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0191 MOORING DRIVE - Health
191 MOORING Df;ttU , Cotuit _ A = 024�- 117 i i No. Wit v i Fee 14 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes j- 01pplitatlon foi ]Disposal 6pstem Construction 30pri it Application for a Permit to Construct( ) Repair( ) Upgrade(%Abandon( ) ❑Complete System individual Components ? Location Address or Lot No. lql 6 rr lrg L&U Ovmer's Name,Address,and Tel.No. b4 f,-rot ' Assessor's Map/Parcel 2 a I V7 G �� ��'6 Tucfkh S { Installer's Name Address and Tel No. Designer's Name Address and Tel.No. �'► Erb I2�, I�orle,.s�i.c C�og� q�l Type of Building: Dwelling No.of Bedrooms : Lot Size 20,b0D sq.ft. Garbage Grinder( ) Other Type of Building No'of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) % gpd Design flow provided M U1 gpd Plan Date Number of sheets Revision Date Title PeA b� ti Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OO Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo d&oalth. Signe A Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / ` p► 1. Date Issued 7 sl it ./ No. A�/ 1 i`1 s i _ r Fee 14 _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: YeF- �: PUBLIC HEALTH DIVISION -;TOWN OF BARNSTABLE, MASSACHUSETTS I application 66Bibtlosal *Pstem-Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(',)/Abandon( ) ❑Complete System ®Individual Components ; Location Address or Lot No. r I9 Ot�qier s Name,Address,and Tel.No. (� IVY ✓�'' Assessor'sMap/Parcel bZGf' 1► rG- ,r' ! 5��1b� V4S1p, SW��" Installer's Name,Address,and Tel.No. t Designer's Name,Address,and Tel.No. y:j &0i4fl!��+rcxti�►t s(OL IF ���> Type of Building: Dwelling No.of Bedrooms Lot Size 212,M) sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons . Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ,� 8�� gpd Plan Date � � /�1( I 1 Q Number of sheets 19 Revision Date f � Title � l,, &J r'�ehl Upg b°�11 t Plot Iq� !�'mobw I-A. R ('44 Size of Septic Tank 1 M i ft,_ Type of S.A.S. 2-ca) o d1uh ( 'mnkri, Description of Soil Nature of Repairs or Alterations(Answer when applicable) 3 T 9a J(I- Q(a I on tt Date last inspected: r;... Agreement: ' The undersigned agrees to ensure the construction and maintenance of•the afore described on-site sewage disposal system in- accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of r � Compliance has been issued by this Boa4d of Health. l / Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. .(1/ P Date Issued THE COMMONWEALTH OFMASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of CbmPliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( .') Repaired( ) Upgraded(�) Abandoned( )by ` at �. 1Q__ fA has been constructed in accordance with the pr(o�visions,.off Title'5lan�tdit�hreef for ,��,Disposal tSystem Construction PermitNo;1M'c�19 dated Installer l`) l ulk �•',� t y ilk( dt fL jy�f. Designer � �� C #bedrooms Approved desi't flow R�tf t 1 gpd The issuance of this permit'sh 11 not be construed as a guarantee that the system will fun�n s designed. �) Date / /�{( Inspector I r C7 v - -- - - - ---------------------------------------- — - - - -- - - - ------------------------- No. Fee /00 ._ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pstem Construction Permit Permission is hereby granted to y�Construct( ) Repair( N) Upgrade(%,of Abandon Sy�tem located at i Mi (, Jf•�I l�c..� >'. � �`� • • y .. Ar .r",Nr and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must bd completed within three years of the date of this permit. Date / / Approved by . Town of Barnstable Regulatory Services Richard'V. Scali, Interim Director BA STABLE, + "^� a Public Health Division s63q. �0R' Thomas McKean,Director 200 Main..Street;Hyannis,N4A*02601 Office: 508-862-4644 Fax: 508-790-63()4 Installer&Designer Certification Form ' � tG � • Date: I (l +� Selvage Permit# Assessor's i� ap\'.Parcel. C�Z C Designer: �n :;�,_�er',nj, t�ior-its . nC • V Installer: k_Y' Av►`sj<�� Address: 1Z W, Crss-P1e W Pl�j Address: �( _ C—y re 5 t c 1�- i�lr (�1 G 2�O t(�f— .�_: (�11A* On 4 ccNr 4j`� vas issued a permit to install a (date) (installer) septic system at i OO f; CC%V%A- �2J.., �— based on a design drawn by address:) inc---nut (:k�rLU' C dated -7 1 Z ,1?' l certify that the septic system referenced.above was installed substantially according to the design; which inay include minor approved changes,such as lateral.relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. l certify that the septic system referenced above was installed with major changes (i.c. •Greater. than 1,0' lateral reloca:ti,on of the SAS or any vertical relocation .of any component. of the septic systern) but In accordance with State & Local Regulations. .Plan revision.or certified as-built by designer to follow, Strip out (if required.) was.inspected and the soils were found satisfactory. t certify that the systen-i referenced above was constructe nce with the terms of the \A approval letters (if applicable) "OF �v TER T a CIVIL (Instailer'sSig nature). `1M t /STE. iDesigner's Signature) (Affix Designer s 'tamp Here) PLEASE RETURN TO BARNSTABILE 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:\&ptic Desiener Cutiticaitic)n Form RcN!8-14-13.cioc Town of Barnstable P# Department of Regulatory services. .