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0009 MOORING DRIVE - Health
9 Mooring Drive 'c:otLiit F/R A = 023 055 0 LA TION SEWAGE PERCIIT NO. VIILLAG INSTA LLE 'S NAME D ADDRESS BUILDER OR OWNER GI�Gc,�d A-, 7,4 . DATE PERMIT ISSUED � _ � 5„ ga DATE . COMPLIANCE ISSUED ��/ 4 � � I s �. ��. - �. TOWN OF HARNSTABLE LOCATION. SEWAGE`# ;Z '0 VILLAGE ASSESSOR'S MAP & LOT S INSTALLER'S NAME&PHONE NO.AP-G/r 3-0;r 7,74 /.3 d.2 SEPTIC TANK CAPACITY Z"X I 5 r i LEACHING FACMITY: (type)Q.Ue v Zv�,/Tit,1.7vot.r-- (size) 2 S-X NO.OF BEDROOMS 3 BUILDER OR OWNER 0,0 Aoek Z D ti ZA&A a PERMTTDATE:.--/aY /a COMPLIANCE DATE: Separation Distance Between the: r Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) - Feet , Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 4 AC = �VP�I 8 s, A No. 6� Fee r V C THE COMMONWEALTH OF MASSACKUSETTS Entered in computer: t Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYicatton for )Sigool bpotem Construction Vermtt z�k',YQj Application for a Permit to Construct( )Repair(,�PSrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addre�or Loots No. i f Owner's Name,Address and Tel.No. Assessor's Map/Parce/I`,60 de I / /v� D f A1/&,//z ©/t,s a 23,-94zA/ 5 - Installer's Name,Address,Vdtel.No. Designer's Name,Address and Tel.No. �12-GH c') --1 s� �)4aRA a /"� EY,2 Sa F_ 7? ..Z �a�� 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 3 gallons per day. Calculated daily flow ��� gallons. Plan Date S��/ S/n .S� Number of sheets Revision Date Title 1 Size of Septic Tank )7 X( S 1 /6 0 d Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer w n gap icable) 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 Certifi- cate of Compliance has 4fore Abytis B d of tt. Sig Date d o Application Approved b Date i Application Disapprovellowing reasons Permit No. 00 Sr— Date Issued //� � ,_ '' �,..'..-. _.!'�` .-yrE,.R..✓ '' 'T� ,.'`..''7r.-.t+..-. }.. ...( � _ .,ki a ,. .,� .co,.,+ ..�.� .. r ... ,. ., :i -r... .. .. ' ��i ' I No. Fee O C ,.- THE COMMONWEALTH OF MASSACIASETTS Entered in computer: N' Yes PUBLIC-HEALTH DI171SPON -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppYitation for Migpozar 6pmem ' Con!5tructiou Permit -zu( J Application for a Permit to Construct( . )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address,or Lot No.. '' Owner's Name,Address and Tel.No. Assessor's Map/Parcel q-.31. .5 � C v r ,/+� Installer's Name,Address, ,1.No. � Designer's Name,Address and Tel No. 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 gallons per day. Calculated daily flow ' a 3 gallons. Plan Date ` i�� ?, Number of sheets Revision Date Title 1 1 + Size of Septic Tank X t S F �6 o d,. Type of S.A.S. S 1+r" Q Description of Soil r"111 Nature of Repairs or Alterations(Answer w en applicable) 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 Certifi- cate of Compliance has been issueja by.,.this Board of Health,. c-.- t� Signed 1 �f �� Date � Application Approved b� Lip, Date �/ 2 (A jr pp pp Y Application Disapproved foAfie following reasons Permit No. " - 0C) S 1 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( VUpgraded( ) Abandoned( �iby at / '�`0 Ode "� 2 y as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Perg No. a � has dated ��a /G �L e 1-4 ��!' GZ .� f.G/�_!"Cl Installer Desig er--Z The issuance of this permit shall noibe onstrued as a guarantee that the syste �,ill�function as designed. Date Inspect 4 —-——————————————————` ——————— —— — — . No. a ' U U S^- I b — Fee /U C) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogat *pgte U on.5tructiou Permit Permission is hereby granted� on�d t( ()Repair( grade Abandon( ) System located at oivi 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:Construct on must be completed within three years of the date of 11 this peMi.� ,^ Date:_ U Approved by `f ti, �i U!i G,. � _ C - �� U,/`y�n.1''P/ (J r' �0 �-} ;�i7 r�+fj�o CU p✓'cY' � -1/ f1 �J r� ToWn of Barnstable P�pFtHE Tp� Regulatory Services Thomas F.Geiler,Director sAWW...ABLF. Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 509-790-6304 Installer &Designer Certification Form Date: �2� Designer: v Installer: 76 Address: . fw q 4 Address:SA-fiVW�A4 On �� �_ was issued a permit to install a (date) (installer) septic system at 0,90tJ Ow 66TV 1T based on a design drawn by address) dated (designer) �-certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical r ocation of any component of the septic system)but in accordance with State &Lo Plan revi ion or certified as-built by designer to follow. o DARR N E Cn . 