*........*------------------*-------------- Design Flow...............-5-5 ..................gallons per person per day. Total daily flow__..._.__._33P....................gallons. 9 Septic Tank—Liquid'capacity./ gallons Lep gth................ Width... I------- Diameter_________..___._ Depth____________._.. No..................... Width___ .... .... Total Length.._ Total leaching area.................. Disposal Trench M ft. Seepage Pit No___________/....... Diameter.___._._, ..... Depth below inlet...23........ Total leaching area...-�O .....sq. f t, Z Other Distribution box (1) Dosing k ( ) — Percolation Test Results Performed by...W., ,�OR.... ................... Date-_ . A ..... A Test Pit No. I................minutesperinch Depth of Test Pit____.________._.____ Depth to groundwa(er.... Test Pit No. 2................minutes per inch Depth of Test Pit.___._._________.... Depth to ground wa er-----V................. ............ ............*---------------"-------........-----------------------*------------------------------.......................................................... ..................... -------- ------- 0 Description of Soil..... ................................. .................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable---- ............................................................................ .......... .............I........................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I TL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been by the b rd of iealth. ,pigned . ....... . ..................... ....... ate Application Approved By......... ....... ...... . ... ................ ..... Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....!. —./ —"A.................................. Date No...........,. ... Fizz..30............... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ................... App iration for Biipoial Works Tonitrurtion jJamit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: ...... ..... -----..... CCc Loca' A�tr�ss or Lot No. ......................--.(�...('::�J......r.�'�? .......--•-•-•-----------. .......... ... .........................••------- _ Y l r Owne ddress --------------------------------- -----------------. --------................ a � InstallerLCx!�J.... Address Type of Building Size Lot.. ........Sq. feet Dwelling—No. of Bedrooms..............3.........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .J.��s _� :..... No. of persons_._..__...(............. Showers ( ) — Cafeteria ( ) a' Other fixtures ................................ . W Design Flow.................': .................gallons per person per day. Total daily flow.............. .........._3. .2...................gallons. WSeptic Tank—Liquid capacity.l '.gallons L� gth................ Width................ Diameter................ Depth................ x Disposal Trench—No./................... Width:..../.._..__-_--. Total Length....�q..�I,_. Total leaching area.._...........�,aq. ft. Seepage Pit No_____________________ Diameter......... Depth below inlet.................. Total leaching area.....:: ....sq. ft. Z Other Distribution box ( /) Dosing t nk aPercolation Test Results Performed by---- . ......:._?-..--•----------..... Date... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._ �2..�-_----__-__. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-__((//. a ••----•------•--- •' • ..................................................