�xrtaraat& Publie Health Division. . Date rzj u' �prE� ta�a� f20okMain Stiee�t;Hyandiis MA 01601. 4 1 `• ? h:t .r DatetSdheduled �ki T ime s:• '. _ Fee Pd.- ( 0 t-C `'y. Soil S, puit�bility lAssessment fior ,Sewage Disposal �b Performed'By: 0C.W-r r{� �s 1 Witnessed By; LOCATION& GENERAL INFORMATION Location Address (9 i� 80 �� Owner's,Name h s tom(--E Z r t�d-v Address r' Co+�r t�- d Z«�3 1 v�2 Assessor's I41ap/Parcel: C5 —( I t. Engineer's Name. noel.t" • NEW CONSTRUCTION REPAIR �/_ ' 1 Telephoned# 77—��"�13 I-andUse' Sr (b �Q'1 Slopes(9ojM1 � _` ISurfaceStories 6^4 _ Distances.from: Open.Water Body ft Possible Wet Arca /� ft, Drinking Water Well• e ft Drainage'Way ft Property Line �h. Other` ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to boles) ' Marc) AJ `fir Paienunaterial:•(geologic) �\P�1� Depth to bedrock. _. . Dep"th to Groundwater..-Standing Water in Hole: Weeping froin plt'F1ce Estimated;Seasonal High.Groundwater 7132 DETERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used' Depth Observed standing in obs.hole: _ _ in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading.Date: IndexWelllevel_ m ,,; �'Acil,'factor y. _ Adf..Groundwnterlevel {, PERCOLATION TEST Do e.- 7'1me Observation + Hole# ( f' Pime at,0 Depth of Peri: / ' i'Ime at 6" _.� �. Start Pre-soak Time_Q 11ime(9'-,V) End Pre-soak RateMin:JInch 2 � c�Gl� i Site Suitability.Assessment: Site`Passed Site Failed: Additional Testing Needeii.(Y/N:), Original: Public.Healtb.Division� ; Observafiola Dole Data To lie Completed omBack-<--------- l**If percolation test isto be,codducted within 100'`of wetland,you must first notify the; Barnstable Conservation Division at least-one(t) week prior to beginning: QAS EPTICPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole#, I _. Depth from Soil Horbmn Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling '(Structure,Stones;Boulders.. Consistency,% ravel g-z4 z$ -t32, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoncs,.Boulders. Consistency,% rave 30 --'05 a C MvC Zr DEEP OBSERVATION;SOLE LOG Bole# Depth.from Soil.Horizon ' Soil Tezluie. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,.Boulders. onsis.tency.%.Gravell i DEEP OBSERVATION MOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders,. Consi ten lz Flood Insurance Rate Map: Above,500 year flood boundary No— Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does-at least-four feet of naturally occurring pervious material exist in all areas observed throughout thetori area proposed for the soil absorption system? ' If not,what is the depth of naturally occurring pervious material?-----,,. Certification I certify that on (date)I have passed the soil evaluator examination approved by the Deparunentof Enviro mental Protection and that the above analysis was performed by me consistent with the required train' xpertise and experience described.in�10 MR 15.017. Signature A Date Q:V,ErMCL PERCFORKDOG TOWN OF BARNSTABLE LOCATIONjqj SEWAGE# 7'0 VILLAGE / ASSESSOR'S MAP&PARCEL 6641 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �t LEACHING FACILITY:(type) CW (size) 077 L Z NO. OF BEDROOMS 6�y OWNER -&" PERMIT DATE: COMPLIANCE DATE: eh I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachirig facility) Feet C. FURNISHED BY I !_®_ 4� � � _ � �� _ I � �}� � � a .� .,. � �� � ► �- .�� ,� N � ._ � �-� `w . oa�l•lI�-. �� '� ti Commonwealth of Massachusetts .� Title 5 Official Inspection Form:- 4-- ' >i Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments{. • 191 Mooring Dr .. r . Property Address Robyn Tolman t_ r+ •1f. { Owner Owner's Na e s.. information is _ r. required for every Cotuit `'.:!' ' MA 02635 6-11-18 + r State Zip Code Date of Inspection page. City/Town � ,�, �• , „. p , 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: : r . w Shawn Mcelroy Name of Inspector ' Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth 'MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification t,•- I certify that] have personally inspected the sewage disposal system at this address and that the . •'information reported belowis 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. ,r , :,. ,: ❑ Conditionally Passes, ,Fails ❑ Needs Further,Ev a Local Approving Authority 6-11-18 JrCpector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 )0ff9 4A V-5 � c Commonwealth'of Massachusetts r r� y Title 5 Official Inspection Form C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is re Cotuit MA 02635 6-11-18 required for every q , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ' ❑ I have not found any information which indicates that any*of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below):. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i • 0 Commonwealth of Massachusetts �.- ;.; Title 5 Official Inspection.,Formr � Sub surfacer i surtace Sewage,Disposal S stem Form -Not for Voluntary Assessments , � ' •9 p y � , ry ' tl js 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every COtUIt MA 02635 6-11-18 .r i-i - .'