1 40 (Installer' Signature) GISTS / SgNITAR\PN D (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARN ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF BARNSTABLE LOCATION �1 4n E' zw z SEWAGE # VII,LAGE Cd �� ASSESSOR'S MAP &LOT INSTALLER'S NAME_&PHONE NO./A2z/r SEPTIC TANK CAPACITYA'' LEACHING FACILITY• (type)C pdsc : .✓•�, (size),2NO.OF BEDROOMS 3.BUILDER OR OWNER v, A," L PERMITDATE: o� 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by is rtn =2G v , a is rx� <Z �^ M N ............................. THE COMMONWEALTH OF MASSACHUSETTS B 0 A R D P F HIA --.-----....OF...... ......... ------ . . ........ .................................... ......ppliration for Disposal Marks Tonstrurtion Permit 'kJJS�X A tion is hereby made for a Permit to Construct X or Repair an Individual Sewage Disposal Sys-t at: 14 ... ....... ..................... --- .............. Lor-atio ddre or Lot No. .............. ............................... ... ........ . ...................... ... ............... wner. ......... . d ......... ... .................... -----------------------------------------......... -------------------------------- Instal'I'e'r, Address Type of Building Size Lot. 9'el....Sq. feet Dwelling—'No. of Bedroom3x9it I,— t -- Attic Garbage Grinder P4 Other—Type of Building No. of persons.....__..4............... Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow-------------------- .........gallons per person per day. Total d;)�y flow..........3-3 .....................gallons. 94 Septic Tank—Liquid capacity/04.0.gallons Length. .-_-!.--.. Width.0..6'... Diameter................ Depth................ Disposal Trench—No... ................. Width.... .............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............. ----- Diameter-------X.!....... Depth below inlet..:7�3........ Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by........ Date...... .......... Test Pit No. I................minutes per inch Depth of Test Pit.............._._... Depth to ground water.._..- "Ck (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-- . P4 . ......... .........---------------"-----------------------------------"-------------**---------*...* ........................................................................................................... .......... 0 Description of Soil...4=40_. . ----------------------- ----- ;W------ ---------------------------*----------------------------*---------------------------------------------- ........................... ....... .......................................................................................................... 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 TL I TLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Signed ---------------- ....... X a e ApplicationApproved By.......... ....................................................................................... ........................................ Date Application Disapproved for the following reasons:........:..................................................................................................... ........................................................................................................................................................................................................ Date PermitNo......................................................... IssuedL........................................................ Date n THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH Appliratiun for Disposal Works Tonotrur#ion Prrutit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: -------- + - - ..................... Location--Address y� or Lot No. - ....... __ { a-_ .....�t..f ....� ............. .. ..............................................{ fr .4 ___ Owner � `� Address ......................... ••- ----•-• 6fz-rGG ............................ ................... ........ ............ ^___ Instalier Address �� Type of Building Size Lot_._...:p__._...'_.___.----Sq. feet 0-4 U Dwelling—No. of Bedrooms______________ ..........................Expansion Attic ( ) Garbage Grinder ( ) p.I Other—Type of Building-/,)d '-:(AtA'___.____ No. of persons......... ................. Showers ( ) — Cafeteria ( ) Otherfixtures ------•------•"---•--=�--"------------------------------------------------------------------------------•"-•---------------......-----.........__.. WDesign Flow.................... ............gallons per person per day. Total daily rflow.........:3_ ......................gallons. WSeptic Tank—Liquid capacity&%4p__gallons Length?__q .__ Width_j _ _ __. Diameter________________ Depth................ xDisposal Trench—No........._........... Width___.J.............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____________ ______ Diameter_ Seepage Depth below inlet_„Z._..,?......... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) '-' Percolation Test Results Performed by...__.__ _ '. _: ✓� "' �+ -> 'j . -•--••..... •••-•-••-•..................•-_._. Date-• -------"--- T'v Test Pit into. 1_______________minutes per inch Depth of Test Pit.................... Depth to ground water_____.. LLI Test,Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___. '�' - a ....................................................------•-------.............._....---•-••-••-•••••--_••-- O Description of Soil...1f............... - V ................................. ......31....... ------------ -------------------•-"------------"--------------------•----------------•--...................•.-----------• ............. l'-•---��`�!l--------/_�z,['�(------ t±= ' ......- ` V Nature of Repairs or Alterations—Answer when applicable`______________________________________________________________________________________________ --------------------------------------------------------------------------------•...........---................---------------------....-----------------"------"-------------------.._..--•--......_._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Ti= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeen•issued by theme board ,oaf;health % Signed -; '•= " _ xG�J �+.�', - /fda.... l :' I Da e Application Approved By.. .::: :.....••--------•...-••.......:............•-•-•---- •--•-•-•---••-----D ----------••-- Date Application Disapproved for the f ollowi g reasons:-•----------------------------------------------------------------------------------•--•-----••-.........--•-- ..............................................................---------••---------- --------------------------------------------------___------------------------------------------------•---- F Date PermitNo......................................................... Issued_......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS - ;.fa i BOARD OF HEALTH err# firFatr of TompliFaurr - '-. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( ) ----...--•--.......-------•••-•. . --•--- :....................................................... Installer at.... } -------------•---•••- -•••--•---•---- ••••-••--...-••---•---•-••----•- has been installed in accordance with the provisions of #.F_' j of The State Sanitary Code as describ�jd in the application for Disposal Works Construction Permit;N ___ ._!_________________ dated_--./ �5"^___0 .._ .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE -�Q/ �°,l Inspector �'r " •` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .f - �-• � 2 S� ..... ' No:.:...................... FREJ.................. Disposal Works Tono#rudion� rrnt�ti# fi�i /r I t✓/ p. Permission is hereby granted........................................ ...... ...�...........-_---- f .....---...._....._--...--•- to Construct (X., ) or Repair ( ) an Individual Sewage Disposal System,- G at No.•---•--•--•-•-•__•_•f.. . .. . L Street as shown on the application for Disposal4rorks Construction Per Co..o______ __ _____ 7. �ated.___ _✓..~ ._____________ C ,r 1?1 Board of�eai�th DATE.. 1----•... ........... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ""• - } COMMONWEALTH OF MASSACHTsiT ® QPEtT11�` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI+RS��t U Via; y STABLE d DEPARTMENT OF ENVIRONMENTAL PROTEC TiP F1�T s R 15 PM 3: 09 S�e - INSPEC n r� you � T ij�''y;,, IIVi1� { s y FIViSION TITLE 5 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A p CERTIFICATION Property Address: 9 Mooring Drive Cotuit MA 02635 Owner's Name: Diane Longobardi 2� Owner's Address: Same V Date of Inspection: March 30,2005 Job# 05-66 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 DF(���t►4� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:```���� H OF MA Passes �,�5 . '• y Conditionally PassesTRI •'N Needs Further Evaluation by the Local Approving Authority _�' M. X Fails - L :y ..0 Inspector's Signature:' Date: 3/30/05Ulm I '�.,,•Tl F•\ �o``��� 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: Tank,D-box and leaching pit all previously full to top. i ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS..r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 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:, T41.G inenantinn Anr 4/1 cilnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 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 