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HomeMy WebLinkAbout0012 OAK STREET - Health 12 Oak Street COtlilt A' 018 - 028 I V z Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is Cotuit MA 02535 A 20 required for April , 2009 every 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: A. General Information When filling out G forms on the I �� computer,use P 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name +� 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority April 20, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposa System•Page 1 of 17 1 Commonwealth of Massachusetts N u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20, 2009 every 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form j _a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is Cotuit MA 02535 Aril 20, 2009 required for p ' every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 0 Commonwealth of Massachusetts H - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is .Cotuit MA 02535 required for April 20, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. h i k A n h A i less than 100 feet but 50 feet or ❑ The system as a septic tan and SAS and the SAS s a more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 '/z day flow t5ins-09/08 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 ,M 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is Cotuit MA 02535. April required for pil 20, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No - ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r l Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham, Owner Owner's Name information is required for Cotuit MA 02535 April 20, 2009 every 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® 0 Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3-4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L_ Commonwealth of Massachusetts W B.Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20, 2009 every page. City/Town State Zip Code Date of Inspection D. System:Information • Description: Number-of current residents: Does residence,have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry.system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 years usa e d 290 gpd Detail: 2007-2008 Sump pump? ❑ Yes ® No Last date of occupancy: current ° - Date Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR-15..203)` Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present?Y ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ' t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20, 2009 every 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is Cotuit MA 02535 Aril 20, 2009 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,"date installed (if known) and source of information: Age: 2+years. Certificate of compliance for repair issued 5/17/06 (Permit#2006-225) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: " ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 6 ft x 5 ft(1000 gallon) Sludge depth: 4 in t5ins"09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top 9 of sludge to bottom of outlet tee or baffle 30 in Scum thickness 3 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is Cotuit MA 02535 April 20 2009 required for p every 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20, 2009 every 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into the leaching gallery. 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 pump s and appurtenances, etc.). Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name, information is Cotuit MA 02535 Aril 20, 2009 required for P every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑, innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into the leaching gallery. 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-09/08 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 w 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20, 2009 every 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 ❑ 9 p Y LOCATIONS LEACHING a GALLERY A B 1 18ft 23.5Ft- 3o D-BOX 2 23 f t- 27.5 f t SEPTIC za 3 21 FL 33 Ft- TANK o t GARAGE A B EXISTING DWELLING WATER LINE # 12 OAK STREET NOT TO SCALE t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is required for Cotuit MA 02535 April 20 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ 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: 5/15/06 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: Approved design plan on file with the Board of Health shows bottom of system to be 5.28 feet above the bottom of a test pit in which no water or mottling was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Oak Street Property Address Kieth and Mary Farnham Owner Owner's Name information is Cotuit MA 02535 Aril 20 2009 required for P every page. Citylrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J N r. a � Lo O u v� 0 o Uct.J� U t N N o v $TNT 'Z--oo 4-5 �. u LIU J Zi �` o J Zz v Town of Barnstable o Regulatory Services • Thomas F. Geiler,Director *: BARxsABLE, • '�b,�E a• Public Health Division. Thomas McKean,Director 200 Main Street, Hyannis,.MA 02601 Office:. 508-862-4644. Fax:..508-790-6304 October 4, 2006 Mr Armando.DeCarolis. 41.Juniper Hill East Sandwich,MA 02537 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,Title 5 _. The septic system owned by you located 12 Oak Street, Cotuit,MA was last inspected April l Oth 2006 by,Robert A..Paolini, a certified septic inspector for the.State.of Massachusetts. The inspection of your septic.system showed that your system"Failed"under the guidelines of 1995 TITLE 5.(310 CMR 15.00) due to the following: Septic system is not structurally sound. You have 2 years.from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to.contact the Barnstable. Health Department. BANSTA.BLE HEAL H DEPARTMENT M s AcKean, . R.S., C.H.O.. Agent of the Board of Health l sue+ 1 1'6` • S\ " ♦ Ij�r °•'r „ / tai, w '� l" Q�, 'w. ♦'°' .*,. 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"F Ak �t;,.