_ ''� : �,.a: ?i page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with, 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)br due to a broken, settled or uneveddistribution box. System will pass inspection if(with approval of Board of Health): "R' a .. ❑" "broken`pipe(sj are replaced `r - ❑ Y _ ON " ' ❑ ND (Explain below): ❑'s ' obstruction is removed .. rf i,, a- ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced"` ❑Y ❑ N`'❑ ND (Explain below): l - •f4 .2a ._ Cf s. ,, .-1. .•a•it'"i ' .� F•�.rt . .f ❑ 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 ON ❑ 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 66aied 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 t _ i'ra,. ' C. +�d • •d. .-.i '.i . ..'i y „4 .• El' Cesspool Cesspool or privy is within"�_ �feet.7 of'if a.-bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i f Commonwealth of Massachusetts .,. Title 5 Official inspection Form . �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 9 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within,50 feet of a private water supply well. ❑ The system has a septic tank and SAS and,the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® , ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposel?system•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form.114 4 16l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Mooring Dr I Property Address Robyn Tolman T Owner Owner's Name ., information is required for every Cotuit s, 3 y MA 02635 6-11-18 +, t page. City/Town ,ti r State Zip Code Date of Inspection B. Certification (cont.) t +a. . Yes _ ,No tr, -_ ,+ :.t. <., _,., _ ,•, •s ++ j. ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ` ,_ T,;C A ❑ , ®, , ,, 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 El ® ' tributary to a surface water supply. ❑ ® • ;E ,Any portion,of a cesspool or privy is within a Zone 1 of a public well. ❑ ' 1,1z " `Any portion of a cesspool or privy'is within 50 feet of a private water supply well. ET ® Any'portion of a cesspool or privy is less than 1.00 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 f . , , k• J +� and chain.of custody must be attached to this form.] The system is a cesspool serving a facility with.a design flow of 2000gpd- The system fails: I have determined that one or more of the above failure "criteria exist as described in 310 CMR'1.5,303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to,correct the failure., E) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"Nes",or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located,in a nitrogen sensitive area (Interim Wellhead Protection t E] ❑ - Area'- IWPA) or a mapped Zone'II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.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 :II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 page. City/Town 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? Y P Have large volumes of water been introduced to the system recently or as part of El ® 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? ® Wasthe 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: " I . ® ❑ 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 flowbased 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form s API Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Mooring Dr Property Address r Robyn Tolman Owner Owner's Name information is required for every Cotuit 0, , - w,; , ,,1 MA 02635 6-11-18 , page. City/Town . state Zip Code Date of Inspection , D. System Information Description: h r Number of current residents: 0 Does residence have a garbage grinder?, El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? `` �' •; ❑ Yes ® No r, Seasonal use? 0 r , ,. r ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): , Detail: Sump pump? �,r �_ , i r'R ❑ Yes ® No Last date of occupancy: { f N/A Date Commercial/Industrial Flow Conditions: ,,,; ,•. , Type of Establishment: Design,flow,(based on 310 CMR 15.203): ;n • Gallons per day(gpd) ,.; • Basis of design flow(seats/persons/sq.ft.,;etc.): Grease trap present? ..I, +� , -+ _ >«r _ ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g p Y rY 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A 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 c rev' in records, if an❑ Shared system (yes or no) (if yes; attach previous inspection r y) ❑ 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 , :.;.. . °, ::,-tt. _,, ,• -,; .a Title 5 Official Inspection Fo ,' rm �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ns 9 p Y ►Y . �. 191 Mooring Dr r„ Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 .a ' page. City/Town State Zip Code Date of Inspection . D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank and pit 1970's with second pit added in 1994 Were sewage`odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): , A ,. Depth below g 12"rade: , . a a feet Material of construction: ` '�• ' ® cast4on" - ' "' `n'40 PVC ❑ other(explain): •` - Distance from'private water supply well or suction lirie: ' ' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Depth below grade: 6„::� ' r feet Material of construction: ® concrete ❑ metal ❑ fiberglass ; El-polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attachh-a copy of certificate) - ❑ Yes ❑ No Dimensions: 1000 gal 12" Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts ,w, Title 5 Official Inspection Form i I Subsurface SewageDisposal System Form Not for Voluntary Assessments 47 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 page. 