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 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: - TitlA C Tncnarfinn Tlnrrr aiT cnnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 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 ''/x 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. Titles 1;Tnvn Ptinn T?nr Ali,;rmnn 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi ; Date of Inspection: March 30,2005 a { 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_ IDetermined 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)] Titles 1�Tnonartinn Pnrm(V1 VInnn 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of.bedrooms): 220 Number of current residents: 6 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)): 2003—90,000 gal.2004—308,000 gal.=545 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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 10 months prior to inspection. 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 _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool r _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 Titles C Tnonwetinn P:n 4/1 VIAM 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: 9 Mooring Drive,Cotuit Owner: Diane Longobardi m Date of Inspection: March 30,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2" 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: 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" 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.): Tank previously full to ton. GREASE TRAP: No (locate on site plan) 4 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 ( P P g outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Title 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 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: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,eta.): Box previously full to top with excessive solids carryover. 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.): Y Titla i Tnenartinn Rnrm A/1 ;mnnn' 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)> Property Address: 9 Mooring Drive,Cotuit Owner: Diane Longobardi V Date of Inspection: March 30,2005 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.):, Liquid level currently 6"below inlet pipe with high stains to top of structure 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.): Titles 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: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Mooring Drive Water service #9 27 39 f 36 39 46 61 T41. 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: 9 Mooring Drive,Cotuit Owner: Diane Longobardi Date of Inspection: March 30,2005 SITE EXAM Slope None Surface water None Check cellar Dry , Shallow wells None Estimated depth to ground water 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: A perc test will be performed prior to repair to determine groundwater elevation. ' b Title Q Tncnsrtinn Fnrm Aii ai,7nnn 11 ANTLANTIC ENVIRONMENTAL P.O.BOX 2384 MASB PEE,MA 02649 Attn: Commonwealth of Massachusetts Date: 02/14/96 Town of Barnstable Board of Health 367 Main Street co .I Hyannis MA 02601 ! � N �� c From : Mr Michael DeDecko Po Box 2384 Mashpee MA 02649 L Dear Board of Health Official; I certify that I have personnally inspected the sewage disposal system at the following address : 9 Mooring Drive,Cotuit Ma. The information reported is true,accurate and complete as of the time of the inspection. I have not found any information which indicates that the system fails to adequately 'protect the public health or the.Environment. If you have any questions regarding this inspection,please contact me at this number: (508)477-14-20. Thank you. Sincerely, c Michael DeDecko phone 508 477-1420 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM e, e�d d b m� Yv t f engineered plan signed e I, ` Cti � � I hereby certify that the engineer p gn y dated l (0 concerning the property located at meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are.no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. - • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: . A) Top of Ground Surface Elevation(using GIS information). B) G.W.Elevation +adjustment for high G.W. _ DIFFERENCE BETWEEN A and B �I �b SIGMD :� V�L '� DATE: NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans: gASephc\percexaW.aoc y Commonwealth of Massachusetts Executive of Environmental Affairs DEP Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1:�, t-kooQ-\��C-\ Address of Owner: (if different) Date of Inspection: Name of Inspector. Ar\GA"-e-cv o Company Name, Address and Telephone number: CERTIFICATION STATEMENT 50�-, LO1— o-,�1A I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system -- Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority -- Fails Inspector 's Signature t ,uL Date: A��Iq The system Inspector shall submit a copy of this inspection repot to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the . system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer,if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �N10p-N ram► 9rL— Owners : S A N V ft D ate of Inspection: INSPECTION SUMMARY: Check A,B,C, or D A)SYSTEM PASSES: •-.I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303.Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: --•- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determinate(Y,N,or ND). Describe basis of determination in all instances. If"not determinated", explain why not. •--• The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---• Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or.due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). •---- broken pipe(s)are replaced -•--- obstruction is removed ---- distribution box is levelled or replaced --• The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ----- broken pipe(s)are replaced -•••a obstruction is removed • r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address Owner : Uwmi Date of Inspection: oh C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: -•-• Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health,safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING INAMANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: --- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ••-- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. •--- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. -•-• The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: •-• I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. ---- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property dress: � too tic l Owner: u 1 Date of Inspect O D)SYSTEM FAILS (continued) --- 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 over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. --- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped ••- Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. --•Any portion of a cesspool or privy is within a Zone.I of a public well. --- Any portion of a cesspool or privy is within 50 feet of a private water supply well --- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. H SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: cSU i vtt Date of Inspection: lc� E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: -- the system is within 400 feet of a surface drinking water supply -• the system is within 200 feet of a tributary to a surface drinking water supply •-• the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area •IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00. Please,consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ,A-� p� Owner: &(IN,Vff)j Date of Inspection: Check if the following have been done: -�umping information was requested of the owner ,occupant and Board of Health. -KNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on the site. -x The septic tank manholes were uncovered,opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc tion, dimensions,depth of liquid,depth of sludge,depth of scum. -k The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FORM PART C SYSTEM INFORMATION Property Addr ss: q I!M(,b f211�Cf Of Owner: S11�� Date of I nspection: f y RESIDENTIAL: Design flow 3 36 gallons Number of bedrooms : 03 Number of current residents: 0 Garbage grinder(yes or no): N6 Laundry connected to system(yes or no): Seasonal use(yes or no): ►.1d Water meter readings, if available: �j '� , Last date of occupancy : v N 0ex 10 , PIf COMMERCIALIINDUSTRIAL: Type of establishment: Design flow gallonslday Grease trap present: (yes or no) Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings,if available: Last date of occupancy Other; (Describe) ::..................:......:..........:..................:..........:..................................... Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ..... .t ............................................... System pumped as part of inspection(yes or no):......l lr?........ if yes,volume pomped: .................... gallons Reasonfor pumping:............