�;,Tr..� < a --.*'• � ..� •_""`. i �'..f�.',A."•• t� t. �,�, -;f!'.��� , r. y�1�.ya i �+G,Y� r�, .f"". °��t a ,..yam R � `v-74' i.., qr s.r' .+ „�.; f ,�4a '�j.M:.�'* �'r• '.t `' - Kyi: t1' ts"":1 �'S.^�, , ?+ i_aw."`5 .. . �♦ yr et'�"�,'" - .\'i:�^' J� _ A ' d.\'"�i7��".. i 41 - r h y r+ u ' � r f '�Mn�•k ''''+♦yh �`� K :- ',4"Ja�":'�' 1- ..y t �`a, 7C'..._a�',.",��4- ,;' +. '�.y'Al, •a-sib": '""�3 • �.�f ..� y.R - �' 'h i +w•♦ --..��"��'c`"-.:'"k+�C+'• �,+•+i �'a„11+rr'�. � .. .�` a f; k�+•. ��\ w sj � �, ?1� ,� n'y``. �E�,�+,..�k•-•��;='i1� 3+.�`�9YT.r�.it�1`.'�y�'�� T� .��E,Qq� F-`4 YJ�9'Y.�.A~'•t"Vy -�srv'f`�'rtiJs��: TOWN OF BARNSTABLE 113CAITT_ON, 0Ak S-'x e eP r SEWAGE# X 8 �V!, iAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. ,T A ,4 M t � t .O/� 'r SEPTIC TANK CAPACITY /. 0 n D LEACHING FACILITY:(type) 3- We.L%S. (size) p NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIAi�TCE DATE: 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 leaching facility) _ Feet FURNISHED BY i i —sa roo, , IQk '', Ju on 16 ` L S,T :. f nn No. V t i Fee THE COMMOI VI EALTH OF MASSACHUSETTS Entered in computer: es Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Apphratiou for Migpogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(N Upgrade( )Abandon( ) [3 Complete System 'individual Components Location Address or Lot No. la DQ ' Owner's Name,Address and TSJ.No. Is"IP Assessor's Map/Parcel Cep 'V Installer's Name,Address,and Tel.No. (5�7 775-5331 Designer's Name,Address and Tel.Noc� 34a`agDA ff)oao^''WwlbV- o.N4 ion Q�l" � ,W x ff�, Type of Building: Dwelling No.of Bedrooms of Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 gallons per day. Calculated daily flow 33 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. A—D UVJ Description of Soil Nature of Repairs or Alterations(Answer when a plicable)©y711T LSJCkt,Y A 2.+ Y1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue t i_ Bo �f�Health. Signed Date Application Approved by v Date Application Disapproved forte following reasons Permit No. 2.U0 6 — 2 2:< Date Issued —��'L u rz w . - 0 a No. Q 14 Fee ,- THE COMMONWEALTH OF MASSACHUSETTS �i Entered in computer: PUBLIC HEALTH9I-VISION - TOWN OF`BAR-NSTABLE MASSACHUSETTS Yes ti3pplication for Digaal 6p.5tem QCon5truction Permit ` Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System`NQ Individual Components Location Address or Lot No. Ja, ©ok Owner's Name,Address and Tel.No. Assessor's Map/Parcel t C.f)�-il to .�i Installer's Name,Address,and Tel.No. (5016) ]"] �?� Designer,s'Na�me;�Address and Tel.N0150�6)5(A—9,9 ►i n tan t .�] ? C*,Yl th 1(I�t (09 r Type of Building: Dwelling No. of Bedrooms �00 �ot Size sq.ft. `Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ?'k C) gallons per day. Calculated daily flow_._?, }. gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank !go Type of S.A.S. Q--D,-tjW Description of Soil: i ' Nature of Repairs or Alterations(Answer when applicable) nnt t L j,,Sa C4't,.t'#1 r: Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thisJBoar.d-o f Health. ` Signed 1, �ia�Zl" / Date Application Approved by r/ ,fin, v �.� S Date Application Disapproved fhe following reasons a� Permit No. '7 llll e r 2 Date Issued . ---------------------------=----------- �THE COMMONWEA,LTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) ^t Abandoned( )by Si�,l�lcyrnmk;r nYir� �a'rar► 'rnc , at to & � C r4-, ),t r- rVin, . has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q OOA —. ?Q ated !�=r,�7-OA , Installer S2pJr-)A t 4-RA ct(t x a Designer i)e 1 r—VYl M P.tl9 K' The issuance of this permit shall not be coa trued as a guarantee that th .syseml l -cncc �i-a-'s-,de�siigned..Date Inspet � No.z �)/� ���! Fee ) �' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligpo.5ar *pgtem Cow6truction Permit Permission is hereby granted to Construct( )Repair(' )Upgrade( )Abandon( ) System located at ! k, A_� rnir L#` On r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this-permit. Date:_-�i/� _ Approved by Town of Barnstable oF e rtic ]regulatory Services Thomas F. Geiler,Director � BARl!iS�Y�BEE, � a Public Health Division $ tide aFFp. a Thomas McKean,Director 200 lain Street,Hyannis,MA 02601: Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: ZZ p4f4-e--ell Designer: Gt;�rP� Installer: Address: . Address: ?9 gam' On p 5 In ?an".I was issued a permit to install a (date) (installer) septic system at l 0 AX Sl-, (OT t T N,based on a design drawn by (address) dated ��• (designer) J certify that the septic system referenced above was installed substantially according to the design, which may include minor approved-changes-such as lateral relocation of the distribution box and/or septic tank- .. X I certify that the septic system referenced above was installed with major changes q' e. than 10' lateral relocation of the SAS r greater. o any vertical relocation of any component of the septic system)but in accordance with State �.& oca1_Reoe�?,ho��• p�„wr. ;o.,;,,• ie certified as-built by designer to follow. a w d RA0. E EVEk% ofismef;d Signature) i No. 1140 ::N(Designer's Signature) (Affix Designer's.Stamp Here) 0 PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CQWLIANCE WII;I, NOT BE ISSUED UNTIE, BOTH THIS FORM AND AS- BUILT CARS ARE RECEIVED BY THE B2NSTA$LE PUBLIC HEALTH`DIVISIOI�T. THANK YOU. Q:Health/Septic/DesignerCertification Form th 1 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I,)A-WA ,hereby certify that the engineered plan signed by me dated l�fl't/ (Q, � ,concerning the property located at 1-2, OA-K' /T ZEE 1 COPij- * meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: v A) Top of Ground Surface Elevation(using GIS information) �-I B) G.W. Elevation +adjustment for high G.W. = N J4 DIFFERENCE BETWEEN A and B JV SIGNED DATE: 0-5111(, dfp J NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc ! Town of Barnstable ,r ... . FtHE Tp Regulatory Services * rAs Thomas F. Geiler,Director BAMS9�A 63 A1� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,.MA 02601 Office:. 