---......-••-•-•......••-•--...--•••---•--•-•-••---.---- O ,r Description of Soil---_.. = = ...'_.:....1.... ................................................................................................................. r L� x _ V _..---•-------•----------- ... f U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•----------------------••---•-----------------------------------•--•--•-------..........--•-•---•-------------------------------------------------•---------------------------------•-•----••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITsZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. -- Date Application Approved By...' l .. .._..... = -------•---•---- / — !� `.__._�_rF.- ._.:.. Date Application Disapproved for the following reasons:_..--•------------------•---•-•-----•-------.......-----------•---------------------....__.........---•••----•-. ...•--•---•-•-------------------------------•---•-••••-••-----•---•---•-•--...••----..........•---•-•-•--••-------------------•---•••--••-•••••••-•-•-•-----•••--•-------•-•--•-•--••••-•-••-------•-•-- Date PermitNo......................................................... Issued-................=...................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............,GC;'6U.............OF........�}�Cf/�/US7Li 1.,� . Trr$ifiratt of Tontplianrr THIS IS TO CE-RTIFY That•the Individual Sewage Disposal System constructed ( A� or Repaired ( ) Installer at--------- ° (,?. ...-/+7�Cc 1[=j. .......L�ti( G ...................... has been installed in accordance with the provisions of T }I 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No G!_3-------•---. dated----- ,.... _ - --�-- �� =---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ; DATE..........a `..1.G) - Inspector.. _--------•------------------•-----------------------•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD_OF HEALTi7, .................u' No..............••�----... FEE...•.•..---............. Disvolli I orko Ton�TAOton rrntit Permission is hereby granted......... !%��.`'"...`�:�)....... ----• �-_------- -----.....--•-•...................................•--- to Construct ( ,/) or Repair ( ) an Individual Sewage Disposalystem atNo... E `•---. ............................................................................ T( &c reet as shown on the applicfation for Disposal Works Construction `err it No...__ .t_... Dated...1 ............................... * �' _ •----•.......................... Board of Health DATE.....-•-•-------••-•---•--------••--•----._ ' FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS LEGEND Of 78 PROPOSED CONTOUR � LOCUS 3 . 79 PROPOSED SPOT GRADE �0 ° I / —97i"/ EXISTING CONTOUR � ,La I R I O Oute TEST P IT a oar Gc 53�MI Dg5TING 5.A.5. W EXISTING WATER MAIN er ar N rJcj2°2$ TO BE PUMPED 4 FILLED W/SAND BENCHMARK: 5take 4 Tack Set gee `° LOCUS F-LEV. = I00.00' ' e (ASSUMED DATUM) Tro�ti 0n5 Rb T S°�Q5 3 w 9� EX15TING 5EPTIC TM K 009 TOP OF TANK EL: 97.7_ � INV.(OUT) EL: 96.3± 12' 23' LOCUS MAP N.T.S. O O i N _ , GENERAL NOTES: _ TP - 1 ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL In `` BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS O M OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE N N LOCAL RULES AND REGULATIONS. 