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (301�I�c( Ok Owner: ;%%,/ftyj Date of inspection: TYPE OF SYSTEM -Septic tank/distribution box/soil absorption system --- Single cesspool --- Overflow cesspool --- Privy --- Shared system(yes or no)(if yes, attach previous inspection records,if any) ... Other (explain). ..... .......................... .............................. .................... APP OXIMATE AGE of all components, date installed(if kn wn and source of i formation .C:( .otA... 3..�t►1.t.1. ............................................... Sewage odors detected when arriving at the site: (yes or no)..... . SEPTIC TANK: .(.ts... (locate on site plan) Depth below grade: ....3.,. Material of construction: ...X.. concrete ......... metal ........ FRP........ other(explain) ................................................................................................................................................ D imensions: .5 A.R.&S Sludge depth:....�'....... Distance from top of sludge,to bottom of outlet tee or baffle:......Al. ................. Scum thickness:....o............ It Distance from top of scum to top of outlet tee or baffle: ...........1.6........................ Distance from bottom of scum to bottom of outlet tee or baffle:....W................ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level'n retat' n to outlet invert, structural integrity,evidenc of le kage,etc.)..... 1laQ..I� �n... ..U. ?SJ.T :��. 20 .11�I�yr2l l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c1 Owner: bUI�1Vhti Date of inspection: DISTRIBUTION BOX:.-U�-?L (locate on site plan) Depth of liquid level above outlet invert:.... -U4 o Comment: (note if level and disty' utio a al vidence of solids carry er,evid ce of leaka e i to or�au of bo , tc.)...)I%�z.�.. :.C�l�.� Zc���. rU ... :.I�Gl..�\Jljuv Q �.►c . J2tl� ...t.... ..( v l CJ�,Q.I�.� .... f..... S�s.�' .-..►........ ....................................1........... ............................................................................................. PUMP CHAMBER:....1 ... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.).................... ................................:............................................................................................................... ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):...... �5..... locate on site Ian,if possible; excavation not required,but may be approximated by non- ( P intrusive methods) if not determined to be present, explain: ................................................................................................................................................ Type: leaching pits,number: ....5. .(,?4G leaching chambers,numbe :........ leaching galleries,number:........... leaching trenches,number ,length:..................... leaching fields,number,dimensions:................... overflow cesspool,number:.......... Comments: (note ond'tion of soil,si ns of"draicilure,level of onding,con�tio f v et lion, etc.). . [i.t.1.... �..... �. ?S. r � t�vt2-�1 : r..�. ... c�,fan�dL,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A Address: IN.O3G c1 Qp, Owner: N\\\VW ate of inspection: �1 q 1� I GREASE TRAP: ...fA6....... (locate on site plan) Depth below grade: ..... ;....... Material of construction: ..... ..concrete.........metal........FRP........other(explain).... ..................... .................................................................................................................. Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:...... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other(explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee,condition of alarm and float switches,etc.) ................................................................................................................................................ ................................................................................................................................................ .�10 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: q Atli rig DP Owner: �`�W Date of inspection: b CESSPOOLS:.9C'n') (locate on site Number and configuration: .................................... Depth-top of liquid to inlet invert: ........................... Depth of solids layer: ............................................... Depth of scum layer: ............... j Dimensions of cesspool: ........... esspool: ........... Materials of construction: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PRIVY : ...ltJ.... (locate on the site) Material of construction: .................