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 2011 Scum thickness lot Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? I I Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: V 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts ✓�l [ RR 4 C�lka� i y�.� as 1•+ '. T �*} , .� ;w Title 5 Official. Inspection Form i-'► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 ,. 9 p Y rY �"` . i l�I 191 Mooring Dr 1 , , Property Address Robyn Tolman - Owner Owner's Name information is required for every COtUIt MA 02635 6-11-18; page. Cityfrown N , . State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet`invert, evidence of leakage, etc.):'� Tight or Holding Tank (tank must be pumped at time of i nspectio n)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): _s Dimensions: ` Capacity:, . gallons Design Flow: ti. +., 5 _6 �" ' 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.6116 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form w i-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 .�._�; 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box had decayed and broken apart. 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 f " Commonwealth of Massachusetts Title 5 Official Inspection Form w: ' hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r; 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit .. f. ,, MA 02635 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) f . .: .'Type. - ® leaching pitsnumber: 2-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number;dimensions: ❑ overflow cesspool rnumber:. ❑ innovative/alternative system Type/name of technology: t Y : Comments:(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Both leach pits show signs of failure with stain lines at and•above inlet inverts. 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 + i�i Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 191 Mooring Dr ._�. g Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts T : , :�•• 1h.� �. Title 5 Official Inspection ,Form} �D i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments; 191 Mooring Dr f' •,, .;' Property Address Robyn Tolman Owner' Owner's Name 4 information is required for every Cotuit MA 02635 6-11-18 page. City/Town 4 .'_ State Zip Code Date of Inspection D. System Information (cont.) ' Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all'welis within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately • ..`r «.. ',�`� ` +} �' =;ice 7 •} _ r `; • *5. gj. + . 1`6 0 }..•.jti 1. C "aJ'' ' � .. t 0. .. = ' F. 01 T m ' 4., a. - ., f r.s. ..,Sr ,t .1` + - t ,..` r'bt, P�p� «•R �tb t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Mooring Dr Property Address Robyn Tolman Owner Owner's Name information is required for every Cotuit MA 02635 6-11-18 ' page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: " ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. 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 I Commonwealth of Massachusetts l�l Title 5 Official Inspection Form w., hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Mooring Dr Property Address -` Robyn Tolman Owner Owner's Name information is required for every. Cotuit MA 62635 6-11-18 page. 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 i�- --- - `P�'WNf 0]F SARNSTOLE Y.00t�'fiiON f�/ ✓I p��� yr SEY+t�,GL� # A�STAIrl• �`S NAND tk PHOM N, 9M. C TAN- CAPACrry 10O� O LEACItn+tG VAN'- , `Y'.ice) ' pper� FIExRNXgT:g3�,' s CQlti9l�r.YR►1iTCE 1Q�TE .. ;�. tlTWttOtY9tStti11t3 Nlxiu►um; Ad ust�1 Grouadw�ter Tabie l�ih�B�ttarn b£Z.�aGhttc�Erncility. ` �ce� Prlv�u'i�Y&t�x Sully V(s��t and i. Aiag Y�aalety �ta�y►wells nRist On sst�0e wit utt Zoo tat Of 1�t�cbi� as �y �fl J . Eii ��o JetBand and L,6i4i,, if a�cAy Of afty w�t, n�exist rlltffl'in'�UO fi:et f eo��tip��'ac�!!ty� 1 �- &gee r 7 s� of - oZ- a- � 3 - �9� ~ 70 t . No...qq k.�....7 FiRzizc ... ... 30 .00 _ APPROVED THE COMMONWEALTH OF MASSACHUSETTS Bern/stable Conservation Department BOARD OF HEALTH Sig ed Date S�TOWN OF BARNSTABLE t Appliration for DioVoiittl Work,6 Ton,itrur#'tun rams# Application is hereby made for a Permit to Construct ( ) or Repair)(Kyj an Individual Sewage Disposal System at: 19.1...Moorixig...I?1:IYe... otuit................................. ................................................................................................. Location-Address or Lot No. Joe Swartz ......................_.......................................................................... ................................................................................................. Owner Address aJ,P_..Macomber Jr . M c Installer Address VType of Building Size Lot............................Sq. feet �., Dwelling X No. of Bedrooms----------------3.._----_.