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HomeMy WebLinkAbout0319 MARINER CIRCLE - Health 31,91Vlarin"er Circle Co`tuit P �A = 039 '013 � I I f,I V� TOWN OF BARNSTABLE LCGCATION 3/Y 111�+1^/11 e�' �irG�/� SEWAGE # Do7-,�03 V.1LLAGE C0T!/!T ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO._SOF-_y20- SEPTIC TANK CAPACITY _MOO LEACHING FACILITY: (type) 2-SO 0 C 4.,MA5rS (size) 13 X 23 NO.-OF BEDROOMS 3 �j BUILDER OR OWNER 44rltS 9W" _R`I Rn PERMITDATE: //- 52 07 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 1✓od Nol9.�ds�l o ��� ,� - �bh h 'L , .Qc, �—�- -- — i �'�Q I � a , � ., 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 ,M 319 Mariner Circle Property Address ALJ REALTY CORP �-A Owner Owner's Name w information is =L= required for every Cotuit Ma 02635 6/5/18 0 page. Cityrrown State Zip Code Date of Inspection v:` I 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 51-0 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. . DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 Citylrown State Zip Code 508-364-9587 SI 13522 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 6/6/18 nspector'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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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: System contains a 1000 gallon septic tank. As well as a concrete distribution box and two 500 GI leach chambers B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �GM ,•' 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the envilronment: ❑ 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 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 319 Mariner Circle Property Address ALJ REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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 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•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 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. Cityrrown 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant 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 use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 319 Mariner Circle Property Address ALJ REALTY CORP Owner Owners Name information is required for every Cotuit Ma 02635 6/5/18 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: Pumped in 2016 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 °M 319 Mariner Circle Property Address ALJ REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 11/7/07 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2feet 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.): System is vented at the roof line Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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 24" 311 Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? 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.): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. City/Town 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 Level and at normal level 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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 t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Ma ssachusetts usetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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: 10+ftfeet 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: 11/5/07 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: Test hole data on plan 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Chambers have 3"s of standing water 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 319 Mariner Circle Property Address AU REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 6/6/2018 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION 31Z Igor-ml-er e,-'l SEWAGE# 009-S Al VILLAGE CQ,p ASSESSOR'S MAP&LOT 99-/3 INSTALLER'S NAME&PHONE NO. SOS- 5 20-973�r�Ose oti D� 1��7rror SEPTIC TANK CAPACITY MOO LEACHING FACILITY:(type) 2-,5-00 6t_+_ ors (size) NO.OF BEDROOMS 3 BUILDER OR OWNER 0,9,1eS "OV7 PERMTTDATE: //-.f 07 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lest ' g fafjlity� Feet Furnished bya_ P �l f � f f /nsPEEr"' Derr / http://www.townofbarnstable.us/Assessing/H Mdisplay.asp?mappar=039013&seq=1 1/2 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 319 Mariner Circle Property Address ALJ REALTY CORP Owner Owner's Name information is required for every Cotuit Ma 02635 6/5/18 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 L3r K. Town of Barnstable # I Department of Regulatory Services ,.w Publ><c Health Div>ts><oln Date. Main Street;Hyannis MA 02601 $ � 200 Date Scheduled cal N10. Tlme Fee Pd. ,: I Soil Suitability Assessment for S age isasal i ,. a Performed-By:' a Witnessed.By. �` W LOCATION'&GENERAL INFORMATION r--1 1 S, A Location Address \ C�` Owner's Name ey,,ct, c s G Y1El.