508-862-4644. Fax:..508-790-6304 October 4, 2006. Mr Armando DeCarolis 41 Juniper Hill East Sandwich,.NIA.02537 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,Title 5 The septic system owned by you located 12 Oak Street, Cotuit,MA was last inspected April 10`h 2006 by,Robert A..Paolini, a certified septic inspector for the.State.of Massachusetts. The inspection of your septic system showed that your system"Failed"under the guidelines of 1995 TITLE 5.(310 CMR 15.00) due to the following:. Septic system is not structurally sound. You have.2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to.contact the Barnstable. Health Department. BARNSTABLE HEAL H DEPARTMENT. Tho as A..McKean, R.S.,C.H.O.. Agent of the Board of Health - I it a� -J DATE 4/10/06 PROPERTY ADDRESS 12 oak street D Cotuit MA 02635 On the above date, the septic system at the address above was Inspected. This system consists of the following: �. 1- 1000 ya e eon zept.ic. tanlc.� 2.� 1- Dizbt.igut.ion aox.� 3., 1-41W ce zpooi made. o-� &undat.ion P.-Oocks., Based on inspection, I certify the following conditions: 4. 7h.i,6 .iz a 7.it ie Five 6pet.ic zystem (78.Code) 4. Sept.ic zyztem .ins .in &i euae due to the fact cez.6/2oo e .iz a2moht ,. &.Pj 9 iz not htauctulta.22y •sound. SIGNATUR � � - Name: Robert_A. Paolini C-, Company: Joseph P Macomber & Son Inc-. Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775.3338 or 508-775-6412 JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & .Installed Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775.6412 • f 7 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICY OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: 12 Oak Street Cotuit MA 02635 Owner's Name: Armando DeCarol i s Owner's Address: Sam Date of Inspection: 4.11 a.1 Name of Inspector: (please print) Robe,r A Paolini Company Name: -j, / (7a c o M 9, ,� .S:o.n Inc. Mailing Address: /3 n y 66 Cen eavc e, uzz.-02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the,sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in:the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section.15:340 of Title 5(310 CMR 15:000). The system: Passes Conditionally Passes Need her Evaluation by the Local Approving Authority XXXFa' Inspector's Signature. Date: b� The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspectlon and under the conditions of use at that ~'. time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART A CERTIFICATION(continued) : Property Address: 12 Oak Street Cotuit MA _02635 Owner: Armanrin peraral i c Date of Inspection: 4.43 0.406 Inspection Summary: Check A,B,C,D or.E/ALWAV'Stomplete all of Section:D A. System Passes:Nd q RS I have nafound any information which indieates'thaf any of the failure criteria described in 3I0 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Seytem .ih .in /iaivae B. System Conditionally Passes: NO One or more system components.as described in the"Conditional.Pass".section need to be.replaced.or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic tank is metal and.over 20 years old*or the septic tank(whether metal or:not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is.imminent.System will pass inspection if the existing tank is replaced with a complying septic tank,;as approved by the.Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: No- Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box.System will pass inspection•.if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled"or replaced ND explain: No The system requited pumping more than 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 Oak Street Cotuit MA 02635 Owner: Armando DeCarol i s Date of Inspection: 4/1 0/0 6 C. Further Evaluation is Required by the Board of Health: NO 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. A. 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: no Cesspool or privy is within 50 feet of a surface water n o Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: 110 The system has aseptic 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. rzoThe system has a septic tank and SAS and the:SAS is within a Zone I of a public water supply. n o The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. n o The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frohl a private water supply well". Method used to determine distance vizaa e "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11, OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r' . PART A CERTIFICATION(continued) Property Address: 12 Oak Street Cotuit MA 02635 Owner: Armando DeCarolia Date of Inspection: 411 al()6 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 X Static liquid level in the distribution box above outlet.invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available,volume is less than'h•day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1,of a.public well.. Any portion of a cesspool or privy is within 50 feet of a private water supply well. -v Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from.that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forT.] q6S (Yes/No)The system fails.I have determined that one or more.of the above failure:criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a:facility with a design flow of 10,000 gpd to 15,000. gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 n "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 sha11 upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 Oak Street Cotuit. MA 02635 Owner: Armando DeCarolis Date of Inspection: 4/10 f 0 F Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No v Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system_components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the systein obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage.back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered;opened,and the interior.of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of I'1 OFFICIAL WSPECTION FORM--NOT FOR VOLUNTARY ASSESSMIENTS SUBSURFACE SEWAGE.DISPOSAL.SYS'TEM::INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 Oak -.Street Cotuit MA 02635 Owner: Armando DeCarolis Date of Inspection: 4/1 0/0 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms actual : 3 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms). 