------.--..._..Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... .. W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter.--------------- Depth................ x Disposal Trench—No. .....------_------ Width-------------------- Total Length..................... Total leaching area....................sq. ft. Seepage Pit No-------------_----- Diameter-------------....... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.------------------•-------------------- aTest Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................I_.. (i Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ a ----•-•-•••---------------------------•---•------•------------------• ....................................................................................... 0 Description of Soil............................................... xSana--&---gfj va ------------------------------------------------------------- V ....•-•-•-------•-------•••-----••--••---•-•----•-•-•---•---...--•------------•----•-••-------------------------------•-•-------------------•---•--.................................................... L-1000 gallon leaching pit to be U Nature of Repairs or Alterations—Answer when applicable............:................................................................................... added__to___an__exist-ing tank & Pit with box. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has e issu by the and f health. 12/27/93 Signe ._.. Date q Application Approved By .............. -- -aZ- F Date - Application Disapproved for the following reasons: . . ............... . ......... --. ....................... ...................... 9 .. ............. .......................... . ....................------._....----------------------.............------------------------------------------------ -------------------------------------- A D Permit No. - ... . ................ Issued .................ace....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Texrtifirate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by-----_J.P.Macomber Jr . ---------------------- -----_------_-------- - - - ..__................. 191 Mooring Drive Cotuit Installer at ..-------------.._.---------------------------------------------------------------------------------- _.. has been installed in accordance with the provisions of TITLES of The State Environmental Code as described in the application for Disposal Works Construction Permit No. - -....7a-8----..__---I.- dated ....._................._._._..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. q � DATE.. . .. ..........�/...-FI° --- ------------------------ Inspector ... --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N TOWN OF BAR STABLE FEE...� 30 0© No.---•=-•=--....... --•--.... Ropmal Workii Tunotru.rtion "rrutit J.P.Macomber Jr . Permissionis hereby granted----- - --................................................................................................................................... to Construct ( or Repair 4XII ax Ind* H al.Sewage Disposal System 19 Moo ing rive otuit; atNo.............................................................................................---------------------------------- .............................................................. Street pp as shown on the application for Disposal Works Construction Permit No.?� - Dated....��-��1-�3........... DATE. ? - ,��/- ..................................... lJ Board of Health FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS ,4 1 No..gt 3...76.g ............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH """TOWN OF BARNSTABLE Appliratiou for Bi_npoottl lVor1w Touitrurtion rrrntit Application is hereby made for a Permit to Construct ( ) or Repair X(XX) an Individual Sewage Disposal System at: 191 Mooring Drive Cotuit Joe Swartz Location-Address or Lot No. Owner Address W J,P.Macomber Jr. Installer Address UType of Building Size Lot................ Sq. feet �., Dwelling X No. of Bedrooms................. ---__-_-___________.__.__Expansion Attic ( ) Garbage Grinder ( ) a1' Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter_------------- Depth................ x Disposal Trench—No. .................... Width.........;-.--------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter_____.____._._-_.._- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed by-------------------------------------•-------------------•------••-------- Date------------------•-•--------••---••-- W -Test Pit No. 1________________mmutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 9 -------------------------------------------------------------------•------------•--•----------...---......................................................... 0 Description of Soil............................................... WBari --&---gzavel------------------------------------------------------------------------------------- V ---------------------------------------•--•-•----•-------------•--••-----------------------••-•.....