¢••1' Address �� Assessor'sMap/ParceL.:.. d 3 q' --. `3 Engineer's Name f� NEW.CONSTRUCTION'. RBPAI1t Telephone# Z� Land Use. F:tj t JteV Ti A I Slopes(96) Z Surface Stones DistaiccA front: Operr Water Body>i� ft Possible Wet Area ft . Drinking Water Well -J if 1' Drainage Way i �� ft Property Line. � ft Other ft... . SKETCH':(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands f`n proxrmtty.to holes) • - 03 �J � '�°� �� Depth to Bedrock Parent material(geologic) 1 G,, p _. �. tJ AJIA- Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater 1 3 U t DETERMINATION FOR SEASONAL HIGH WATEK;TA►BE Method.Used. Depth Observed standing in obs,hole: __ _�.in, Depth o still mottle:; ln. Depth.to weeping fiomside of obs.hole: in, Groundwater AdJusttnent Index Well# Reading Date: Index Well level Adr,factor..- ._. di dtnubdwater3levn(,,,;, PERCOLATION TESL' >n�t� Observation Hole# tl it ere 'Time'at'6" Depth of P yj M ✓� Start Pre-soak Time® i d //Time(9"-G') .End Pre-soak Rate Mm.Mch Site Suitability Assessment: Site Passed Sita,Failed:.�_ Additional.Tesdng 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. DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other' Surface(in) (USDA) (Munsell) Mottlin (Sducture,Stones,l3oulder9. B C �.00 DEEP OBSERVATION HOLE.LOG . Hole# Z Depth from Soil Horizon $oil Texture. Soil Color Soil Other SurPaee(�n.) (USDA)' (Mansell). Mottling (Structure,Stones,Bouldeis. Z-1 $ C M-c 141Z,_5 �° 6 DEEP OG Hole# Depth frgm Soil Horizon. Soil TextureSortColor $oil Other Surface{ro.) `. (USDA) (Munsell) Mottling (Structure,'Stones,i3oulders. DL�EP OBSERVATION HOLE LOG Hole# Depth from Sori•Harizon Soil Texture Soil Color Sall Other Surface (USDA) (Munseli) MQttiin g (Structure,.SEones,,Bouidars, ;r Food InsuranceRa_te`Man_ niWi € . Above300�.year.floodboundary No' VYithIo SOO;,yaar boundary' No Yes WitHrnl00=:year flood boundary No Yes . o De th o a, vr UccttrrIns<<PervIous Mate Does at leA t four feet of naturall. occurrin y g pervious material exist in all areas observed thrpughout the area proposes far the-soilabsotpgon'syetem? of If not,what is the depth of naturally.oecuning pervious material? Ctirtcation I certify that on t l q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the-above analysts was performed by me conststent'with i the;required training,expertise and experience described in 10 CMR 15,OI,7. Si nature.- _.• 4 II !I Date (0 t gASEP'rIC1PBitCFORtvt No. a.oo7- 5o3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplicatiou for �Dtgonl *p5tem Con0truction Permit— Application for a Permit to Construct(4—Repair(,_-)- �pgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.,3/,? Nlvrie er Owner's Name,Address;and Tel.No. Assessor's Map/Parcel _ / Instpller's Name,Address,and Tel.No.Jrdg- 2g0.7752 Designers Name,Address and Tel.No. 68 29s e,oy t o alwa5 �h9eh s9gs wor/< l G i./� - la,101115 Type of Building: Dwelling No.of Bedrooms — Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 d gpd Design flow provided 3 31. gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �- ��T1 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 i�3 Date Application Approved by c Date �t S `nt Application Disapproved by: Date for the following reasons I Permit No. oZ C97' S03 Date Issued I ————————————————————— -------- _ ————————————-- �No. a y07- 56 - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes s Application for �Digogil-6pgtem Con0truction Permit Application for a Permit to Construct(!a—Repair(,Y'CJpgrade( ) Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. j/� f��r'/�er /rG�i� Owner's Name,Address,and Tel.No. Gory/ Assessor's Map/Parcel Installer's Name,Address,and Tel.No.S"Dg"Aga.,7752� Designers Name,Address and Tel.No. ✓Ds�pl l��.(3r�r•^a5 EH / r Type of Building: Dwelling No.of Bedrooms — 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type.of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) d - —gpd Design flow provided 3 3 ' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil t I Nature of Repairs or Alterations(Answer when applicable) !A� OO ,r I_ Z'15X:r1 �2bs t / � -- � �_rs 41Z/T� Date last inspected: Agreement: J 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 i ` u,C.f o�2� Date f'- Application Approved by Date ' s Application Disapproved by: DateY for the following reasons Permit No. a d 0-7 — S o3 Date Issued l- SCF THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded ( ) Abandoned( )by at d-?I q d19oellye: - 6Drdi r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ;2 da-f � dated__ �� s•e Installer �O,S! .�.