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system.(yes or no)n o [.if yes separate inspection required] Laundry system inspected(yes or no):n.o ` p -�7 Seasonal use:(yes or no):n o o`1CA`� �d�000 y41�41 G"P Water meter readings,if available(last 2 years usage(gpd))%�I0Q6'5y,.000.LDUflenS �r,d�v '�by Sump pump(yes or no):n o '—� Last date of occupancy:R 2 e z eat COMMERCIAL/ STRIAL Type of estaTW "nt: NIA Design floed on 310 CMR 15.203): �pd Basis of d69i' tow(seats/persons/sgft,etc.):. Grease trap present(yes or no): Industrial waste holding tank.present(yes or no): Non-sanitary waste discharged to the.Title 5 system-(yes or no):_ Water.meter readings,if available: Last date of occupancy/use: . OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: 912104 /2um12 7 ma-in.t ;o P., macomCe2 Was system pumped as part of the inspection(yes or no):n o If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool T Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP,approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1983 aoe Dua�zte Were sewage odors detected when arriving at.the site(yes or no):_aQ 6 Page 7 of I'] OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Oak Street Cotui't MA 02635 Owner: Armando DeCarolis Date of Inspection: .4/1 0/0 6 BUILDING SEWER(locate on site plan) Depth below grade: 3 0" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: 0.�, Comments(on condition of joints,venting,evidence of leakage,etc.): to-in t.3 a .1?ea2 t.iahf ,No innknno Voni ed.—f64a1,ah 4 o u 6 a '>>ent SEPTIC TANK: (locate on site plan) .1000 ga i 2 o a 6 Depth below grade: 2 4" Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_.(attach a copy of certificate) Dimensions: 8' 6"X 5' 8"X4' 1 0" Sludge depth: t 2 a c e Distance from top of sludge to bottom.of outlet tee or baffle: t to ce Scum thickness. taace Distance from top of scum to top of outlet tee or baffle: t eta ce Distance from bottom of scum to bottom of outlet tee or baffle: t to c e How were dimensions determined: mea-suited Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): l umR tank every 2 Inlet outiet tgAA 2av .in ,�pnry . Tank .i s ztauctuaaib/ zound i GREASE TRAP:n o (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): gaea.3e taap .is not paezent 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Oak Street Cotuit MA 02635 Owner: Armando De -a rn 1 i s Date of Inspection: 4110.106 TIGHT or HOLDING TANK: NCI (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass .polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight o2 hoiding tank.6 ate not .snn-f DISTRIBUTION BOX: Y e-s(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 2" 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.): /30x 1-6 ieve2.+ Kays 1 ;a.tegai., Smatf 2mnunt ni An oid No eeaka ge .in o2 put_ n'e O.n r_, PUMP CHAMBER: n o(locate on site plan) Pumps in working order(yes or no): . Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): tLm12 eham9e2 .iz not Rnezent 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Oak Street Cotuit MA 026,35 ` Owner: Armando DeCarolis Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: oca#vd .tvv Xzaa 9n Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: 7-overflow cesspool,number: innovative/altemative system .Type/name of technology: Comments(note condition-of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ^, Loam/ In mvr/ium Aand Soiez aae dny , Tega 'nfinn u-6 nnnmag CESSPOOLS:ye-6 (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: o v e/1 .i n v e a t Depth of solids layer: o Depth of scum layer: 0 Dimensions of cesspool: 4 X 4 Materials of construction: eoun-da.t.ion g io ck 6 Indication of groundwater inflow(yes nr no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Loamy to medium .band., Ce z oo2 .is uE .60un oc .6 ate eooze & c2umUinq 3.torze .is .seeh.ina .in., PRIVY: NO (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l2.ivy .ins not paesen.t 9 C`1 Q of 11 QFFI IAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C r� SYSTEM INFORMATION(continued) ddress: 12 Oak Street �e�rty A 7rf _ Cotuit MA 02635 Armando DeCarolis oh .-spection: 4/1 0/0 6 CH 4 SEWAGE DISPOSAL SYSTEM v ' a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or 4 , chiriarks.Locate all wells within 100 feet.Locate where public water supply enters the building. fi u^y uy F 3 W TI 10 I V4i, art• .. ..`„ r Page 11of11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: .12 Oak Street o ui Owner: Armando DeCarolis Date of Inspection: 4/1 0/ A SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: .NO Obtained from system design plans on record-If checked,date of design plan reviewed: y e.6Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explaima i 9.U.L.P.t r ri 2 d no Checked with local excavators,installers-(attach documentation) yez Accessed USGS database-explainA;t i/2 r t o wn.'&a a n,6�-a g i e.,m a.,u.3 You must describe how you established the high ground water elevation: 11.sed. : Cape Cod Commzz on Yatea 7agie Cori.touah 4nd %ugiic I.datea Sul2piy Ueii head Raoteet.ion aaeaz map., Sept 1995 �atea aehouacez o O-Dice cage cod comm.cz.'on 1 Top of C;rouffr Leaching Pit �'. ;eet Groundwate ' Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Z Therefore,the vertical separation distance between the bottQ of the leaching pit and the adjusted groundwater table is I� feet. n 11 „ J . .�rrran�wn�r •rrrrnrn rwrrR+'r'rarnn�anren+wr�••nri a JRrlll'!7i!!i•,r”"•�' 'DOWN OF B.