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0204 MOORING DRIVE - Health
204 MOORING DR`�_V��� A= 024 114 f i i 't x I x CL FRONT ELEVATION Addition * ROOF TIMBERLINE HD 50 YR 23' * ICE&WATER 5HEILD 100% I * RIDGE VENT * PVC 1X4 WINDOW TRIM * PVC 1 X 5 CORNER BOARDS *WHITE CEDAR R&R CLEAR 5" EXF. *HOUSE WRAP ADDITION *LEAD FLASHING FRONT DORMER WINDOW/DOOR SCHEDULE WINDOW5, FELLA PROLINE EXISTING ROOF* EXI5TIN B A B EXI5TING DOUBLE HUNG ROOF ROOF �� �� REROOFI GM REROOFING A. 29 X55 B. 58"X 531, 8" ROLLED LEAD FLASHING E �® t D EXISTING HOU5E EXISTING FOUNDATION • Du ion PROJECT ADDRE55: ?i Karen Brown PO BOX 368 204 Mooring Drive Cotuit MA Gummaquid MA 02631 _ 1/4 - 1.65, 506-362-3g3q ....................................................................................................................... cr o) M-5T ELEVATION I 24' • ROOF TIMBERLINE HD 50 YR 12' • ICE &WATER SHEILD 100% • RIDGE VENT 2-1, PVC, 1X5 CORNER BOARDS ADDITION ' PVC, 1X6 FREEZE BOARD •WHITE CEDAR R&R CLEAR 5" EXP • HOUSE WRAP 18' EXISTING HOUSE EXISTING GARAGE El] FOUNDATION Grade ........................................................................................................................................... PROJECT ADDRESS: : Duffy Construction BROWN, KAREN PO BOX 366 �o-r uooMNG DR Gummaquid MA 02631 1/4" = 1.65' 508-362-3939 cn a EA5T ELEVATION 32' 12� ` ROOF TIMBERLINE HD 50 YR " ICE& YVATER 5HEILD 100% ADDITION " RIDGE VENT PVC 1X5 CORNER BOARD5 23� ` PVC 1 X6 FREEZE BOARD NHITE CEDAR R&R CLEAR 5",EXP. `HOUSE WRAP EXISTING EXISTING HOUSE ROOF 14' EXISTING _ HOU5E ®0 EXISTING FOUNDATION El - El .......................................................................................................................................... Duffy Construction PROJECT ADDRE55: PO Sox 368 BROY4N KAREN 204 MOORING OR GUmmaquid MA 02631 GOTUIT MA 1/4" = 1.65' 508-362-3939 o� BACK ELEVATION ADDITION I Ridge Vent ADDITION ROOF TIMBERLINE HD 50 YR STEP FLASHING ` 100% ICE &WATER SHEILD WEAVING OF SHINGLES ` RIDGE VENT PVC, 1X4 WINDOW TRIM Ridge Vent 8"ROLLED LEAD FLASHING ` PVC 1 X 5 CORNER BOARDS 'WHITE CEDAR R&R CLEAR 5" EXF. 'HOUSE WRAP AB3 A A �. EXISTING WINDOYWDOOR SCHEDULE YVINOOWS, FELLA PROLINE ADDITION DOUBLE HUNG A. RO 29-3/4"X 53-1/2"1 B. RO 29-3/4"X 0-1/2"tempered El EXI5TIN6 HOUSE F El EXISTING FOUNDATION k ....................................................................................................................... PROJECT ADDRESS: Duffy Construction ` Karen Brown s .PO BOX 368 204 Mooring Drive cotuit MA Cummaquid MA 02631 1/4" = 1.65' . 506-362-3g39 ROOF FRAME LAYOUT Page 5 24' 2X6 OUT5IDE YVRLL5 f EN B KIVG4FT-qC- DY6A BrOGKI-N-(5-4Fr G r l ...tee--^-- �..•-.,•�,.�s..'�.• �.F _ .,a.,.�-� .�r.+wtc:+ . r i w y _ emIL . N 't! L1�KING:4FT OG Ei�iD BAY BLOOICENG:4FT G Duffy Construction PROJECT ADDRE55: PO- Box 366 BROWN, KAREN Mumma uid MA 02631 204 MOORING DR Q Q COTUIT MA 5OS-362-3g39 1/4" 1.65, , FRAMING LAYOUT Page 6 4 CLL AI T S © " RIDGE LVL 1 X"X11 1/8" � I " RAFTER 2X8 181 E13B 4P O.C. 2 C8RUN FT 161 "COLLAR TIES 2X4 2X8, G I L I G .1 (5"T16' I ' • EBB 4 O.G. I IN5U ICON R 8 •2X8 CEILING JOIST, �I i i t ( ( TRIPLE 2X8 " r � t i . I! i I f f, HEADER CHANNEL VENTING -2xbLo[�sI .PE �_ " 1X6 WIND BLOCKING " % COX ROOF PANEL NAILING 4" EDGE/12" FEILD Ro i Rp RO W 100% ICE & ATER SHEILD 58%"X53 1! ' g4 Site 29%" 1/2 { 58 X"X53 1/ . " ROOF ASPHALT 50.YR V ON6 .' � "2X6OUT51DE WALLS EXISTING OOF ;l s�, 1ON 1 I + EXISTING ROOF " 1-3/4" LVL FLOOR JOISTS x6 no1 -L f # ! "R-35 INSULATION } • i �l .,4L_2=1L° LEA L E COX WALL PANEL VERTICAL, NAILINGA" EDGE/12" .� -- ) = �._n._ .- �. (2X6) (1-3l4X5 I/2 LVL FLOOR JOI !'�� FIELD " HOUSE WRAP 2X6 DOUBLE KING "WHITE CEDAR R&R CLEAR 5" STUDS ALL WINDOW EXP. FRAMES "RED CEDAR CLAP BOARD " 1 X 5 PVC CORNER BOARDS 1 XS RAKES WITH SHADOW_ "1X8 FASCER "1X6 SOFFIT WITH VENT Duffy Construction PROJECT ADDRE55: PO Box 368 BROWN, KAREN .......... 204 MOORING OR Cummaquid MA 02631 GOTUIT MA SOS-362-3939 f Page'I-A- CROSS SECTION 8Al2' . . ''. f, %" COX Roof 5heathing 100%.Ice and Water Shield Architectural Asphalt Roof , - •�' - �� Ridge Vent End Bay'Blocking � .' LVL 1 %"X 11 1/8" RIDGE �� X ChanneLV ntin 2 8 Rafters 16 o.c. e g . R-38 Insulation F y 2X4 Collar Tie 16" ox- 2X8 Ceiling Joist '� /' 1X6 5PRING BOARD Wind BlockDrip Edge Edge U R-38 Insulation t 2 X 8 KD 16" O.G. ' SFT strapping = Soffit ent Hurricane-Clips %" Blueboard w/ skim.coat, 2X6 Double Plate 2X6 Triple Header i 7' i F -'2X6 Exterior Walls %2 GDX 5heathing Vertical 3 Ice and water, window, trim ' House Wrap White.Cedar Shingles R&R 5" exp . R-21lnsulation T&G COX PLYWOOD R-21 IN5ULATION (1w/''"X+5 YS" LVQ XN(2Yx 6 KD) : Duffy Construction PROJECT ADDRE55: 0 BOX 365 BROWN, KAREN 204 MOORING DR € Cummaquid MAC 02631 COTUIT MA 508-362-393q Page 1-5 Gable End Framing RIDGE LVL 1Y4"X11 il8 '-,,, 12'� >� 2X8 KD RAFTER 2 OL R 15 :4 • 2X6 RAFTER PLATE XbHEADE LIU 2Xf61 bi'OG 2X6 1 : t I J L LI LIL, Jl- 1 .11 1 il- L,jL--+- ,. ._ :...........................................................................................................................: Duffy Construction - PO Box 365 PROJECT ADDRE55: BRowN, KAREN Gummaquid MA 02631 204 MOORING OR GOTUIT MA 50�-362-3g39 NOTE: (2 X b)X(1 %"X 5 %"LYL)WILL Page b BE JOINED TOGETHER U51146 3" FLOOR FRAME LAYOUT LEDGER LOGK5 5TAGGERED PATERN 16 O.G. KEEPING 2 AWAY FROM EDGE5 llplryr rg 3 continuous fire block HEAD OFF FOR , �..