• y 4 Designer �� /Hl/ #bedrooms _ Approved design flow // // gpd The issuance of this permit shall not b co t ed a uarantee that the system wil�tion as11desyi ed. C✓ .) ,tXj Date Inspector rl%! 1`? / No. d _563 Fee /00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=igpo5a1 *pgtem Congtruction Permit Permission is hereby granted to Construct ( 4-) Repair ( 4--- Upgrade ( ) Abandon ( ) System located at 3/4 lWw"r l e/^ �i^G�4-:- ril/r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pit. Date ' S"d Approved by t __ t F p A a. Town of Barnstable { Regulatory Services Thomas F. Geller,Director s POW Health Dwsi9n Thomas McKean,Director 200 Main.Street,Hyaunts,MA 02601 Office• �QS ,86�=4644 Fax: .508-79.0-¢3:04 Installer 8�Designerertificahon Form Date: ! -off SewageTermit# 1oQ �39 -©J 7� Assessor's MaplParcel. 3 Des re s S Inst it r: �2 e . i a Address: ?l �r w►ow,-4 J s sl d6L& MA 1771- � KG(rs 40-rL On 1/ S ©y was issued a permit to install a (installer) septic cyst a at l q r,'ri e- -l- (address) based on a design drawn by dated b �-7 (tiestgttei) _ I ter ly that.the septic system referenced above was installed substantially accord n to the d'.ssln, which may include or approved changes such as lateral relocation a�the tt©n box and/or septic tank .-�. Iy Zateral <septic system re rented above was installed with major clatiges ( .e. gtr t1a relocation of the SAS or any vertical relocation.ofA.'re f system) but in actor ce with State & Local Re y designer to follow, anO vision or DF'M,d'. e � PETER T. GR; McENTEf —� °' CIVIL ,0 9 No.35109 �Q /STEF'� 4 , �Ss�CNAL ��'\a (]�estgnr's S>gttature) (Affix Designer s Stamp Here) E P UBLIC DION, E C. CO t.Ifi� I.L NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEID BY.T1F BARNST ABLE PUBLIC HEALTH T?MSION THANK YOU Q:Health Ttiq'M.0gner Certification Form 3-26-04.doc qe Q-5, COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION h 6y� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 319 Mariner Circle otuit MA 02635 C � Owner's Name: Cheryl&Charlie Brennan Owner's Address: PO Box 1043 Cotuit MA 02635 Date of Inspection: July 26,2007 Job#07-163 p C)sq 0�3 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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 Approving Authority Fail Inspector's Signature: tM Date: 7/26/07 Zh f, The system inspector shall submit a copy of this inspection report to the Approving Authority(BoarC6f Health or rya DEP)within 30 days of completing this inspection. If the system is a shared system or has a design f�w of 10,000 j gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o ce of the' DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and t,e approving authority. ,N) Notes and Comments: Leaching pit had previously been full to top of structure.Septic tank has no evidence of leaks and appears to be structurally sound. ****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: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has aseptic 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ]This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:0 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)): Two years total: 210,000 gal.=287 gpd. Sump pump(yes or no): No Last date of occupancy: Three weeks prior to inspection. COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped 15 Months ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 10/9/81 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 BUILDING SEWER:XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_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:8.5'long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Outlet baffle is missine; liquid level is at bottom of outlet invert. GREASE TRAP: No (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ' Page 8ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) 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.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,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: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: July 26,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X leaching pits,number: One 6x6 pit. 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.): Leaching pit had solids on top of inlet pipe and high stains indicating pit had been full to top. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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): Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: duly 26,2007 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. 