1"N D�Gtc z 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR O INSPE TION ER D APPROVAL BY THE BOARD OF HEALTH AND THE 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING No•21 FROM THOSE SHOWN HEREON `SHALL BE REPORTED TO THE DESIGN 15TM• GA ENGINEER BEFORE CONSTRUCTION CONTINUES. �-Wo. •12 MAP 23 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. tPARCEL —f 2 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF p THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 23,942-+' SF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER MAIN. t 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. ! 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE THE LOCATION OF ALL UNDERGROUND UTII:..ITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. /1/79 03nEyjAss9 AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). MARINER. CIRCLE �`` �LI� ► �� PETER T. �, McENTEE SEPTIC SYSTEM REPAIR/UPGRADE v CIVIL No. 35109 21 MARINER CIRCLE, COTUIT, MA Prepared for: Lydia Yoffey, 21- Mariner Circle, Cotuit, MA Engineering by: Surveying by: SCALE DRAWN JOB. NO. EngineWngWorky HOOD SURVEY GROUP 1"=30' P.T.M. 104-05 12 West Crossfield Road 1$ Route 6A ' Forestdole, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET 2 (508) 477-5313 (508) 888-1090 1/20/05 P.T.M. 1 of 2 - i 6 NOTE: TO PREVENT BREAKOUT, THE PROPOSED {, TOP OF FOUNDATION F.G. EL: 98.5t FINISH GRADE SHALL NOT BE < EL:96.2 f EXISTING FORA DISTANCE OF 15' AROUND THE M EXISTING F.G. EL: 98.8t(EXISTING) F.G. EL: 99.0t(EXISTING) PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.SFLI INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D—BOX TO 2-500 GALLON LEACHING CHAMBERS INSTALL RISER OVER CHAMBER SHOWN ON PLAN AND SET COVER/S a TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES WITHIN 6" OF FINISH GRADE a L =28' L 13'(MAX) 4' SCH 40 PVC 2" LAYER OF 1/8" TO 1/2" s" 4" SCH 40 PVC EXISTING; is EXISTING 14 ® S= 1% (MIN.) — 6" ® S= 1% (MIN.) ®®®�®®® DOUBLE WASHED STONE 1000 GALLON INV. ELEV.=96.00 INV. ELEV.=95.83 2' EFF. DEPTH , ®®m, 0,, 3/4"-1 1/2„ a' EXISTING SEPTIC TANK 4' 5.2' 4' DOUBLE WASHED EFFECTIVE WIDTH = 13.2' STONE INSTALL INLET & OUTLET TEES GAS BAFFLE TO BE INSTALLED ON VI 96.3t INV. ELEV.=95.70 OUTLET TEE AS MANUFACTURED BY TUF—TITE, ZABEL, OR EQUAL D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE TOP CONC. ELEV.=96.40 —BREAKOUT ELEV.=96.2 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED INV. ELEV.=95.70 ®®®®® STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). ®®®®®®®®®® 1M SEPTIC SYSTEM PROFILE ! BOTTOM ELEV.=93.70 3' 2 x 8.5' = 17.0' 3' 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.0' N.T.S. f T.P. EXCAVATION OR G.W. LEACHING SYSTEM SECTION NO G.W. ENCOUNTERED AT OR ABOVE EL: 87.5 Mq (3) 5" DIA.OUTLETS ts_ o�' PETER T. ✓� 2' DESIGN CRITERIA C> McENTEE o CIVIL No. 35109 i SOIL LOG t 5.5' NUMBER OF BEDROOMS: 2 BEDROOMS °� FGISZE��� 6„ 8° � SSA F G� T DATE: FEBRUARY 20, 2005 SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 2 MIN./IN. H-10 LOADING 2" --� SOIL EVALUATOR: PETER T. McENTEE P.E., C.S.E. O IZQ' D--BOX INSPECTOR: NOT WITNESSED—CLASS 1 SOILS DAILY FLOW: 220 G.P.D. g p„g.l� DESIGN FLOW: 330 G.P.D Elev. T P Depth GARBAGE GRINDER: NO LEACHING AREA REQUIRED: (330) = 445.9 S.F. 98.5 A 0" .74 ®®®® ® ®®®® et g SANDY0 YR 3/3M EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (ESTIMATED) ®®®®®®®®®®® 33„ 98.0 6., W ®®®®®®®®®®® - 1 B SANDY LOAM N Z ®c71ia®®®®®®®® 0c� ` 10 YR 5/8 USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 1 96.0 - - 30„ 102" C SIDEWALL AREA: 2(13.2' + 23.0') X 2 _ 144.8 S.F. µo.21 BOTTOM AREA: 13.2' x 23.0' = 303..6 S.F. 1 �• GAL 448.4 S.F. 4" KNOCKOUT WO,fw• 12, TOTAL AREA: 20" CIA. COVER f j•�.1`• 104 41 MED. SAND DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. 