�.-.-.�.-. TOILET STACK' _w 3 2xb OUTSIDE RIM � - J015T BLOCKING lu Q O _ Au c JFT- ! Q _ J -�—_ _ Z ;`ui Lll all _ X_ . O -- -- 24 X35-TINJG-2X(-FLOOR J015T - PROJECT ADDRE55: Duffy Construction BROWN, KAREN PO BOX 365 204 MOORING DR CUY1 ma uid MA 02631 GOTUIT MA �I - - 508-362-393q Page 9 FLOOR FRAME DETAIL I I � 1 %"X 5 %" LVL EXISTING 2 X�b KD `• ��_ � .� • CENTER CARRING YVALL 12%:" 1 W . 1/, .._ L , I 12 � U 2 X 6 FIRE BLOCKING I 11'7 Y". 0 3. X W _ 1. X 5 /�� LVL -_ II _ EXI5TING 2 X b KD !Z J 3, b EXI5TING 2-X 4. z OUT5IDE`YVALL' . v; NEN2X6KD 6- R055 BLOCKING � z w OUT5IDE NALL 1��, 1/,� _ 1 %"X 5 %" LVL EXI5TING 2 X b KO NOTE: (2 X 6)X(1 %"X 5 %"-.'LVL)WILL.. BE JOINED TOGETHER UBING 3 . LEDGER LOCKS STAGGERED PATERN 16"O.G. KEEPING 2"AWAY PROM EDGES, °..............................................................................................................._......... . Duffy Con5truction PROJECT ADDRE55: BROWN, KAREN PO BOX 36S 204 COTUIT MA q MOORING DR Comma uid MA 02631 GO - 506-362-3g3q 0 o>' rn Proposed 2"D FLOOR PLAN 64'-1 1/16" 14'-1 9/16" 49'-4 5/16" -————————— �— -- —————————— — -- ———— ---- "®" i \ / I \ ;/ 2'--k 2'-5" i \ / \ 9 4'-2" 2' �o \\ / 2xb plumbing wall \ -- must be place above Z9 OPEN existing 18t-fioorwail N \\ N Garage Attic• �;TO%2/GE EXISTING OFFICE storage I i---------------b------------- 'Center _ I zo a 4'opening to _ I exlsting — _ —————————U1,——— I ridge "' O EN LOW rsnILIN!• I I II I E 13'-101/2" 22 T-T' I - I I UstIng Computer room I I N I II co i i Wo Mirror to other RAIL I bo I I I I M double window _� Centered In ---- Window room - - - - J--------------- --------- Genteratl4' N 14'-1 9/16" 1 i 11'-1 7/8" 38'-2 7/16" 64'-1 1/16" ................................................................................................................................................... Duffy Construction PROJECT ADDRE55: BROWN, KAREN PO BOX 365 204 MOORING DR COTUIT MACUmmaq uid Mrs 02631 ' GO 508-362-3g3q 1 e Page 11 EXI5TING 15T FLOOR PLAN - EXI5TING SMOKE DETEGTOR5 II 'DECK �I � I e la • i � I I • - j FAMILY ROOM, jg ' I I i r I I I I I I I r I DETECTOR I I® I I i UP DECPei n I b f - I - T � I i KITCHEN BATHROOM i� 15EDROOM GARAGE \�\I REEZEYVAY y EXISTING SMOKE —> DETECTOR i s I— 1 — UYING ROOM i - i I I 2 BEDROOM I I P I ------- EXISTIN SMOKE DETECTORS BA5EMENTLEYER PROJECT ADDRESS: DUffy GOnStC'UGtIOn BROWN, KAREN PO BOX 366 204 COTUIT MA q MOORING DR GO Gummy uid MA 02631 • � 508-362-3939 - C Grsicfe to Wood ruction in I i�ah WzxdAreas_lie Xgh �rrd Zorte . l f6r CanmpUMM CM CIIVIR53or-2�1 l:)� = 4 . �st� EL From Tables 1tt and 11-and location afwall and Su�s,I Aspect!fur det wmine.Percent FuII-He • Shmdhhvj and tall .. - - - -- datbi& L Pwre�dW be wed t h stye rg6r arils W"fa sus. gL onsk&d Mal&shah be attached to battont plates and fDp member of the double - top plate. - - plate and W band jolst at boom of panel.Lipper atladunent:of paned shah be made to hand Joist - and k weraM daent made to IQwest plate 3t fast f&rf MbV- v. Horimrdal nab wing act dome top plate,hand joists.and gitdm shd-be a double raw of ad staggered at 3 hr hm on career per figLm befog:Vertical mid Horimt M taming for Panel Attachment S_. Gang protu t a),naw house crh adcOm— M re nap i ordoserta share.(gwm*.-cotes of b)vertical addtl an—not requ i eat unless tfrere Is WdNOW ranavatbri to fhe fast floor c)mphmnentWdows—needs energy►conservation carnpbdxm wily(chap 93) ' B:Wood Frame Consh'ucdon Manuel ffimm)for 110 MPH,Eq==$maybe obtained f m the Am iicEit WD�(bra (AV&)wed. - - ra:eaea�t�aat . IA Is es s !a [i ' rl ►I. _ a . n� � +�Q it ift a s• t t r as € - u i , t �,tAE;SpJ.Lkk' Tt42PlKf78�tt PAMR. • �- P�lB� �S Fes. � iX.?L=��-= k�ETiSL - - - ` Sea DalQ on Need Page - erl?cel and Hwv t Marling = MAW ' � Verli�i snd tialmrh Qadad hlar7mg for Panel Aft' dumad - foF Parted Af chment ." 1 cc _ al '`� - X - R R P t� LOT 95 ° o, 9' P SP 20,000 S.F. .. _ off` ti OF a°$ tl Al ell TO THE BEST OF MY ' INFORMATION, "EXISTING" PLOT PLAN . KNOWLEDGE, AND BELIEF THE CQTUIT, MASS. STRUCTURES SHOWN ON THIS PLAN LOT 95, TUBE 167 HAS BEEN LOCATED ON THE GROUND DATE 11�5�14 A SCALE 1" m av^^' AS INDICATED• JOB 7509-00 CLIENT BRO ,c W ..� _ ; SWEETSER E`_NGII�rE'F'RING _ _ 2�J3 SETUCKET ROAD DA. ! PROF SSIO'� AE LAND SJR�IE 'VK PO BOX 713 SOUTH DENNIS, MA 02660 �. C (O�F 508-385-0900 FAX. 508-385-5921 f' i 0�—EPP. DA' Li ✓i5 S '.—�—"ET$Et. :-.,vv11sL•L'.;�T7C' C�w':J %� 'l: C ' rayc XI5TINCG 15T FLOOR PLAN �^u PROPOSED 15T FLOOR PLAN 24' f pRoPC�---oDE=K PROPOSED DECK Q 6 } e 1A."LY ROOD PROPOSED " PROPOSED ADDITION t y O N - T 20' UP > DECK 3-11'x3•-+ (see amc--a vasc -!- 2-LVL 1 9, -i Y. BEAM ` 9 20' qTC F—N BATHROOM 1 BEDROOM GARAGE T F-1 /p ®5MOKE EXISTING HOUSE 1 LIVING 2 BEDROOM i I PORCH I UP SMOKE&CARBON BASEMENT LEVEL ........................................ Duffy construction PROJE:6f A�DORE55: Pa BOX 36S SROMA.REN 204 MOING DR Ciummaquid MA 02631 corul � 508-362-3g3q . ............................................................... -- x Map Pagel of 1 Town of Barnstable Geographic Information System New Search Home I Help Parcel Custom Map Abutters Map Size ' ®� Zoom Out'1 j j'j e j 11n Viewer fn,/F _�/ Q — - � __ Iv ® =JPG .. .. ... ... :I �..:.. Turn map layers on/off by 1 ele g heck boxes below ....