------•--------•--------------------•-•-...--•---------------•---•----•--•-••-...------••-•-•--•---. .......................-------- x L-1�00 gallon leacririg pit £o be U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- added to an existing tank & Pit with box. •----------------------------------•------•-----•----------•--------------------------.........-----------------------------------------------------------------------------------------........_...-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has •een issu d by the board o f health. Signed . ��- -----,./�.� ..� 12/27/93 Dace Application Approved BY - / .I......------------------------------------------------------- --- Application Disapproved for the following reafonr- ------ ----------------------------------------------------------------------------------------------------------------------------- ....................... ............................ ............................. . ................... . ..................................................... . . . .. ...... ........................................ Dale PermitNo. ----- :�-- �0-a-------------------------- Issued -----------------------------------------------------._.......... Dare TOWN OF BARNSTABLE ,.LOCATION SEWAGE # VILLAGE, ,.i ASSESSOR'S MAP 6z LOT Qom `"�/7 INSTALLER'S NAME' & PHONE.NO.. , i y��Cdrrl�J�'✓ ' . j SEPTIC-TANK 3CAPACITY: , l t p LEACHING FACILITYs(type) =(size)Zl � v0 NO. OF BEDROOMS PRIVATE WELL�OR PUBLIC WATER BliR OR OWNER ;ram DATE PERMIT ISSUED: Of 2 f ,,,Z5, DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No . �� ,� ,. �/ �, ��� � � �i , . Cam' � � �.. _�� � � �,1 `C' �� �� �`�r - �, f-. `� '7•�" �� ��� �� .. � � .� �, � b.y •'� 1 �,. ,. N 3 Fxs. . �r�..11.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFj�MTH OF. ---------------------------------------- Appliration for Uiip•aoal Works Tonstrnrtion Famit Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal Syst ...... ... .-----.A-- ..---------•- ...--•-•- -� / ��p��� Loc e ... Lot No. f ddress W " �_ n. .... ........��-••_..._ -- •----••-• ..............••----------•--•-•------- -•-- Installer Address d Type of Building Size Lot_C?V1_ ......Sq. feet U Dwelling—No. of Bedrooms_________ ____ _____ _Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building _ _ _ No. of persons........ Showers ( ) — Cafeteria ( ) Q' Other fixtur W Design Flow.......;__ _____________________gallons per person per dray. Total daily flow------�s��.......................gallons. W -' 'Septic Tank—Liquid capacity gallons Lengthy.____ Width G�__�___ Diameter________________ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area___:_ ..sq. ft. Seepage Pit No......../---------- Diameter.____46f.......... Depth below inlet___]° ...... Total leaching area_ .....sq. ft. Z Other Distribution box Dosing to ( ) Percolation Test Results Performed b J ._ _ _ Date_ ............ Test Pit No. 1___ ___minutes per inch Depth of Test Pit____________________ Depth to ground water._ >._t�s� /� 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.,.i__ �Ks �+ -•-----------------•-•------•---------•----•-•-•--•---.....-------------------•-•--•-_.._._......................................................... 0 Description of Soil_________ ______ V .....•-••••--•-•--•••-••---•• --•-- -•--••--- ----•••-•.....•-•••••--•--••••--••-----•-....----•--- 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 TITi 1Z- 5 of the State Sanitary Code—The ndersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ssued, he aril of health. ,:,,)Signe - ----- -----•-•----•-•-•••• •-•-•-•--•---•--••--••-----•-••-•- Date Application Approved By.......... - -••--• � Date Application Disapproved for the following reasons---------------------------------------------------------------•................................................ .........-•-•--------------------------•..---------------•-.--------------_•--_._._....-•----•--••-•••••.--•--•-------•--•-•-•---•-•----•-----------•--••--•••--••-•••-••------•-----•--••••---•..._.... / (� r/ Date Permit No......................................................... Issued...�1�_._. jyrf/ Date 0 C 10L 1f SEWAGE PERMIT NO. VILLAGE INS LLER' 'N ME i ADDRESS B U I L D E R OR OWN ER DATE PERMIT ISSUED 7_ /�-_ 7Q DAT E COMPLIANCE ISSUED �� � � G � � �� o �� �. , � .. F �, fir! // (i N ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .......0 F......e ----------------------------------------- Appli-ration for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct (X) or Repair an Individual Sewage,Disposal System at: ..................... ............................................. ..................................................................................... .......... Location'--Address t No. ................ .... ..................W:Lot ................................................... Address ........... ......... Installer r Address Type of Building Size Lot_119e:21//770......Sq. feet U Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder P61 Other—Type of Building-/ No. of persons.......