^6,�$BL,E� WARD QF 11RAIT11 _011SURFACR SEWAOR DISPOSAL SYSTEM INSPECTION FORM - PART D., CERTIFICAT-10N «•amp•r••.n:a••e+„gMtitTlllRrfnr•rrn*rTSRs ►1ft11t'r17'�AO � �'wr••r• -TYPE OA PAINT 01,90bY- PROPERTY rOPECTED STREET ADDRESS 12. Oak Street Cotuit 0263.5 ' ASSESSORS MAP BLWK AND 'PARCEL OWNER's NAME Armando-end rrj 1 ; c PAIiT'.' D 0EIiTIFI0ATX0N NAME 'OF 'INSPECTOR Ro 8 e.� P.aobn i oae h :n.� Macomrle�� Son Inc COMPANY NAME a /�_ Box 66 Cen ea�.i2�e Oa.sb' 026.32 ' COMPANY AUD .RSS �t a Town-or City - StaL� L!P COMPANY TELEPHONE ( 508. )' �7.5 ' 3338 -PAX 1' 508 JI90 f578 . QERT•ITICATION. STATEMENT ' I certify that. I have persohally .inapected ••the sewage 'dioposal. S.Votem at this address and that. -tiro hat -tiro inrormation reported .is true,. accUra-te•, grid omplete as of the time ..af•inspection,►• The inspection was performed and any recommendations regarding Upgrade-,' .ma•intenance l* abd repair .are. oonnis'tent with my trainip,g and exP.erience in the proper fuhcti'on' and maintenance of on- site sewage d$sposal systems. Check one; :s ' Systeo PAS92D The inspection which •I have .•conducted has .,n•at found any information . which indicates that the system fails to ' adequately. protect .publi•e health or the enviropment as defined in' .310 CMR. 15' 30.3', Any failure criteria riot •evaluatbd are as stated in the FAI'LUIM CRI'PE•RIA .seetion o•f this, form. System FAILED* The i.nspectioh which I have pan 'ted 'hag '•found that the System fails to protect the public health and the envAronmen•t ' in acvo'rdanee with Title 61 310 CMR 15 . 303oan�.,da pecifically. noted -on -PART' C -►. FAILURE CRITERIA of this '.form. Inspector Signature' 'Date ' .rs.r ne copy of this eex•tl f ioAt•i'otl must -he rovided 'to : the •QWNhR•, t�ht. BUYER where appli:owble) and tht DQARD OV HEA TII. * It the inspection FAILED,, thv .6wner' .9r' 9pexator •e.hall upg•r�ade'•the system. within one year of the date of the inspection, unless, allowed Qr• req tt ,rerd n t.hArw{se as Provided iz q;10 CMIi 16 , 306 1. . No. 3 Fee THE COMMONWEALTH OF MASSACHU SETTS= Entered in computer: ..PUBLIC HEALTH DIV SION - TOWN 01`� BARNSTABLE, MASSACHUSETTS Yes Rpplicatiou for �Btgozal :�Pp.5tem Cottgtructton Permit Application for a Permit to Construct,. )/>Repair( ) Upgrade( ) Abandon( ) ❑ Complete System PQ Individual Components Location Addressor Lot No. �� � `S Co i'� Owner's Islame,Address,and Tel.No. Assessor's Map/Parcel LyHvLI Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: •�� 36�� 02 42-L._ Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alte/r�tions( wer when applicable 4o�( �� G ?� SI i r_ CC K;Z tr �n c 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 En ronm tal ode and not to place the system in operation until a Certificate of Compliance has been issued by t is B ar e Signe Date p- Application Approved by �� Date O d W_ Application'Disapprove b Date for the following reasons p r Permit No. r 3 Date Issued 0 U(p 960Get Fee ,. Entered in computer: ✓� THE COMMONWEALTH OF MASSACHUSETxTS�.,� p _ PUBLIC HEALTH DIV►SIG TOWN Q?BARNSTABLE, MASSACHUSETTS Yes i op "cation for �Dizpogar *p5tem Cow5truction Permit Application for a Permit to Construct) Repair( Upgrade O Abandon O ❑ Complete System LXIndividual Components' Location Address or Lot No. �� Q12I� 5 , �7�f,� Owner's Name,Address,and Tel.No. // ©�� G�a2 � ��! / / c t✓<i awe ? t / Assessor's Map/Parcel 44-1 S" iLL Installer's Name,Address,and Tel.No. — Designer's Name,Address and Tel.No. Type of Building: Jra C- 9, n Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other I Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title ' Size of Septic Tank Type of S.A.S. Description ofjSoil Nature of Repairs or Alter tions( swer when applicable c•c--1 7-1-0 _ S7�/'7. L 41 y r T P c190,06 -r 2 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 E y1ronmental ode and not to place the system in operation until a Certificate of Compliance has been issued by this Bo&rdt^ -14eealth-.' Sign r ✓ d v Date Application Approved by �P/• �- Date Application Disapprove Date for the following-reasons ! l X Permit No. aGo(, 3 Date Issued ya _ __. -------------------------------- ------------ - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (k ) Repaired ( ) Upgraded ( ) Abandoned( )by / s. at I:? 00n S o�� has been/constructed in accordance p with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 DUb dated p L� U�n• Installer Designer #bedrooms Approved design flow �o gpd The issuance of this permit shall ( not be construed as a guarantee that the system will functio, as d si mod+ Date ( Inspector No. (y0 t0 3 t Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS wizpoal *p!9tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located atx 7!s�- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Cones' [cctt10A must be completed within three years of the date of this ermit. Date D l/ U Approved by r u3 F L0'CATION SEWAGE PERMIT NO. ogk d J i pa w ,PILLAGE INSTALLER'S NAME i ADDRESS J o��� S D v�►af� �? _ /°JgRST.✓ /�i�/s /rly. .. cry G U I L D E R OR OWNER - AR n',»Mdo . Oc 1'.4 rt a A ' TR Gin WeitT4 O DA T E PERMIT ISSU E D DATE COMPLIANCE ,ISSUED ,I i I �F r • T 4 p, ,f�d� /... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ' O �� �"..: .... .. ..: ...........OF......... B... . .................. O �� plirtttion fur Disposal Vurk Tonstrurtion runtit pplication is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----•------•----•--_.... ----------------------------•----------.•...... .......... q� Location-Address , or Lot No. Own Address W Installer Address Type of Bui ing Size Lot.... 49!qj...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) per•, Other—Type. of Building .21L/f./j11YONo. of persons.........4............... Showers (' ) — Cafeteria ( ) Other fixtures .. -�---•-.'�` �t' ---------:................................................................ W Design Flow.........; . .........................gallons per person per day. Total daily flow...........Z.A".4 ..................gallons. WSeptic Tank—Liquid capacity/0-0 allons Length-...,Y....... Width. _... Diameter................ Depth................ x Disposal Trench—No. .................... Width................... Total Length..............:.. Total leaching area.................... ft. Seepage Pit No........,�.......... Diameter........4.__..... Depth below inlet................ Total leaching area...�.I Y.sq. ft. Z Other Distribution box (�(') Dosing tank ( ) J Percolation Test Results, Performed by.... /'z� 1 Y�,d�. ........... Date......4... Test Pit No. 1____ ______minutes per inch Depth of Test Pit-----JP__7.... Depth to ground water_____ ® 44 Test Pit No. 2.....�_---•minutes per inch Depth of Test Pit....J..A........ Depth to ground water-----/Y0. Y a • ....-•-•-•-•------------•----••-----••--------•--........•---•--•-•.........................•....----...--•-•--•---••........_-------•-.e.................._. O Description of Soil.........td-//.......... ....................../©/ af----- ......-....%ram iD_.. x W UNature of Repairs or Alterations—Answer when applicable..................................................................:....:........................ •••----••-•--••---••----•••-••--.......•-••--•---•----•-•------•--••--•-•-•----••-•-------------•---••-•------------------------•----•----••----•------------••--••••--=-•••••............-----••.•..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. Signed d ! `r �./- ... 4� ._ ate Application Appr v d By.._-•--. •°--` - ... ... f ------------------ Date Application Disapproved for the following:reasons-................................................. .............................................................. .................•-••----•-------•--•------•---•------------•-----....-•------.......------.....--•--------••-•---•-•----•-------•------•-•-•-••-------•-------- ............................... Date PermitNo......................................................... Issued....................................................... Date a No..... .r�.. ------ = F�s....-��.- < ..........._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -! .. _W.-Y...........OF.......... .A.I.S .0_4.'d .................. Appliration for Diopoiial Workii Tow5trnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at • .......--•----------------------------•---•••-••••-•••••-•- r _ Location-Address or Lot No. OwneF ,.' Address a — -•----------•---•-•----••-----•-•••--- ---------------- ........ ..............••-------- ._..._............. Installer Address dType of BuitPing Size Lot..... ...�g4...Sq. feet U Dwelling—No. of Bedrooms_________________...........___ _Expansion Attic ( ) Garbage Grinder ( ) 04 . Other—Type of Building- , t,?__j_hVallo. of persons.........A_______________ Showers Cafeteria (. ) dOther fixtures a ...............-4 J Z ✓ "s............................................................................ W Design' Flow......... ' ________ __________gallons per person per day. Total dailv flow----------- _ , ................gallons. WSeptic Tank—Liquid 14 capacity, ��gallons Length__.__..____ Width,_ Diameter................ Depth___......... x Disposal Trench—No_ ____________________ Width........ ._........ Total Length...._............... Total leaching area.........._..........sq. ft. Seepage Pit No.__.__._I---------- Diameter........l!........ Depth below inlet........ Total leaching area__ _1.41.sq. ft. Z Other Distribution box (, ) Dosing tank ( ). Percolation Test Results Performed by....__ f( , „ _ .......... M.B_S. Date.......4__1A. ,,�v_ Test Pit No. 1____At __minutes per mch . Depth of Test Pit Z � _ Depth to ground water AfOA� (s, Test Pit No. 2_____X.....minutes per inch Depth of Test Pit__._-/A......... Depth to ground water-----/a � P4 ..------•--------------------------------------------------•---......---------------......---................_....._._......._....-•------------- --- O Description of-Soil 1� ', d?.l..,L........ - -'�---- ° ........... W UNature of Repairs or Alterations—Answer when applicable.................................................................................................. •---------------------------•---•-------------------------...-----------------•--------••-._.......----•-•--•----•------------••-----•------•---------------------------------•--•-•----.......••--•-_.. Agreement The undersigned agrees to install,the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate �p/moo\fJfCompliance has beeg issued by the board of health . V JV" 4 1 _______"__•_ Signed _._ -_--•, Da te Application Appyvd Y----_--... ✓ .:-- '-- .................. . �> .. "Date Application Disapproved for the following reasons---------------••---------------•----•-------.................................................................... ------------------------................................................................................-------------------------------------------------------------------------------------------•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ' HEALTH ..........................................OF..................................................................................... Trrfifirab of TautpliFatta THIS IS TO CERT Y, Thy the Indiv ual Sewage Disposal System constructed ( ) or Repaired ( ) by----------------------------- �. �,�•.r-----•------ ...........--........................................................................................................ Instal has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ........... dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SI4ALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL FU CTION SATISFACTORY. DATE......11 ................................................. Inspector.... .. ---------------------•-----------------------------•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.g ...........................................OF...................................................................................... _....... . t ... FEE._._: $ Ropooat or ion udioat anti# Permission is hereby granted............. ... to Construct ( - or Repa�� ) an I >vidual Sewage Disposal System at No........ ; -ate^ r n Street as shown on the application for Disposal Works Construction_Px_ xmit No..................... Pated.......................................... ...................................... �� Board of Health DATE................ �•- .-•................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS No......................... FEic............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ......... ........... . -..._..-.._OF.-....-...--....--....-..-._........_....----•-----.....-•--------------.........__....._. Appliratioat for DhipmFal Workii Tomitrurtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ --••-•---•--••-•---•••-•••-•--•-••---....•••-•---•---•••-••...-•----------•-•-••----••.........--- Location-Address or Lot No. ......................-.......................................................................... -•._...._...._...•-•-•--••-•-•-•---........------...-•--•---•••••-............................._.. Owner Address W Installer Address Q Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms________________________________ _____Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building _______________ No. of ersons_._._.___.______._._.___.._. Showers — Cafeteria Pa YP g ------------- P ( ) ( ) a' Other fixtures ---------------------------•---• - Q --------------------------------•------ 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........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------------------•-----------------•--•__--•-•••--•------------------------------•----•----- •----------------------- ODescription of Soil........................................................................................................................................................................ x - - V .....-•------•---•--•••-•-•-••••-•-----•--...-•-..__.._..-•••---•---•------•--......-•----------•••-•--•-•---••------•------•-•--•--•----•••-••••--------•---•••-••-•--•..................•--•-•---_----- W VNature 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 TITLi, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ........................... Date ApplicationApproved By....................--•••--•-•-•-------•-.........•-----•-•----•---•---•-•••--•-••---••--•------- .....................--•-................ Date Application Disapproved for the following reasons:................................................................................................................ •---.....-•---•-----•----...-•--------------•------------._...------------•-------...---------•---------------------•--------•-----•--•-----••-••----••-••-----•----.................................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.................................................................................... CwrrtifirFate of Tootph attrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System'constructed ( ) or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at....................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_......................................... _.._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ ' Inspector................................................................................... t- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................................... No..................:...... FEE........................ Disposal Workii Tott11 U Vamit Permission is hereby granted................................................................................................ --••..._..._...-----•----...._.............. to Construct ( ) or.Repair ( ) an Individual Sewage Disposal System atNo...........................................................................................................................Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •--------------••-•-•---------•----••----•-•----•••---------------•-•------.....•-------•-••-••-•-..- DATE................................................................................-••••- Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a No......................... 7 ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........................................-----------.......---••--------••--------•---..... Appliration for Dhipas al Workii Towitrurtion Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ •.....---------•-•-••••--.....-•-•----••-••------...........-----------•-••----•.-..............•. Location-Address or Lot No. ......................--.......................................................................... ................................................................................................. Owner Address W Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures --------•-----•-•-•---•-•-•••••• - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.........--.gallons Length................ Width................ Diameter---------------- Depth................ 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........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.--.--.....--....... Depth to ground water-----------.--.------ Test Pit No. 2................minutes per inch Depth of Test Pit.--................. Depth to ground water........................ •-••------••-----------•--••••-•-••••......-••••...•••-•-----•----••--•..............•--••-----.............................................................. ODescription of Soil........................................................................................................................................................................ x U --------------------- •------------------------------------------------ .. -------------------------------------------------- •------------------------------------ ........-----•----------------- W •••••••---••-------•....