31 61 26 45 Water Service Mariner Circle Page I 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 Mariner Circle,Cotuit Owner: Cheryl&Charlie Brennan Date of Inspection: ,July 26,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: n/a Please indicate(check)all methods used to determine the high ground water elevation: 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 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 THE Town of Barnstable OF � Regulatory Services szAs� ' ; Thomas F. Geiler,Director '$A1639. •�� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,b receiving this report the Town of Barnstable Health Division does not Y g p automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. P COMMONWEALTH OF MASSACHUSETTS JD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED DEC 1 0 2002 TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME&JTt2°cPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ` PART A CERTIFICATION Property Address: ` /�. Owner's Name: e o MAP <)3 9 Owner's Address: Date of Inspection: // 30 0� PARCEL , ®i 3 ` Name of Inspector:(please print)Timothy E. Cash LOT Company Name: Cash's Trucking Inc. Mailing Address: PO Box 7 Yarmout port 02675 Telephone Number: (508)362-3221 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 Approving Authority Fails Inspector's Signature: Z2 Date: 111,306-,' 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 R R R*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. Title 5 Inspection Form 6/15/2000 page I I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address Owner: Date of Inspection: D 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 CUR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: R System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please explain. 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 ex0 ation or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 _ obstruction is removed distribution box is leveled or replaced ND explain: . The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 fr Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of inspecti 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 a bordering _ Cesspool or privy is within 50 feet of vegetated wetland or a salt marsh 1 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the w. 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 wells'.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coritinued) Property Address: lual C / L Owner: Date of inspectio D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �( Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ' Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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 REP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CUR 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 15,1100 To be considered a large system the system must serve a facility with a design flow of 10�000 gpd gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — — 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 CUR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Ahrv, mud,- Property Address- / Owner: elpO Date of Inspec n• 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 g inspected for si!gns 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 thh, taffies 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: 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner Date of Inspectio FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 Ctj 15.203(for example: 110 gpd x#of bedrooms): _ Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected es or no):IV Seasonal use:(yes or no): / 7 Water meter readings,if available(last 2 years usage(gpd)//A Sump pump(yes or no):Al Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15203): gpd Basis of design flow(seats/persons/sg8,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information-_!} Was system pumped as part 4AVo e inspection(yes or no): .. If yes,volume pumped: allons—How was quantity pumped determined? d1 0 _ 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) _Tight tank ____Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: /9w h&Z l�li�l2ar_ Were sewage odors detected when arriving at the site(yes or no):J . Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Ins on: ! BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): i I SEPTIC TANK_(locate on site plan) Depth below grade: y Material of construction: concrete metal_fiberglass_polyethylene other(explain) If tank is metal list age:0 Is age confirmed by a Certificate of Compliance(yes or no): Al (attach a copy of certificate) "Dimensions: IM 9-9"O s Sludge depth--_ ' Distance from 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: How were dimensions determined: Alew&jjer-D Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inert,evidence o,f leakage,etc.). GREASE TRAP:_(locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: 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 4 Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: '/b Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of lea4W into or out of box,etc.): saw aA-6d 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 chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. 