&............... Showers Cafeteria Other fixtures ....................... .......................... .......................................................................................... ----------- Design Flow......... __________________gallons per person per day. Total daily flow____.t,?-M.......................gallons. 1:4 Septic Tank—Liquid capacity/K ____gallons Length... ...... Width/Z. Diameter................ Depth________________ Disposal Trench—No. .................... Width.___.__._.__._._._.. Total Length.____.______.___..__ Total leaching area . .....sq. f t. Seepage Pit No......../......... Diameter.....Z........... Depth below inlet... .... Total leaching areazzxt-7Z.—....sq. ft. Z Other Distribution box Dosing Performed by......tank .1r,!.e, Percolation Test Results --- 44: �_. Date__/q ... Test Pit No. I... ....minutes per inch Depth of Test Pit____________________ Depth to ground water........�2 Test Pit No. 2................minutes per inch Depth of Test Pit.___._.__.______.___ Depth to ground water./.�._& ----------------------------------------*........*.............*----------------------------------------------------**"'*-----------*------*-----"..... 0 Description of Soil...............................0�.................................................................................................................................... �4 /��,�Ifldlcl'. U ....................................... ..................................................................................................................................................... W ........................................................................................................................................................................................................ �4 U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .....................................................................I.................................................................................................................................. Agreement: The undersigned agrees to 'install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been'issued by Ate board of health. ------------------------------------------------------- ------------- ------------Date"--------------- Application Approved By......... ------------ •-- - -- - ------- Date Application Disapproved for the following reasons:...............................47......................................................................... ..................................................................................It................................................................................................................ Date PermitNo......................................................... IssuedL............................. Date THE'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 tp .........I................. OF.... (9rdifiratt .of Toutpliattrr THIS IS TOrCERTI'FY, That the Individual Sewage Disposal System constructed (A) or Repaired ;zl , by................. ..... . 11Z�e ...................;;-6.....L,!,/................................................................I......................... .................................... at. . ........... 7 ......................;V............................................................................................................... has been installed in accordance mfith the provisions of/t 1 5 of The State Sanitary Code as described in the --------- --- 7 application for Disposal Works Construction Permit M� -----�V_71............. dated ... .. .... & .....f-A................ THE ISSUANCE OF THIS CERTIOICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Ins.- tor............................................. ................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF„HEALTH ............OF..... ...............7...................................... Nh)��.71....... .............................. FiEj�.............. Disposal Works Tonsthirtion. per it Perniission is hereby granted--..-- C.�� IV ------------- ---------------------- ------------ ....... ......------- at to Const�4cConstructor_Repair an Individual Sewage DisposySystern .7. IV ` "o........ . ............................................................................. Street as shown on the application for I:Disposal. Works Construction Per No-_- -------0, ated----- .......... ... ..• .. . !�-X--------------------—DATE....." ATE..... ..4 r ealth ......Zf.........................V.�......... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS `.y —— 98 —— EXISTING CONTOUR x 100,98 EXISTING SPOT GRADE N W PROPOSED WATER SVC. �oG (, EXISTING GAS SERVICE W OVERHEAD WIRES RoV�e 2$ c < <o �� TEST PIT BENCHMARK z °o< LEGEND Shooe` n � o u� o LOCUS • �Q� Rd Dee F LOCUS MAP NOT TO SCALE MOORING LANE CATCH BAS;N PK SET 97.36 99.83 99,56 9912 98.31 97.89 • edge of clearing \ ED 97.27 \\ S 32'28;53" W �� x CB 125.00' 1 97.61 CB 100.78 > x 100.06 \G� '98.67, :. `:. / 97.98 / LOT 99 es° 20,000 ±S.F. 97.81 x 9g PAVED / \ DRIVEWAY, 99.23 x 9 ,73 + 100.99 ALK x 9 6.43 C 100.62 01.16 / ( / of m EXISTING GARAGE l 11 _ HOUSE(#191) I TO. =102.3f J l l 96�6 PATlO � � --� -- ::_ GREEN O - DECK � . -- HOUSE _ -- - 100.4 .