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.). ................................................................................................................................................ -4.4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C\tA00 0 pc� Owner: 8 v W dRv\3 Date of inspection: a1 CA SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. _..---.- _...____........ __._.___.__ cl Hoo2ttiq Co-FujT Q Dkm�bkoN S -11)00 4-517 �1 61 DEPTH TO GROUNDWATER: Depth to groundwater: K: ?feet Method of determinatio r approximat've: I �3.:5... � ��Q.. �u�.. ..,... l (ta�A ►.c ....tq1�kHj...... .,.1 .....��i.2.1. 1-3Q� `I ............................................................................... i F.FL.,ELEV.=� xn FINISH GRADE =C'l�ix� FINISH GRADE , FINISH GRADE _ TOP OF FOUND. OVER TANK = OVER PIT ELEV. 4411, CHIMNEY BLOCK �� 4° C.I. BACK 3 PEASTONE --_ 4" V.C. 4"V.CJ� WHERE NEE DWELLING - / W-.X V o p o © O o o l o t CELLAR FLOOR L-- GALLON i' • • • +_o�• c o' d o O p O o 4" TO 1-1/2" r �C b o O Q O o o ,� CRUSHED STONE ELEV. = - REINFORCED GONG. d o o O O O o ' ' a o • o r • • e a �' • ' DIST. Box 1 ► /J o 0 0 0 0 o oe d e - o O O O o n ° , f SEPTI TANK -� � <=� '' (TO BE LEVEL � a � a ' o 0 0 o o . � op a/ � BOTTOM o►��� AND STABLE) /�\ C O O O 0 o v �JELEV. /,N elli tiY SYSTEM PROFILE ;._ ... c Nor•ro SCALE) LEACHING PIT DESIGN CRITERIA N11MBER OF BEDROOMS = GALLONS PER DAY GARBAGE GRINDER = ' TOTAL DAILY FLOW LEACHING AREA PROVIDED= N5S 45"f',19 0 C, o PPLIV. DWG, l E _ , SOILS LOGS, 0" ELEV. M 0 rA Nv- 44 } PROPOSED SEWAGE DISPOSAL SYSTEM Mill • ` � � '�f� ``'�' ea"a, �.- PROPOSED DWELLING INSPECTED BY DATE . �/lL, �LJTJ/�) MASS. PERCOLATION RATE MIN./INCH •,kA,f �� F q� SCALE: AS NOTED /�"JO DATE :1Z, /y/i�I,EC.f> `��'�% �!/A?/ V>` /VIA�,L .�ATcJ/V! '�GRti�AY ,' OWNED BY r g 2. L6r7- . ;qoi-o 1 010 R.41V 7-06� /!7 r.,►�oss,n i LLf 6,4617 bN_ PP. -w ,t' ,Y/J LrL / '��� ^ �'Kiu�► �� NORMAN GROSSMAN P.E., R.L.S. 226 HOLLY POINT ROAD �` CENTERVILLE, MASS: 6 V ASSESSORS MAP: ? TEST HOLE LOGS NOTES: Cahoon PARCEL 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH o . Cj�j useum c SOIL EVALUATOR: L'• �5 v�?G S PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF z c H A fl —� BOARD OF HEALTH REGULATIONS. �y FLOOD ZONE }SON ZAFZ WITNESS 'UII?.ap OP'O REFERENCE: 8K- l2$�$ DATE: 12J L 'Lr�O 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION(ON RATE-.,. SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO Z $tTE Py `N C<-/�S T t�, (� - 0,7 PA� 7� INSTALLATION. k U IT s terl-i2 - y t9_ �. 't TH- ) = TH--2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION i� f E{��N(,� �' �DI `` ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE . . ---- -----� DETERMINATION. r ♦ _ -- 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/9 "/ FOOT. (UNLESS tIURMMI)(op% cl� �••t ,� �T SN DEbW3 SPECIFIED OTHERWISE) ('N M� T.S• a VM e 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A LOCATION MAP R 53-13 GARBAGE DISPOSAL. Cp�rrlsE �52.2 3 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) �j MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. LC s++-r r To ,gE j?V1Ul�F. Gi�IS O d•23 .-aR - PEA. 11 TLE V. _ NO z 0lbcuE7�0 $, o w ---KA►o�l N.__Pativ,A�'E WELLS wJr_N 150 OI:-.pRoP, l-E'9c,�# SEPTIC SYSTEM DESIGN 9�NQ_ W�TT.�N�_-Wf!N l�v`O� PRv�. C,$RL►t� _tt�l' UNSucTA6Le Soars 5 4�c.o FLOW ES" I MATE IlFlff ►i __10 fit.,_ 53-2..3 09-70 P OF- G c*- 0 _ Pam/ - - -Dc 5*N1D 3 BEDF60MS AT 10 GAL/DAY/BEDROOM' - 32X)GAL/DAY - - - I 1 i\ No V�R-1�N t-i✓5 `try Tl Tl.�V_�:�i1 tc��o�_ J SEPTIC 7ANK .-off 5 �- Tb REXtOv� EL- �3,?3 0 T� 10 330 GA JDAY x 2 DAYS ((00 GAL ----- - _ - --- --... - - oG C c. tEly USE (tp)0 GALLON SEPTIC TANK` FYJS'0 - 12EPLAK,& tiu' (/5)06dbm SCP'nc1G tF F+tttx�D OAnMtGlf'0 ey15riri SOIL A8 It3RPT I ON SYSTEM A BENCH MARK 0 N07r--7) i TOP OF DRAIN GRATE �--� � ,1$ l�j� ��1 If�l�l L"TR ArTL�P..� 30 SO 0AJ ITS yil ELEVATION - 65.40 D 215.12 f USGS DATu9 0 4 t StONr: ON i 2 p ' t�� I-x - S'DE AREA:C�i2lto} Z+-�25�2,7�2 X 0-7�1 /10. 6 TTOM AREA ZS' x 1 Z r L X 0.7 334,14 GP >330 64 .� SEPTIC SYSTEM SECTION h o (^ r T- Q° y;` ;, atZ1 CWKs ' q"Mi 4 io Ma 1,; ir 0 {h►S� r �-Z w' j ►`GATE yyAY ��,�';,! 64 �•0S BAWO � (o2.8Q• / i �,��� ��,.._ � , (03 . - D-BOX W. [)RIVE 000 GAL ro2.44 f So U �► �'`� � e (r✓ lGUQIgeS) 60. Eacjsn�tc -SEPTIC TANK D 27 g 0. •3 25L. ' ' 2� 68 LOT 113 66 ® AREA - 23604 s!_ g r --- — SOITO,M ,2 3 (.40 SITE AND SEWAGE PLAN I' -6s �I 3y y J �-� L LOCATION : � � U Dtz6 COT-UT- now tT' ZH OF MA A C J 46 so►► 46PREPARED FOR : 14*a LoN DZDI G $ " 0.AA40 — p 'N— ,30 �FcrsT��`a DARREN M. MEYER, R.S. SCALE W SgMITAR�� p 1p� DATE: l b P.O. BOX 981 EAST SANDWICH, MA 02537 W DATE HEALTH AGENT Ph: (508) 362-2922