111fL Date of Inspe ion• n SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type jleaching�pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): C CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and figuration: 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 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 of hydraulic failure,level of ponding,condition of vegetation,etc.): Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L Owner: Date of Inspec don• 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 3 `�� Lfi� AB 6P, A b wz B-p A6�, ID-B A8 �fl Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: LC! ' Owner: Date of Insp tion: / SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water/0 feet Please indicate(check)all methods used to determine the high ground water elevation: 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 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: � III t Illl II it Title 5 Inspection Form 6115/2000 11 1 L.O CA SEWAGE PERMIT NO. YIILLA//G'�E 614 4 INSTA LLER'S NAME & ADDRESS olt iUIL0ER OR OWNER/ r� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED D I � .,_ � � � 1 3� 33 SI i �b ys �- / ,. f 1' No.........A .:.. THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HJE�LTH �O...G`. 'v...............OF......� ..._............................................................ App iratilan for Disposal Works Tonstrurtiun Prrutit Application is hereby made for a Permit to Construct ()e,) or Repair ( ) an Individual Sewage Disposal S stem at .-mot... ._!..�'-� ....... - ��'�, f% .._..•• ..:....- �/, ......Loca' o dress or Lot e ..... a ... Installer Address ^ Type of Building Size Lot...c)d__�P..Sq. feet Dwelling—No. of Bedrooms_.......... .... __......................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building No. of persons..........(a............. Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................._............................................................................................. -------.........__.. d <— W Design Flow.................S--S-...........gallons per person per day. Total daily flow........ J�®...._._______._.__.gallons. W Septic Tank—Liquid*capacity./dM.gallons Length../D._�... Width...s,�__.... Diameter................... ............... Depth.....__........ Disposal Trench—No. .................... Width.................... Total Length.... . Total leaching area..... Seepage Pit No.......f.......... Diameter....:........... Depth below inlet.....�F------ Total leaching area. __sq. ft. Z Other Distribution box (f) Dosing tatik ( ) Percolation Test Results Performed by- ....._. - .e ••-- _... Date----`� � ,.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground ater.__� .. . fi Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water../5 � . �+ -- - -- - 0 Description of Soil....®_--L.�............. . --------------- - x --••-•-------------•...........0..•-�y............ ... --- ...........................................--•-•---------------•••-•-••-•--••--............----•••---•----••-•----- 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 iI'i U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of.Compliance has bee issued by/t �oard of health.Sign ... k' I;C D Application Approved By....... f _. __ _ __ r —.............. - = Date Application Disapproved for the following reasons-----------------------------•---•---------. --------•---------_-------------.-------------------...._..---.._... .............................•---•----------•------•----.._...--'--------------------•-'----------•----.....-•--------------------•-------------------------------------. .............------------------ Date PermitNo......................................................... Issued_........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �!..!4.`. ....—...............OF......:.Gc�tfa-GJ - ....._....-------------•--.....-----...._..............._. Apptiraiion for Diip.a i of Works Toustratrtion Vamit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage',Disposal System at: Location-Address--1' or t No. •-- L_t_G� i.� �v jj�J • / .....__... ................/_...-..-----••--•-•••-•...........----•---•-...._ -••-•-• v , aa Owner 5 e�is wt.It- ..�.....................................^ a _fJ. <f - �.�11.1G...( dress.......................•---..............-- Installer Address U Type of Building Size Lot___ feet Dwelling—No. of Bedrooms________ _ ........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .... No. of persons.........�_____________ Showers ( ) — Cafeteria ( ) Otherfixtures ----------------••--------✓---------------------------.•••----------••••--••--•---------------------------------•-•----•--...------•----••--•-••••---- W Design Flow________________!_=.______.__...__gallons per person per day. Total daily flow............ 9...................gallons. WSeptic Tank—Liquid capacity� !__gallons Length__h_ ._._ Width.. ....... Diameter________________ Depth................ x Disposal Trench—No_____________________ Width......_._.____._._._ Total Length..______.__.__..___ Total leaching area.. t. Seepage Pit No------- ----------- Diameter_________ __ _____ 00 Depth below inlet__c�9__...._.. Total leachingareasq. ft. .......... Z Other Distribution box (1 ) Dosing tank ( ) '-' Percolation Test Results Performed b ..__._V/ ��'_!: .^,.l.dwt....". _._. Date_____..... Y -'� �1 �4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water_________:___..______. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.____................- 1:4 - ------------••--•--•••-_-._--•••----------•---.....------............__.._..---••••......................................................... O Description of Soil..._.__ ------------- :`- V '� - �/ � c '-— -'---•-----•— —... —:::_.... — — -------------------------------TG'-----2 �Y_------jLfl rrl� 1 UNature 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 TITLE 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., len Sig d, �`�f�.; � Fr'tC/!/ f/ J ApplicationApproved BY_ y? ----------• ••.................. . ........................ •-••--•------ -----•-••----•----------- Date Application Disapproved for the following reasons_______________________________________________________________________________________________________________ -----------•-------------------•-•-------.....__...----------•------------•--------------......-----------------------------------•---•••---•----•-----•--------•••-------••-•-----.................... Date PermitNo......................................................... Issued....................................................... Da,te THE COMMONWEALTH OF MASSACHUSETTS r BOARDI�OF HEALTH -OFJ`�C�'d�` .................:. T rtifirtttr of '--ut�rf Fanrr i THIS IS TO CER�TZ'FY, hat`the Individual Sewage Disposal System.constructed (,�) or Repaired ( ) / r� ........................................x ` at./�.: _(l/�/--� :1...........................................'�� Insta�er �• ---•----------•------------- has been installed in accordance with the provisions of TState Sanitary C �asr _crIedn the -----------•----- _ ____ date ...............................for Disposal Works Construction Permit _ "THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................./�-j/-•-�--��_......_..-•-- Inspector......---- !!_:lt`'................................... THE COMMONWEALTH OF MASSACHUSETTS �_--' BOARD OF HEALTH- ....../1�Gt! y -:.......OF............/:� ......LJ( .................... � L No............... ........ FEE........................ %posa l Workii Tons inYrrutit l JC/ . Permission is hereby granted_______________ <<_. �E?=l? .__ ......... to Construct �) or Repair ( ),an Individual Sewage Disposal �3�st � at No.•--� �/ �C-.,iii,t�L�C �{r C.....- -- ------------------------------------ ----....---------------------•----•------------------------------•-- Street as shown on the application for Disposal Works Construction Per No.. .....-,. ated............ .......................... .. ' . L'/1 DATE......... F�--••`--=�...--_..-b-�--"-�`._/............................••-----•-• Board of Health FORM 1255 HOSES & WARREN. INC.. PUBLISHERS { LEGEND N LOCUS S 3245'18" E L _NEE PROPOSED CONTOUR 2 125.00' 79 PROPOSED SPOT GRADE Gym ' o�so N 02 �2 t+�� EXISTING CONTOUR �O te TEST PIT c oi�O O 16, —W EXISTING WATER SERVICE Schooner �n r i30 - -'"" / �~ i_ —G EXISTING GAS SERVICE os O.H.W. OVERHEAD WIRES ge 13.2 •.� I } —U UNDERGROUND WIRES �� °� Ar TP-1 r�b 4 ? BENCHMARK Srout efoov one Rd FQ9 f ny I'.0 O �� O EXISTING S.A.S. So I 2 TO BE PUMPED do l. c14 Ito ,'I i TP-2 tYx t FILLED WITH SAND ` I'v O -- I I 3� EXISTING SEPTIC TANK LOCUS MAP N.T.S. TOP,-OF TANK, EL.=96.19 15—�I INV.(OUT)=94.85t �(b ` �,;,_ I Benchmark Set ��' Lu -- 1;� �-- - -1 On sonotube Ar El.=98.61 (ossum ed) Cb GENERAL NOTES: 10� 1• ALL CHANGES TO THIS %° PLAN MUST BE APPROVED BY THE LOCAL Cry 1 ( i '= �•.� — BOARD OF HEALTH AND THE DESIGN ENGINEER. LO `'� ( � � Otis � 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE j I � cV LOCAL RULES AND REGULATIONS. 00 � I + 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR j f T TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE y / 'EXISTINd 1, / GARAGE, ^ 1111 DESIGN ENGINEER. / 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING r / / /HOUSE (,#319) �i / �:! : ' , ` FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN / TOF=100.24 ,' ', !' '/ ENGINEER BEFORE CONSTRUCTION CONTINUES. (Assumed) ' 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. Q) \ + 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 2 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF ' HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER. _ ( v� ( �1(,' 8. THERE ARE NO ABUTTING WELLS LOCATED WITHIN 15O' OF THE S.A.S. x � \ G) w CP 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED �b 1 - O T TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. �. Lot 69 5 . 1 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY J 20,000f�S.F. THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 0.461- AG.� �' r 1 CONSTRUCTION. Ma 39 \ } 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. o Parcel 13\ IZDP��� OF MgSs9L� AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). PETER T. G� 125. 18 °� r M CIVIL PROPOSED SEPTIC SYSTEM UPGRADE. N 32'45'18" W No. 35109 �— — 4A Q�� �£c, ����� � 319 MARINER CIRCLE, COTUIT, MA edge of pavement �} At I Prepared for: Charles Brennan, 319 Mariner Circle, Cotuir, MA 02635 D� 1� U� Engineering by: Surveying by: SCALE DRAWN JOB. N0. o� L� Engineering works WARNER SURVEYING 1"_20' P.T.M. 203-07 CIRCL ` ' ,2 West Crossfie RoodMAR/NER + Forestdale, MA 0 2644 Harwich,Long Rood MA 02645 DATE CHECKED SHEET N0. 1 26 {}j (508) 477-5313 (508) 432-8309 10� /07 P.T.M. 1 of 2 r 1 i I NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION jIPROVIDE RISER OVER D—BOX F.G. EL: 97.5(MAX.) FINISH GRADE SHALL NOT BE < EL:94.5 j TO WITHIN 6" OF FINISH GRADE FOR A DISTANCE OF 15' AROUND THE EXISTING F.G. EL: 97.5t F.G.WEL:ITHIN 97.3t PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.S. =GSRADE PVC PERFORATED PIPE WITH SET TO WITHIN 3"-OF FINISH INSTALL RISERS W/COVERS OVER INLET 2-500 GALLON LEACHING CHAMBERS SERVE AS INSPECTION PORT. & OUTLET TO WITHIN 6" OF FINISH GRADE , IN SERIES WITH STONE ALL SIDES INSTALL RISER OVER CHAMBER L=37' SHOWN ON PLAN AND SET COVER L =5 WITHIN 6" OF FINISH GRADE �. 6• 4" SCH 40 PVC 4' SCH 40 PVC -2" LAYER OF 1/8" TO 1/2" 10., ®® es® DOUBLE ia" ® S= 1% (MIN.) 71ni���l (4 S= 1% (MIN.) ®�� ®�® (OR APPROVEDDISTER FABRIC) T4.1 EXISTING 48LEVELUiD INV.=94.27 NV.994.10 2 EFF. DEPTH J ®�ra®®®� GAS PROPOSED D—BOX 4 5.2 4 DOUBLE WASHED BAFFLE INV.=94.$5t EFFECTIVE WIDTH = 13.2' STONE EXISTING 1000 GALLON SEPTIC TANK EXISTING I INV.=94.00 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING I TOP CONC. ELEV.=94.8 ----BREAKOUT ELEV.=94.5 PIPE INVERTS PRIOR TO CONSTRUCTION. i INV. ELEV.=94.00 ME SME3 3 2) D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE ON A MECHANICALLY COMPACTED SIX BOTTOM ELEV.=92.00 INCH CRUSHED STONE BASE, AS SPECIFIED 3' 2 x 8.5' = 17.0' 3' IN 310 CMR 15.221(2). 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23,0' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. T.P. EXCAVATION OR G.W. (3) 5" DIA.OUTLETS 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE LEACHING SYSTEM SECTION 16" AS MANUFACTURED BY TUF--TITE, ZABEL OR EQUAL. NO G.W. AT EL.=85.8 (TP-2) SEPTIC SYSTEM PROFILE 15.5" 1 r 8" 12' N.T.S. 6" T 2" DESIGN CRITERIA D—BOX / NUMBER OF BEDROOMS: 3 BEDROOMS SOIL LOG SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 2 MIN./IN. DATE: OCTOBER 26, 2007 (P-1 1983) SOIL EVALUATOR: PETER T. MCENTEE P.E. DAILY FLOW: 330 G.P.D. TOR DESIGN FLOW: 330 G.P.D INVERT C:0 ® ®®�® BACK OF HOUSE ' WITNESS: DAVID STANTON—HEALTH AGENT GARBAGE GRINDER: NO ®®®®®® 33" "" " Elev. TP- De th EI@v. TP—`2 pe LEACHING AREA REQUIRED: (330) = 445.9 S.F. ®®®E@10®® �_ pth 24" E�l®®®®®tH 97.5 0" 97.3 0.1 .74 t l ;, {:-� FILL A SANDY LOAM EXISTING SEPTIC TANK: 1000 GALLON CAPACITY, 102" 0eck 96.8 8" 10YR 4/2 SECTIO C _. 96.6 B USE 2-500 GALLON LEACHING CHAMBERS IN SERIES �. LOAMY SAND 10YR 5/4 SIDEWALL AREA: 2 13.2' + 23.0' X 2 144.8 S.F. 4" KNOCKOUT 94.6 32" BOTTOM AREA: 13.2' x; 23.0'. = 303.6.0 S.F. 20" DA, COVER TOTAL AREA: 448.4 S.F. W 44" 4"KNOCKOUT O/ 4„ KNOCKOUT 62" '�9. 'J 1•.'- PERC - E DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. M—C SAND ----- 2 5Y:6/4 4" KNOCKOUT PROPOSED SEPTIC SYSTEM UPGRADE I I PLA I N I M-C SAND " a E 2.5Y6/4 319 MARINER CIRCLE, COTUIT, MA N , 500 GALLON CAPACITY, H-10 LOADING 1 O i : Prepared for: Charles Brennan, 319 Mariner Circle, Cotuir, MA 02635 CHAMBERS Engineering by: Surveying by: SCALE DRAWN JOB. NO. _ ____; gg.0 136" s5.s 138" EnglneeringWorks NARNI�R SURVEYING N.T.S. 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