•------------------•----•••----•-•-•-••-•--•-•---•-•----•--•-•--•-••••-•••-----••••--•••--------••-----•-•••-•--••-•--•-•--••••-•--•••----••••••••••••--•--•-••-••............-- VNature of Repairs or Alterations—Answer when applicable---------...................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....................•-•------------•---...---•-•-------------••-----------••-•......-- ................................ Date ApplicationApproved By................................................................................................... ........................................ Date Application Disapproved for the following reasons:................................................................................................................ .....--••--•--•-•---•---•-•----•••---••••••••••--•-•••-----•--•-----•-••-------•••--....----•---•--•---.........--•••--•---•-•••----•-••----•---•--•-••-•----••--••---•-•------••----•---•--•••---------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......:........I....................OF..................................................................................... TertifirFate of Tootpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at..................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-....---.------..--,---------.---................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................•-•---••--•-----•--. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................O F..------•----------.................................................................. No......................... FEE........................ Disposal Works T-Fon,strurtion eranit . Permissionis hereby granted......................-----•--...............--•••----•••••••-••-•---•-•--•••-•••-•-••••----•••••••............-••-••......•--••............ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo................................................................................................................................................................................................. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ••..............•--•-----•-••---•••••••••----•----------•-•--•••••-----•-----•••--•••-----.........----- Board of Health DATE............................................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 8PoS,9 T,LI)Al \,\ OF M �� 9 Dre lemvvUD ZEECf 'e4415 o THOMAs W• �^ MORRIS ti No. 610 CQ TU.iT c) RFC/STE��O . 1/• sgNITAR�P� b y _._ 01 LMING-TON VW5.5 kl�,cs hlo AIL oo,c o ��s d DA V✓ —lot Rea 25 21 3 B. 24' �WFLuaG 77 13 4; 1 46 To kZ>E 6 F 7c,y qT &FG/NN/NG 3 \9 s OF 41E>,�AN,j �-- q� k. :r JO/i- / Z5 / �/iT4 EL 44 EL 3 T�:-S> -PgTE /8. %oP4� W17'NG55,' ;F �5/FfrLIZD SUBS o i L TES j P/T ¢® P S ,Syf>2� SANS SfH�IiPAND � .� To /2'0 /Z p Tz) /2-o PEA 2c R,97"E.' <' 2414111W /✓b wWTE2. 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' -�,0 "' x °' kr p}pF �s � r .� 715 .. - -. 0 - JZ� , N s 1 zyg' i Ob 75 OVY a ZVr 6 � g9P gi'I � s c 1 SHE11 a 3 ASSESSORS MAP : j ��Y TEST HALE LAGS NOTES: Z " PARCEL : 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH RO ,tom t o NUI SO!L EVALUATOR:�.M�° 2-� ���. cs� THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF Kl FLOOD ZONE: jOr (.. �%A 1 �x �7 WITNESS : t,+��-!�I`7`f A'P�(, BOARD OF HEALTH REGULATIONS. . REFERENCE �?7IL.. fj�(� DATE ��GT �C� T V JICKE SON + ��l�AQVp"`1 , 2) HE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, Fla.+% TO ,�o Q �r PERCOLAT I N RATE: A- Z -1 J•`4 1riQ4 SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO t;� Cl-ASS _L. 50t(„$ L.7-�= (�.��/ �� y INSTALLATION. 4� r� R ��PRrb 7 HD rr TN- ! " TH-2 D� 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION _ U��.. - G-rl t Q ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE : LC: `�' _ . -._ �. ��. q" I=I 2t fa► l�nrn-(5 � InY ��� Z.t DETERMINATION. N. r (,vA,v+ 2l #'t.-� UF: �.A-n!q,__L'�� 1`{• �-� �� ` � �• ��r��� 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 `Y FOOT. (UNLESS .�._4a �u SPct�i•7 �O �Z �2.y' & a SPECIFIED OTHERWISE) J U5� (` �2 ..... ................ .. _ f � LOCATION MAP (t�`3 t 5 . �? UJAM' f(Tf rL S/ r • 2' 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A rf r v ZS !r► vv GARBAGE DISPOSAL. S NLG-Ulvm ,� 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) r+D G� 5t7 (n '� f�0 o MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON 1• ABASE OF 6"OF CRUSHED STONE. A- t - 2.-�5 �- I �� �, � 1� zC ,, a S'� 7} _�xr�:�.�?.�...�aG�rr�c� .Pf r"......7`�. r + _Z. �--7 `�• lit �a' A f �!a w OEC'sa-Vp-0 ND C+N G/�-c-l't o I _•3 r g FfZt w,t. w r ry 1 ,C f 6 2D r✓S�=r SEPT I C SY$TEM DES I GN * .t<jp') 150, OF- Pa Oros 6.nro ... FLOW ESTIMATE A- (. �'� � ' � � BEDROOMS AT I 0 GAL/DAY/BEDROOM - 44o GAL/DAY �r1�wSTt��'.Cr ��`� o� ����t �5...�cC?Ul��.•.. SEPTIC: TANK zo CAL/DAY x 2 DAYS - GAL / �.. USE (,000 GALLON SEPTIC TANK -E�p,-7Tit-� • RePLk.S w j I)S-U (9 AL,tell/ �/ 5G�c- TIC i FBIU00 t) -AA E xis rl\--l" I O SOIL ABSORPTION SYSTEML •PcTQ c�rZ .., t o.•�.,C�.•5' 4f . �• J �' ``%' �f�l C� I�' L � Sf} Wt' ( ` r ' o C�\, r :: 0N1ri: 2- Grp trrJro L.x {o rwx Zrpl - E)(.15r 1 C� 1 � Ior TSIDE AREA:[(`°)=-4-i to)2�x2 x a74- j - d BOTTOM AREA: qa x 1Q - 0,7q - Z- 6h5 --�5e-p-v4.La SEPT I .. SYSTEM SECTION �� •fir, a ,�tJl�7 �Lev. C� --"off EL- I Ste- NJ � � � .---�._�.-�..-...,_,,,._. `�'' G L� �• -- 11 r 4•b�� � . t, W...... r. l �,t �� � ��$• � 17 �°5 $a.F�(a ,,.�;' `�"Z- �. � 2` w3l " pavt*7{� fr�5l�� t~a P PCB• � - D-Box 06 _ L_t � t�i' I�•S3� CoNTc 12.. � 't c?U GAL t(r`hZ w4kr ht> (( . t �� � ttJ 5S_ SEPT I G TANK (f�. 3 _ .... _......_................ ...� ------ r s i��r� j �� •� (��_�3) /a'-.j '�" l70u�Ie SITE AND SEWAGE PLAN t� `t° 1`' FnC' ION : 57-Ai�E �y t)/ ry^ L •S�f \;i fTrii��� PREPARED FOR : C S SCALE:/ ��2.0 70 DARREN M. MEYER, R.S. Z DATE: P.O. BOX 981 G EAST SANDWICH, MA 02537 115 A.Uiul r5lZ2l t� Al 1) (`nr DATE WEALTH AGENT Ph: (508) 362-2922