- C.r CA CA o N O 96,75 x T r`� oCA p p 9� A6 _ -� \ p p CT00 v N'';/.. 9 �' / BENCHMARK MAG. NAIL SET ON TOP RET. WALL 25 TP-2 95.10. JTP. 1 9I3.8 EL.=101.32 \ � edge .of ' / 0 '9j/ f \ \*Q 0 / \ x 95.36 12 ARBIORi � 94. 0 / 0 EXISTING SEP77C TANK IL (TO REMAIN) I TOP OF TANK, EL.=95.27t + INV.(OUT)=93.9t 94.00 i EXIS77NG LEACH PIT SHED / I TO BE PUMPED, FILLED WITH SAND & ABANDONED fence line 125.00 a IN N 52'28'53' E PARCEL ID: 024-117 PROPOSED SEPTIC SYSTEM UPGRADE PLAN MoG�.J�1�g 191 MOORING LANE, COTUIT, MA R is�``Q Prepared for: Robyn Tolman, 17 N Shore Road, Derry, NH 03038 S P� OWNER OF RECORD SCALE DRAWN JOB. NO. ESTATE OF JOSEPH A SWART Engineering by: �1 1 ROBYN L TOLMAN Engifieering Works, Inc. 1"=20' P.T.M. 201-18 '� ) 1 17 N SHORE ROAD 12 West Crossfield Road, Forestdale,.MA 02644 DATE CHECKED SHEET NO. DERRY, NH 03038-5102 (508) 477-5313 1 7/2/18 P.T.M. 1 Of 2 r� NOTE: TO PREVENT BREAKOUT, FINAL GRADE SEPTIC TANK SHALL NOT BE AT, OR BELOW, EL.=93.0 INSTALL RISERS & COVERS OVER INLET & FOR A DISTANCE OF 15' FROM THE EDGE OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED D-BOX OF THE PROPOSED S.A.S. INSTALL RISER & COVER PROPOSED S.A.S. T.O.F.=102.3t (FRONT) SET TO 6" OF GRADE INSTALL RISER & COVER OVER one CHAMBER AND T.O.F.= 98.3t (REAR) SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT F.G. EL.=98.0t F.G. EL.=97.0t F.G. EL.=96.0t F.G. EL.=95.0t MAINTAIN 2% SLOPE OVER S.A.S. ;s ' L = 18' L = 13' ® S=1% (MIN.) p S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/8- TO 1/2" s" DOUBLE WASHED STONE to'I n G aaaSaam (OR APPROVED FILTER FABRIC) 4" aaaBaa6 EXISTING 48" LIQUID aaaaaaa �-3/4' TO 1-1/2' DOUBLE LEVEL WASHED STONE ' ADD INV.=92.87 PROPOSED 4' 4.8' 4' GAS BAFFLEJD BOX INV.=92.70 .. INV.=93.90t EFFECTIVE WIDTH = 12.8' (FIELD VERIFY) 3 OUTLETS H-10 RATED INV.=92.50 EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-10 RATED TOP CONC. ELEV.=93.3t NOTES: BREAKOUT ELEV.=93.00 50=92 V ELE . . ease 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & INV. eases INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. aaaaaaaaaaa 2) D-BOX SHALL BE SET LEVEL 'AND TRUE TO GRADE BOTTOM ELEV.=90.50 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED 4' I 2 x 8.5' = 17.0' 4' . � ) PERVIOUS MATERIAL STONE BASE, AS SPECIFIED 310 CMR 15.405(2). 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' - 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' (MIN.) ABOVE G.W. 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TEST PIT, EL.=84.2 = LEACHING SYSTEM SECTION AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. _ SEPTIC SYSTEM PROFILE GENERAL NOTES: HOUSE(#91) GARAGE 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL T.O.F.=102.J±' BOARD OF HEALTH AND THE DESIGN ENGINEER. 2• ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE GREEN GREEN DECK DESIGN ENGINEER. HOUSE - -4-:-ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING -- - - FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN N^? ^- ENGINEER BEFORE CONSTRUCTION CONTINUES. 43.6' ,�R• �^ 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF TTHE I HEALTH FORCTOR PROPOR OWNER TO ER INSPECTIONS DTIFY -THE URING CONSCAL TRUCBTIION. OF �I ki O_ I 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE: 11 _ OP_S.A.S_ 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS SEPTIC LAYOUT AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE'RESPONSIBILITY OF THE CONTRACTOR TO VERIFY SOIL LOG THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS DATE: JUNE 27, 2018 (REF P#15,698 IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND SOIL EVALUATOR: PETER McENTEE PE(SE 1542) REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). WITNESS: DONALD DESMARAIS RS HEALTH AGENT 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. ELEV. TP- 1 i DEPTH ELEV. TP-2 DEPTH 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 95.2 A 0 95.6 A 0" 14. THE ENGINEER IS NOT RESPONSIBLE`FOR ANY UNDOCUMENTED SEPTIC LOAMY SAND LOAMY SAND SYSTEM COMPONENTS NOT SHOWN ON THE PLAN 94.5 10YR 4 2 8" 94 9 10YR 4 2 8" B B LOAMY SAND LOAMY SAND DESIGN CRITERIA 92.9 1 OYR 5/8 28" 93.1 1 OYR 5/8 30" ' C1 C1 i NUMBER OF BEDROOMS: 3 PERC SOIL TEXTURAL CLASS: CLASS 1 (LOADING RATE=0.74 GPD/SF) 30"/48" DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 GPD MED. SAND MED. SAND DESIGN FLOW: 330 GPD 2.5Y 6/6 2.5Y 6/6 GARBAGE GRINDER: NO-not allowed with design LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 84.2 132" 84.6 132" .74 GPD/SF PERC RATE <2 MIN/IN., "C" HORIZON EXISTING SEPTIC TANK: 1000 GALLON CAPACITY NO GROUNDWATER OBSERVED PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-20 RATED USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 191 MOORING LANE, COTUIT, MA SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Robyn Tolman, 17 N Shore Road, Derry, NH 03038 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. ' N.T.S. P.T.M. 201-18 DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. 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