� ...... ... ..... '.. Refresh s din c K'.':: ':: :'.'::'.':: ::' :: '. '� ."'i:':-i: ::•'::'.: :i'::r::: ' ® Town Boundaries n EM ..:: :: .::` ::.•'::".::'•::::: :: i':5 '.. ❑ Road Names :'• :..•::..:::..::::: ❑ Voter Precincts ❑ Multiple Address House Numbers " '• " " -' "' " "�' El Map&Parcel Numbers •` ® Parcels E Set Scale 1"= g6 �_Aeri6l-Photos I MAP DISCLAIMER ❑ FEMA Flood Zones Effective July 16,2014 Copyright 2005-2010 Town of Bamstable,MA All rights reserved.Send uestions or coQerffsAtOMScity Zorie - BarnstableMA v1.2.5833[Production] - ❑AE-100 year flood - AO-100 year flood ❑0.2%Annual Chance Flood ❑Open`hater ® Neighboring Towns ❑ Water ❑ Streams - - ❑ Jetties El ❑ Edge of Water v http://66.203.95.236/areims/appgeoapp/map.aspx?propertyID=024114 1/6/2016 r Commonwealth of Massachusetts Title 5 Official.. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name information is required for every Cotuit MA 02635 7/28/14 page. City[Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return key. Name of Inspector Company Name P.O: Box 49 Company Address era Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally irispected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am'a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth r valuation by the Local Approving Authority 7/29/14 Inspe�tem s Signature Date The 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 tc 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 inspecti_ n,does not address how the system will perform in the future under the same or di f erent conditions of use. vv ' vI{ G l5ins•3113 Title 5 Official Inspection Form:S bs ace Sewage Disposal System•[�Ieof 17 a Commonwealth of Massachusetts Title 5 Official,- Inspection Form Subsurface Sewage Disposal'System Form = Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name information is required for every Cotuit MA 02635 7/28/14 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 i 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. I Comments: r: s ,I B) System Conditionally Passes: i ❑ 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 anti 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): i 9: 15ins•3/13 ;' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i; Commonwealth of Massachusetts r . W Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name 14. information is required for every Cotuit MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.)::, ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage,backup or break out or high static water level in the distribution box due to broken or obstructed;pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with,,approval of Board of Health): ❑ broken pipe(s)areTreplaced ❑-Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box,.is leveled or replaced ElY ElN ElND (Explain below): i P: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND.(Explain below): C) Further Evaluation is Required by the Board of Health: El 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 r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 4 I ✓ Commonwealth of Massachusetts _ Title 5 Official; Inspection Form Subsurface Sewage Disposal'.System Form - Not for Voluntary Assessments 204 Mooring Drive s Property Address Peter Muncey Trustee Owner Owner's Name information is Cotuit ' : MA 02635 7/28/14 required for every , 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 environmenti; 6. ❑ 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 septc;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: y, **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: i ... i t D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"'or;"No"to each of the following for all inspections: Yes No ❑ ® Backupof sewage into facility or system component due to overloaded or CIO( ged 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" bellow invert or available volume is less than 1/2 day flow I5ins•3/13 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name information is required for every Cotuit MA 02635 7/28/14 page. CityTTown State Zip Code Date of Inspection B. Certification (cont.)! c, Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El . ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any potion of cesspool or privy is within 100 feet of a surface water supply or tributary"to a surface water supply. is - ❑ ® Any portibn of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portibn of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system-passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of am►honia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00,0gpd. ❑ 0 The systtem 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:bwner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you musf indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. is Yes No t: ❑ ❑ the system is within 400 feet of a surface drinking water supply is, is within 200 feet of a tributary to a surface drinking water supply El ❑ the sy ❑ ❑ 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 