4' KNOCKOUT O/4" KNOCKOUT 62" i 10YR 6/6 4" KNOCKOUT SEPTIC SYSTEM REPAIR/UPGRADE 21 MARINER CIRCLE, COTUIT, MA 87.5 138" FForestdole, ared for: Lydia Yoffey, 21 Mariner Circle, Cotuit, MA 500 GALLON CAPACITY, H-10 LOADING S.A.S. LAYOUT : Surveying by: SCALE DRAWN JOB. NO. PERC RATE <2 MIN/IN. ("C" HORIZON) CHAMBERS N.rS. ,, Works HOOD SURVEY GROUP NTS P.T.M. 104-05 N.T.s NO G.W. ENCOUNTERED field Road 18 Route 6A 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. (508) 477-5313 (508) 888-1 090 1/20/05 P.T.M. 2 of 2 I ---�• -'"� @p— 1PITC34 AL-k- I..t IJES A !mil'aJ t"0#4 C4' 4b"/f;0Mt - � � --� U�.l t�SS OTC-4E�►.)t5� 3P'�c�i is r,i�'L7. ;'•,,�' i. . m - AL_L_ PIPES TO •&w o i" T-wA SYSTEM S l;#,l 24 ,� -� �� �l \ J ESEC.^ST ti?,O•J OC 13C � 10t»%.E AC PVC. 0 0 m O ® ® Q- ALL. -3EPrIC TA*11CS, a K. , oaa I.EI.CN1.16� perS SNa�� Z6 vgmwm&je > vkw- 0 30 0 0 (a Do 0 0 3000 0 C 0 , t&3%/Estr CLEVAM O"S OF �acw� , PrM �. "' f _a . _ IA A. } --`j-- �' n'oft ^ O A QAt�I US of Ado eIrcxF-%L&- \dj ITN C LA.,i-F i -F- i j U00 o 00 irW f N _ 3 o C) 0 �E P40rj FI W MMEJ.� Tt F '" y11�T�1•� tS h1r to• J V 0 (D 0 O ® ® O +1+4w• 1 �— V1�11..f�'S OT�1�t�l�U 1�E h3�C's6�t?, �4i.. Z��'"'�1� h � Z 0 G 0 O ® ® 1►C'�.Gi�OA�JC� W 1TN T IT�..+�: o`!� TM� ' `rY F I C A L D I'5TR-1 C,uTI o�J 5 o x i 0 � 000 C� � �? COOre- A4-40 A�4 �_ �sM Lj o'r' --o Sc At-E �* r�ri-=- --- _,� -�- _ �c.1I1 tGN 1�►�J►N P►P'�'�.-y �CirTTc �T'e, ►a.,� sok ago I oo c- _ Tti(P t Go. t QO �a� Sr�:P'r tc. -r-�J k -ry P I C.6 i. :moo I-A t►.1 G. p \T i�-�oa Sal c Trr.►Ji gy AM•{E.� c. ! tat'Fc.r..S r ►.joT T� s�.4 ►JoT To 5c.a►L E GEC'- Ep�A(... . ►.�. T�►+.1KS �i►.IFor�•FV T1+QOc.�HOv"� W cTN E LS�Teke— w ELm0 "cl t QF w(T H / 2,A - 4" EMBrni7� fi t_ zoos .J �J OTC ACCESr'S HX"t-�S Tb / �� �` oTo►�. Clowl iS -AC)oO Ps_ T�T SEPTIC T�yJ1,L A J0 LEAC-"►►..1Cs, Prt'S TU bE Bu t t.T l s P - n 1-404 i4em `�C�r' FOc_�rJDATt cS�..S �•'-) F 1►_.)�5�-1 �cGAOE T_ r Ar F�a..1tSN Gerd Ft►..��Sla C,rQ,s�OE F�...��5►-�, 6�¢�[� ch/m� �o .. A,U L C.k F1►11 S►-t UtLA !�_ p�lE2 TA.S1C Jam'ti '1 �IEL'O'131x ' ` -'7 C-EPC-1-���-1C� c ;x , (D goo L.1'AC.vNO � 1 � • 006 4 f•,r y7 I • 0 .� 8 O 0 0 -NSEPT•t G TA IJ . • / 2 s� " �,�'r0 CIE t.L�/Et-� St AFL yY Qs_a` E PECC O L.AT 1 �4T� �` �M i►.!/ 11.1 C TV P I CL�.I._ 5 W/'� ra '�� K X Z o ti►o'T� x.A L� oese12✓ATIo►.JS A,L7 VA,-t-.� . NOV, V i L�a e"o PC�QQ� � � Q 1- 1DE:5ICrr`.I Ce-t-rE: Qt ,d.. PROP05co 01sposku. Svsmm. lQUmfsec- OF SErveooMS ExtST SPor._ tv_-L.EJ LO•T" ' /�,.J1 '` ! k.:_` ► - 14, -- PEQS00 S PEi2 8E�11'capM __� �:- peO P SST r_-_Ej ;d . ' CAA LLCo.15 P4EAZ tiae2,SOxj PEV- PAY .___�'�. o PEfzcnL.l�i,o►J z�sT "c'L If , ►,JG� v1e ►� dSSE 2J`►.TTto.J T' ► .. ; ��•. C �Q� F oP+os Et> c.t. .�+I..IE, P t T SC A.t�AM X's Kscff R o OA 4"'� s F P t� �? r a � 3. �' _ 71 ` � - / J�1 !+� 1� �•� JT'P 7 7- J. . r s 'I,.JL.J�/r �.J".T 0►N S( �i..J ✓ e 1 A_:-•`+ �� . _[��,1 _ n y... ,/1 ^ / '1.'�•T�, �"r' �/t/ ��f� Bo TMA /\JCS,E A �ttk OF 04 tH OF PLOT F�Lam.r�� yC j G r F; ,_ q2 <A U NORMAN J'�n rS7TA 4 2 G I;"F,�.: . GROSSMAN o GROSSMAN y U 127 5 U ,p 12705 0 .�JO Dl��sAL_ p w '°poc�:,- v sUOti Ssrpr;At C 1 � � .: