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Home My WebLink About0040 MELISSA LANE - Health 40 MELISSA LANE, COTUIT A=010-010-002 a Commonwealth of Massachusetts NO D/d - DUZ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,.. ,o 40 Melissa Ln. Property Address " Na3 Gooden Owner information Owner's Name is required for -�Y Cotuit ✓' MA 02365 2/2$%18 every page. Cityrrown 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: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 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 2/28/18 Inspect ' Signa Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit' MA 02365 2/28/18 i Cityrrown State' Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 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 M � 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 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 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 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 ❑ ® 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 Tess than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 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 40 Melissa Ln. Property Address Gooden Owner information Owners Name is required for Cotuit MA every page. 02365 2/28/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 0 E 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. t` 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 El El the —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.doc•rev.6/16 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 M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 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.doc•rev.6116 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 ' _ G M s•°�• 40 Melissa Ln. - - - Property Address Gooden J Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump?„ ❑ Yes ® No Last date of occupancy: Nov. 2017 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.doc•rev.6l16 Title 5 Official Inspection Forth: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 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for Cotuit MA 02365 2/28/18 evryp 9 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: bate Other(describe below): General Information Pumping Records: Source of information: No recent pumping 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.doc•rev.6/16 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 G'M 40 Melissa Ln. . Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan)- ` 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' 2-6-1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Outlet cover raised to 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 10" t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 City/Town 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 '12 411 Scum thickness Distance from top of scum to top of outlet tee or baffle n Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for Cotuit - MA 02365 2/28/18 every page. Cityfrown 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.): H-10 tank appears to be structurally sound 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.doc•rev.6/16 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 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert On 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.): H-10 d-box 3' below grade, cover raised to 6",average condition 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M 40 Melissa Ln. - Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 .2/28/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 4 ® 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.): Infiltrators were video inspected, piping from d-box to chambers is clean, chambers are damp at this time, no indication of past backup, bottom approximately 5' below grade 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit' MA 02365 2/28/18 , Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Soils are compact and dry e 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.): t t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 -Jac 1 - 14S TOWN OF BARNSTABLE LOCATION D I"/v 1 f j Cr) i--> Y1 e- SEWAGE, _ VILLAGE C u `I' ASSESSOR'S MAP&LOIw-�o INSTALLER'S NAME&PHONE NO. -a t4- 4, s SEPTIC TANK CAPACITY_/,� eza t LEACHING FACILITY:(type) ::r4 -ri-A t"' (size) X NO.OF BEDROOMS BUDDER OR OWNER C.Oposs the PERMITDATE .9f 14 Z-6( COMPLIANCE DATE: 2 U t t ,tao Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N'i' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Me it Y Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin�]factli ) Nt)t Feet Furnished by�In.rUriJLa..ncrs/J 40 Mebssa 3 1-31 3- 3-aa' t ' 0 G _ b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar f ❑ Shallow wells >144" Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,date of design plan reviewed: Daatete NGW 144" D ❑ 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: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Melissa Ln. Property Address Gooden Owner information Owner's Name is required for every page. Cotuit MA 02365 2/28/18 Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLEC- U0 f L LOCATION ' . I"/sv t��rt Ste �—7 h e_ SEWAGE # � �U-1wQ2 VILLAGE 1' ASSESSOR'S MAP & LOTlg� INSTALLER'S NAME&PHONE N0. .�7 SEPTIC TANK CAPACITY i l LEACHING FACILITY: (type) : 1 tEA t Li (size) 3 in 16 NO. OF BEDROOMS BUILDER OR OWNER 4,aS PERMIT DATE: -)/ ��yt'; COMPLIANCE DATE: 1 2 H Zva Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _INI4:ii e Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Na o ti_ Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leachin facili ) Nt 0 Feet Furnished by �t c ixeytcr r /\ � i1 Q . �. �. 1r� �j �' Q C r �7 S `� r o ro C� �,� e J`�, ^� � r. y ' t �,-` '-C W � Y �. � � __..._-.�..._ _ _ _.._ - �- .� w 9, W � � � �W M7 ' R rm Cl No.9C5D 1 1i I� THE COMMONWEALTH OF MASSACHUSETTS �., FEE _ ` BOARD OF HEALTH V QW OF �'11sTici-bAe_ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (% Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components I' 7 �® 10 -2 Location wner'sIle '2 L1 Map/Parcel# tsA --� L �� e Caller's Name �� i O dress ss r L La 6qo - cp Telephone# Telephone# Type of Building: Lot Size AwnF Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required)3�gpd Calculated design flow gpd Design flow provided-36k gpd Plan: Date 'Ol Number of sheets f Revision ate Title C> __ Wall ` Description of Soil(s)_ u ` Soil Evaluator Form No. Name of Soil luator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and rther agree of7tolace the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed k tA AU4 Date r1j- QU Inspections / FORM 1 -WIMPLICATION FOR DSCP DEP APPROVED FORM 5/96 THE COMMONWEALTH OF MASSACHUSETTS FEE _ R '. .Y BOARD OF HEALTH f' CERTIFICATE OF COMPLIANCE Description of/Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the-Sewage Disposal System;Constructed Repaired( ),Upgraded( ),Abandoned( ) by. has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built G plans relating to application No.-91 dated �� / Approved Design! Flow 530 (gpd) Installer r —J Designer: VLO,,le,[R IA C (_, Inspector 'W Date b 0 The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96'-•—� . No. THE COMMONWEALTH OF MASSACHUSETTS FEE i BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described dated in the application for Disposal System Construction Permit No. ��— y`S PP P Y Provided: Construction shall be completed within three years of the date of this permit..All'local conditions must be met. Date Board of'Health j FORM 2 - DS.CP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON "THE COMMONWEALTH OF`M-ASISACH-USETTS ..IEEE BOARD OF �dE>ALTH �/� _ _ / APPLICATION FOR DISPOSAL SYSTEM-CON_S_TRUCTION-PERMIT t Application for a Permit to Construct (,JiRepair ( ) Up ) Aband'on (�) - omplete System El Components ad Locatt n •�. wner's Name ' Map/Parcel# A dress Lot# T e one kftb T- 1 •..,,,,r, '�, - staller's ame a's me I M-�nti) s' �^ r ddress A r ss 61 r Teleph�#' i z Telephone# `. � t Type of Building: 1 , I (1 Lot Size A_ Sq.feet ` 'y Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria :6 Other fixtures Design Flow(min.required] gpd- Calculated design flow gpd Design flow provided gpd Plan: Date _^zTh�! Number of sheets 1 Revision Date I Title Description of Soil(s) a flu " Ali "� _.,Soil--Evaluator Form No. Name ofSoil E�aluator Date of Evaluation yi DESCRIPTION OF REPAIRS OR ALTERATIONS t <: The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further.agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. u... Signed S �Ai. Date r� Inspections ' ,w f FORM t - APPLICATION FOR DSCP DEP.APPROVED FORM 5/96 t1S TOWN OF BARNSTABLE 2bo' LOCATION I'SA A h e'_ SEWAGE # '1 VILLAGE �1F f ASSESSOR'S MAP & LO'I /O_/o-1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ;, .` �'%,�.' ,�:$ (size) X it', Its NO.OF BEDROOMS BUILDER OR OWNER CgiA Z0,SS Et PERMIT DATE: COMPLIANCE DATE: 0'Ll ,Zao jSeparation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Algh r- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) r3 Feet Edge of Wetland and Leaching Facility (If any wetlands exist �t within 300 feet of leachin facili ) i1�e— Feet. Furnished byt txAlicr 40 13 1.31 J 3-W 3�aa` 6�ftRA6r r 1 -to 67, 5^ SSA 5"-3&� Y o {- e 90 cot-(j 0IU OaZ ASPHALT W430,SLlS —►•. _ . e ' — ZA s Z1.J►t6v1. , I� i .T..>d_M.(, WE -- PtcHT_-ELty7A21QAt R¢Ar. ELEVATIOM. .: - - nr�.Vocs. - .. 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AREA PLAN S YS TEM PROFIL E SCALE: 1 "a 50 ' FINISH GRADE NOT TO SCALE NOTES.' �� FINISH GRADE FINISH GRADE OVER TANK OVER TRENCHES TOP 717 A �C` / ` APPLICATION NUMBER P-8456 . •,.• : ::•.:.. .,•.:.;, SCH 40 PVC , ' •.� �4, ,C? �� CAST IRON 1 EESOR •' �' 1. ELEVATIONS BASED ON ASSUMED ¢' ;' .:• 3_ 4 2. TOWN NA TER ON SITE BSM•T FLR ` 1500 GAL. ! EOUALIZERS 035(� 3. FLOOD ZONE 'C' �? .•: �: REXNFORCED ya CONCRETE �+ GAS DIST.BOX �� R ,.r::.:�:..r•'- . BAFFLE .erg ';:'::.":: .; '. ,:: .'.,.; F,:•R:..y� ..i�`.' j �;:,3•.::!.:�::i•:''.':' '%: ::0:. �•. •v TO BE INSTALLED ON A • • '•• ` LEVEL STABLE BASE SEPTIC TANK TRENCH LENGTH TO BE INSTALLED ON A 92'-0' NOTE.• LEVEL STABLE BASE THIS PLAN IS A REVISION OF 5'MIN.HEIGHT A PLAN DATED MARCH 2B, 1995� NOTE: DO NOT RUN HEA V Y EQUIPMENT O VER S YS TEM ABOVE OBSERVED GROUND WATER LEACHING INFIL TPA TOR SECTION NOT TO SCALE SOIL AND PERCOLA TION DATA NOTE: A SOIL EVALUATION IS REQUIRED i FOR FINISH GRADE PRIOR TO EXCAVATION. THE SEE SYSTEM PROFI L E CONTRACTOR IS TO CONTACT MIN.2" — FERREIRA ASSOCIATES TO VERIFY •�//��` :s'�VR�S� �i� �V /�'�VVR��`/F�� V'�'��` /� WASHED 7 TONE PERC. RA TE 5 MIN/IN. imiiw THE SOIL CONDITIONS ON SITE p v A� (12"MIN.J > TAKEN BY RICHARD FERREIRA WITNESSED BY ED SAA9Y • :;.: ••:' : 3 DA TE NARCN 24. 1995 4"CIA.PIPE ' TEST PIT ELEV. 65.7 �`•'• ,,• (PERC'D AT 60') APPLI. MD.P-B456 CU4VE RADIUS ARC NA TURAL SOIL -, — — �_- 1 25.00 21.74 + ~e 3 j �• �', q! � EFFECTIVE 0 a y e .,. DEPTH ° ' ' TOPSOIL—S1A9 SOIL WA SHED S TONE ,R .'r; e o• .. .. ••• j EFFECTIVE WIDTH 36• 10'-10, CXCA VA TEC SIDEWAL!. f LOT 2 , NUMBER OF TRENCHES HEvrcw snn D w { NUMBER OF INFIL TRA TORS '4 ez yt} a 3 go ez 5° _ P s� f 144 a 4ts (4- (,L ' NO 69POWVWA TER ,/ DESIGN DA TA 20 FT HIDE ORAINA6E EASEMENT� ( 171 � 7�/ ��6 N i3.4o•14'E f S. F. SIDEWALL AREA GALS/SF GALS. a ,' ? -- NO.OF BEDROOMS 170.64 t{ `$ -.,� 346 S. F. BOTTOM AREA . 74 GALS/SF 256 GALS. ESTDISP�OTAL DAILY EFFLUENT0 GALS. 517 S. F. TOTAL AREA GALS/SF 382 GALS. SEPTIC TANK 1500 GAL. t ( , 40 t P B5' r r.Aury� 0.4jo �- 3 c1 w, tiF. . _. GENERAL NOTES NOTE: SHALL E INSTALLED N I . ALL S YS TEM COMPONENTSB I 4'9. + A CCOROA NCE WI TH TI TL E 5 OF THE S TA TE SA NI TA R Y CODE Op F EXCA VA TE TO ELEV. 57,5-OR LOWER AS REQUIRED MOVE ALL LOAM AND CLAY CONTAINING DATED MARCH 1995 AND ANY LOCAL RULES APPLICABLE e � LOT 3 �• g � ' -r � MATERIAL BENEATH THE LEACHING AREA.REPLACE 2. ANY CHANGE IN THIS PLAN MUST BE APPROVED , �4y PWa°OlsEO LEACHING Q; a Box Tom, WITH ry EXCA`VA TED MATERIAL WITH CLEAN, CLAY FREE GRAVEL BY. THE BOARD OF HEALTH AND FERREIRA ASSOC. N 43, Jam'61 S, F. . Iwo , Ine nvuTags WITH MECH4NICe;LLY COMPACTED IN PLACE \` 'a \\ �,, ' SEPTI�L� ��' •�--- u '' STrALL Ar{a"'m 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING \ r '`+...TALC �' h „ S2' X 10'-10' X 2' _ d `� ti 0 % (SEE~ILFJ i" \ �'* � , NOTIFY BOARD OF HEALTH FOR INSPECTION m ' e� ---- so. 0 rOA��i LOT 4 4. FND. ELEV.MUST BE CHECKED WHEN COMPLETED LEGEND 5. THESE EL EV V. MUS T NO T BE CHANGED WI THOU -- THE BOARD OF HEAL TH APPROVAL s5 0 6. BOARD OF HEAL TH INSPECTION REO D WHEN EXCA VA TED Go-- EXIST.GROUND ELEV. 1` ! FINISH GROUND ELEV. SEWAGE DISPOSAL . SYSTEM. PL A N 175.14 `. C .80 PIPE INVERT ELEV. S 70'35'04"N PREPARED FOR TEST PIT L OVA TION M 46 4Z a` �\� 52 54 r 44 o o SEPTIC raNK , . COMPASS REAL T Y TRUST • o DISTRIBUTION BOX LOT 3 MEL ISSA LANE LOT A 4•C.I.OR SCH a0 PVC '" M� ... BARNSTABLE - MASS. *� 4"BIT.FIBER PIF -TIGHT JOINTS ` . PROPER T:' LINES �{ 4 , w DESIGNED: SAP DATE:MARCH 1. 2001 , FERREIRA ASSOCIA TES _ SETBACK.DISTANCE' ..#, %` DRAMN him SCALE:AS SHOMN 10 10-3 3 - _ .�31 SPRING BARS ROAD , FALMOUTH MASS. T MAP SEC PCL LOT HSE CHECKED : SS DRAMING NO.*