i.D above the large system has failed. The owner or operator of any large system considered a:signifi;cant threat under Section E or failed under Section D shall upgrade the system in accordance with:31.0 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ISins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 . , p. a 1; 1. Commonwealth of Massachusetts Title 5 Official,,, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments it a a 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name . information is required for every Cotuit MA 02635 7/28/14 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: `I Yes No r; Pum In information was provided b the owner, occupant, or Board of Health ® ❑ Pump in P Y P ❑ ® Were alpy;.:of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available;note as N/A) ❑ ® Was the. facility or dwelling inspected for signs of sewage back up? t 1 ® . ElWas the site inspected for signs of break out? N. ❑ Were 611,system components, excluding the SAS, located on site? ® ❑ Were t6!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? El ® Was the:facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The si 111 eiand location of the Soil Absorption System (SAS) on the site has been determined based on: it ,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)] u ' D. System Information Residential Flow Conditions: 3 2 Number of bedrooms (design):. Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 j' it .E it (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 4' i� Commonwealth of Massachusetts w Title 5 Officia ' '.Inspection Form Subsurface Sewage Disposal,'System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name R information is required for every Cotuit i" MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Informatid 6 , Description: y' l Number of current residents' Eli Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No i Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable ii Sump pump? _ El Yes ® No y Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: t � Design flow(based on 3104CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ El No i' Industrial waste holding tank.present? ❑ Yes ❑ No Non-sanitary waste discharged„to the Title 5 system? ❑ Yes ❑ No i .. Water meter readings, if available: 15ins•3113 i, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Officiasl Inspection Farm Subsurface Sewage Disposal.'System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address u. Peter Muncey Trustee ` Owner Owner's Name information is Cotuit MA 02635 7/28/14 required for every I page. City/Town a State Zip Code Date of Inspection D. System Information.(cont.) Last date of occupancy/use: Date Other(describe below): R` ii General Information is Pumping Records: Source of information: unkown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped`determined? Reason for pumping: t' Type of System: ,r ® Septic tan., distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection`of the I/A system by system operator under contract A. t. ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Ir .� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a„ 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owner's Name information is required for every .Cotuit MA 02635 7/28/14 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: installed on 9/23/80 n Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): t c.o Depth below grade: y; feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water-,'supply well or suction line: feet 1. Comments (on condition of joints, venting, evidence of leakage, etc.): i. r i: Septic Tank (locate on site plan): i' 16" Depth below grade: le feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) f' / tt I ' If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: " 3 t5ins•3/13 ?` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 l t 2. Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I " 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owners Name t- information is ,. required for every Cotuit t, MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) t: Septic Tank (cont,) . 3; is Distance from top of sludge tto bottom of outlet tee or baffle 29 Scum thickness 4 4 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scumm'to bottom of outlet tee or baffle 15 i How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to out invert, evidence of leakage, etc.): Baffles were present. There is a big bush growing on top of the tank,it must be removed to pump and maintain the tank. 1, t . i` Grease Trap (locate on site!,plan): Depth below grade: feet Material of construction: ,, ., I, ❑ 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 scumxto bottom of outlet tee or baffle Date of last pumping: ' Date l5ins•3/13 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t. A .y� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e$1� 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owners Name information is COtUIt required for every MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7f J 7{ Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal - fiberglass . ❑ g ass ❑ o polyethylene ❑ ther ex lain N/a p, Dimensions: is Capacity: 1� gallons Design Flow: { gallons per day Alarm present: } ElYes ❑ No It .. Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): f i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No a, (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Officia-1, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 204 Mooring Drive Property Address I a Peter Muncey Trustee Owner Owner's Name information is ; required for every Cotuit MA 02635 7/28/14 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 even 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.): The box was normal t � Pump Chamber(locate on site plan): Pumps in working order: El 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): i. If SAS not located, explain why: r : 1, 15ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address - Peter Muncey Trustee Owner Owner's Name ` information is required for every Cotuit MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: f• . i ® leaching pits, ' number: 1- 1000 gal. ❑ leaching chambers number: ❑ leaching gall;rips number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ,t ❑ overflow cesspool number: II ❑ inn ovative/al:tern!ative system Type/name of.technology: I, Comments (note condition of`soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 1' of liquid on the bottom. The stain line was at the level.There was no sign of failure. The cover was 2.5' below grade`: r l . i, i l Cesspools (cesspool mustbe pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet,invert Depth of solids layer i I!. Depth of scum layer {' Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•3l13 S; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ''�..A,•''t 204 Mooring Drive Property Address «. Peter Muncey Trustee f . Owner Owners Name information is required for every Cotuit MA 02635 7/28/14 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 Ill soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a 1 4. e . r . 9 , 15ins•3/13 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 14 of 17 ' _ I Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal`;System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address 1 Peter Muncey Trustee t Owner Owners Name information is required for every Cotuit MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal,System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Y" f ' � Q , n I , E• l F� yS pa a t' 15' So I t 3 L(3 ss l l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 a. • Commonwealth of Massachusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owners Name information is COtUIt reo uired for every MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Informatia (cont.) Site Exam: ❑ Check Slope i' ❑ Surface water i ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 45 feet Please indicate all methods used to determine the high ground water elevation: s. i ❑ Obtained from system design plans on record If checked, date of designplan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Using topo and'vvater contours maps ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USG5 database-explain: You must describe how you established the high ground water elevation: see above f. t' Before filing this Inspectiop Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 6 r � • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 204 Mooring Drive Property Address Peter Muncey Trustee Owner Owners Name information is 4 required for every Cotuit MA 02635 7/28/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A,,, B,,C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed i ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I. t :i r a s 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 `•" TOWN OF BARNSTABLE LOCATION o SEWAGE # VILLAGE �'l�v i ASSESSOR'S MAP & LOT- l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ID Q Q 5 b�{ LEACHING FACILITY: (type) Pt (size) NO.OF BEDROOMS__ BU LDER OR OWNER ® d -- P DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fee, Edge of Wetland and Leaching Facility (If any wetlands exist within 300 sect of leaching facility) Fet Furnished by ��27.ae(GCS e � N s r 6 ei • a • o � Com-NION-WE.AlTH OF MASSACHUSETTS EXECUTIVE OFFICE OF E.\-VUONMEN TAL AFFAIRS c DEPARTMENT OF ENVIRONMENTAL PROTECTION ,OBE RTNTER STREET, BOSTO\ 1L-k 02105 (617) 292-5,5(Ill UDY CORE �. Secret.an- a CO DAVID 8 UHS ARGEO PAUL CELLUCCI Governor Co o.-,er SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM � � PART A CERTIFICATION t�O Property Address: ItA � ,�-� Name of Owner U—O 'l99 er Address of Owner: iPctN�Z_ Q� 9 Date of Inspection: Name of Inspector:(Please Print) 1 am a DEP approved system inspector pursuant to Section 15. Tr L340 of de 5(310 CMR 15.000) ,L ` Company Name: lq r C kks C &1+1 F Mailing Address: ?,o &., � �4 N N_ I r�r ,2C4'c Telephone Number: /L� . Zo 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 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 v `. _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: l Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS y revised 9/2/98 page torn n Panted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: dw"OVS Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, 8, C, or D: A. SYSTEM PASSES: t I have:not found any informationwhich indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure +critena'not evaluated are indicated below. COMMENTS:,-,,-" Fes.li-� 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 ihe`replacement or repair, as approved by the Board of Health, will pass. t f Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying 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(s1. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;t PART A ACERTIFICATION (continued) Property Address: T Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: <y �J L' Conditions exist which.require further evaluation by,the Board of Health in order to d/e'termine if the system is failin; to protect the public health, safety and.the environment., I 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: r, _ Cesspool,or privy is within 50 feet of surface water .x._ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 21 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 PUBOC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well/water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that fabity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). . 3) OTHER f r revised 9/2/98 Page 3of11, 4, Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (conti/ed property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions aibed it 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be c7oan, ted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due: overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the round 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 overloadec or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below inl4ert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the Isat year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption Systeryt, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is w'�hin 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is ithin a Zone I of a public well. Any portion of a cesspool or privy's within 50 feet of a private water supply well. Any portion of a cesspool or priv is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analys s. If the well has been analyzed to be acceptable, attach copy of well water analysis for •coliform bacteria, volatile orga is compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" toe h of the following: The following criteria apply to large systems in addition to the criteria above: 0 d or greater(Large System)and the system is a significant threat to public facility with de sign n flow of 10,00 gp The system serves a fa y 9 health and safety and the enviro ment because one or more of the following conditions exist: Yes No the system is withi 400 feet of a surface drinking water supply the system is wit n 200 feet of a tributary to a surface drinking water supply the system is to ted in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply w II) The owner or operator of any suc system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for furt r information. revised 9/2/98 page 4of11 F l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' _ PART B CHECKLIST Property Address Owner: Date of Inspection: o Check if the following have been done: You must indicate either "Yes"or "No" as to each of the following: Yes No r Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they'are not available with N;A. The facility or dwelling was inspected for signs of sewage be , _ The system does not receive non-sanitary or industrial waste flow. • _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria.related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) The facility owner(and occupants,if different from owner)were provided with information on the propermaintananr.8•of Subsurface Disposal Systems. ij revised 9/2/98 page sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION troperty Address: Owner: 3. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d.lbedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow Number of current residents: C7 Garbage grinder(yes or no): f� , Laundry(separate system) es or no): i": If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no)jt,�5 Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): f--1) Last date of occupancy:CQ t— i L K-,- -k 143 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow 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: Yi- System pumped as pan of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: F 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ( l APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 -Pige6ofII v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'roperty Address: OW (v Owner: ! ; Date of Inspection. BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC._'other (explain) Distance from private water supply well or.suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK (locate on site an) Depth below grade: Material of construction: concrete metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions. CCU 4 r� t Sludge depth: Lk`I Distance from top of sludge to bottom of outlet tee or baffle:( " Scum thickness:_ i1 }' Distance from top of scum to top of outlet tee or baffle:_ i 1 Distance from bottom of scum to bottom of outlet tee or baffle:_ . How dimensions were determined: comments: (recommendation for pumping, condition of let a d outlet teJe► or baffles, depth liquid leve in lation t out et invert, structural02 in grity, avid nce of leaks e,etc.) GREASE TRAP: (locate on site pl n) 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: (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.) revised 9/2/98 = Page 7ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Irop-ty Address:0�6 UAMV-4 Owner: Date of Inspection: TIGHT OR HOLDING TANK:_(Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) !� T- Depth of liquid level above outlet invert: C U 1j(4,4 Comments: _ strit but• n i e ual, evidence of solidi s carrryver vidence of leakage into or out of box, etc.) (note if level and di PUMP CHAMBER- (locate on site pla 1 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.) revised 9/2/98 Page sortt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) "roperty Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):.i4A&5 (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type . leaching pits, number. �><� leaching chambers, number:_ , leaching galleries, number. leaching trenches,number, length: leaching fields, number, dimensions: r ' overflow cesspool,number. f Alternative system: " ...5 Name of Technology: Comments: (no conditio of soil, igns of hydr ulic;failure, level of ponding,,d mp so' ea ition of veget lion, tc.) —� CESSPOOLS: , (locate on site plant Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: - Materials of construction: Indication of groundwater: r. 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:_ (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.) revised 9/2/98 * Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ''roperty Address: Iwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i 2 i i L� A1- iS A1-- i Ll,("I ft3- \.\G �3 a72 14 reise 9/2/9 Page v' d 8 a 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: Owner: a Date of Inspection: NRCS Report name ` Soil Type_ Typical depth to groundwater v. USGS Date website visited Observation Wells checked Groundwater depth: Shall-low, Moderate Deep SITE EXAM Slope Surface water t./(, Check Cellar Shallow wells &>1 L Feet ed De pth th to Groundwater. EsUmat p _ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc:) Determined from local conditions 1 Checked with local Board of health Checked FEMA Maps „ Checked pumping records: Checked local excavators, installers Used USGS Data `• (Must be completed) � • l Describe how you established the High Groundwater Elevation (M D Y aw revised 9/2/98 Page 11of11 y.. r LOCATION SEWAGE PERMIT NO. s - VILLAGE 0.7 /lY INSTA LLER;S NAME i ADD ES 0 i 3 U I l 0 E R OR OW7 ER DA T E PERMIT ISSUED DAT E COMPLIANCE ISSUED O cr� o �` � W �\ f N4.. ............. Fim.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ...`.ate- . .. ................OF.---., Allpfiration for Uispoiial Works TomarjArtion Urrutit Application is hereby made for a Permit to Construct (D<) or Repair an Individual Sewage Disposal system t- A---4.. .......... .... ................... ........ 7....... ........................................ -------------------------- Loc drMrl— r Lot No. ..... ... .................................... ............................. Y4".... J---------- ......44w,&. ............................................... es..... ............ ............. ........................................................... ......... Installer Address Type of Building Size Lot_djQv..Ig�.....Sq. feet U Dwelling—No. of Bedroo ......................Expansion Attic Garbage Grinder PL4 Other—Type of Building ... No. of persons.........V------------- Showers Cafeteria 04 Other fix es ........................................................................................................................................................t <� OL Design Flow......._ ...........................gallons per person per day. Total daily flow----J-4p._---O ------....................gallons. 1:4 Septic Tank—Liquid capacity/ gallons Lengthrw!... Width..4'19 ................ Depth_............... W Disposal Trench—No. .................... Width ............... Total Length___...._.__......... Total leaching area....................sq. ft. Seepage Pit No______/---------- Diameter..... Depth below inlet...*..�........ Total leaching area,_r4A.1__.'_sq. ft. Z Other Distribution box (/) Dosing to ( ) 'Percolation Test Results Performed by A . ...... ..................... Date_�O! "-&!I.,,.... 5 Test Pit No. I................minutes per inch Depth of Test Pit_._..........._____. Depth to ground water. 4q Test Pit No. 2................minutes per inch Depth of Test Pit___................. Depth to ground water. ......r�L-A 9 ............................................................................................................................................................. 0 Description of Soil.........A................ --------------------------------------------- ------*---------------- ........................................ ..........�. ........................................................................................................................ U --------------------------------------------------------------------------------------------------------............................................................................................... 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'LILIL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been * ued by t bo d of I Ith. I ................ 2S19 . . . .............. ................................ 0T. .............. Date t 4"�... ................... ..... Application Approved By....... r_.o_4Kjr.... .. ......... ...... ------ Date Application Disapproved for the following reasons:............................................................................................................... ......................................................................................................................................................................................................... Date ...............................................Permit No......................................................... Issued......Y 2—j—A",I Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........ ...........: ,Apure#inn for Dispnstal Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal system t .... .: ........................ . ---_--•-- ----------- --------------------------------------••• Location- f dress or Lot No. Or• , j Address 72 - ./trSf fr - ����L I ------••-•----•---•---•--------------- - ----� � :_ �--•- - -•--Addres- ----s... ___ .------.. _-------•------_____------•- � nstaller UType of Building Size Lot___ f.. .....Sq. feet �, Dwelling—No. of Bedrooms.............:..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building-/ f.r' ........ No. of persons.........!� ............ Showers ( ) — Cafeteria ( ) Otherfixtgres ..................... ......••-•--•-•--•.... .........•-••-----•••••-•-••••-••--•-••-•••••••••-•--•-••-••-••••-•••-•-•-•-•.........-••--......---- W Design Flow...........'5:�..........................gallons per person per day. Total daily flow----- _,2.:�:©_.........................gallons. WSeptic Tank—Liquid capacity 4".gallons Length?�'._��''___ Width.. N. Diameter........:....... Depth................ x Disposal Trench—No..................... Width............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.....0.......... Depth below inlet._,l__1....... Total leaching area..fl' -sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by......_..�i��.`9s rG..t..': Cr......... ��� W - ------------------ Date-----� ----f......... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water?!!!�,2_--�. f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.?../-l.___._... a •-•--•--•-•••---•--•••-•-•••-•---•••----••••-•---•-•---•----••-•...................••-----------•-----•--•--•---•-•••-•••-•••••--........................... O Description of Soil....... n s'.......... -----•-•----------------------------------•-----------------•---------•-•-••.........•--------•- U � g - � W x ••-•-•••--------------------------••---•-------•••------------••-----•-•----••----•----•-••---•••••. .................................................................................................. 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the'bo�a'rd 6f health. •--------••--------------- ------ -----..... Date Application Approved By....... r ....• .. . � Date Application Disapproved for the following reasons_____________________ ....................•---•••••......••....•-----......-•---•............ ••...._....-- r ..................... _... Date PermitNo...............................................--------•--- Issued................................................... Date THE,..COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. -! .........O F.... A ?.c . +11 lr .—. .......................................... Trrtifirttr of TnntvliFan r THIS IS TO-C-E'RTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( ) by -------------- J�,�,� Install at.•--�.----==----••.•-•-: ------------------'�-f.'::�•------------------------•-----------•-----------------•---- --------------------------- has been installed in accordance with the provisions of T 5 o The State Sanitary Code as described in the P Y application for Disposal Works Construction Permit �'o._ ___.__'1��1x-------------- dated--".'__7''e.,r-"`r.9._...._________. w THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL 7_FUNCTION A TISFACTORY. DAT __..._..... .. Inspector... ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7y `CC OF...-----&_ !:111 _. ...................... No.................d•'•- FEE...X...........:... Permission a hereby granted_.. ...........................................----------- ----- .._._.. - ��/ to Construct (X or Repair ( ) an, Individual Sewage Disposa[lysem t ' $/j 1 at No.•••• .... ✓r-° ry -1 L/� = ' t th' ! G _ , _.._._._.__._._..._•_•___•__ .................. .. ..... ............................................ ...................... Street y� as shown on the application for Disposal works Construction Permi No-------............. ............ vjvc Board of alth DATE....... " J7 FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 1p F-i N GSM GrAr ae.4 V or _ --�- - 1, � OvC+t TiF N�'C _ G l�tS O✓FI[ /��T � ��ifl TOP o/�F�e v Iry• 1 ' 4"C Z. IQW4~ ..wA�s Q�Kl�csi�L t7 rvQ"IN G 17 00 1 , . 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