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0075 OLD OYSTER ROAD - Health
F 75 Old Oyster Road, Cotuit A= 021 —011 McKean, Thomas From: McKean, Thomas Sent: Tuesday, February 27, 2018 10:16 PM To: Dita Henderson Cc: Conor Lally; Ben Goldberg; Dake Henderson; Steve McEleney Subject: Re: Notice & request for approval for alternative septic system, Cotuit MA Dear Mr. George and Ms. Edith Henderson, r The Town of Barnstable Health Division has no objection to the proposed installation and use of a composting toilet at 75 Old Oyster Road Cotuit, Massachusetts. Prior to installation, please seek approval and permit from the Town of Barnstable Plumbing Inspector. Sincerely, Thomas McKean, R.S., C.H.O. Director of Public Health Original Message From; Dita Henderson Sent: Tuesday, February 27, 2018 8:21 PM To: thomas.mckean@town.barnstable,ma.us Cc: Conor Lally; Ben Goldberg; Dake Henderson; Steve McEleney Subject: Notice & request for approval for alternative septic system, Cotuit MA Dear Mr. McKean, Please see the attached notice and request for approval of a Phoenix model 200 composting toilet to be installed at our house at 75 Old Oyster Road in Cotuit.The installation is scheduled for sometime during the last two weeks of March. I mistakenly sent a substantially identical communication to the Barnstable County Board of Health and Environment(by email and hard copy). Please forgive any confusion if you receive a very similar letter forwarded by them. A paper copy of the attached letter is also being sent by regular mail. Thank you for your attention to this matter. Regards, George ("Bunker") & Edith ("Dita") Henderson 9 Robinwood Ave., Unit#1 Jamaica Plain, MA 02130 (617) 522-1071 ditabunk@gmail.com 1 George&Edith Henderson .10 9 Robinwood Ave., Unit#1 Jamaica Plain, MA 02130 ice' 110 (617) 522-1071 C h ditabunk@gmail.com _.F s� h� February 27, 2018 -1 Thomas McKean, Director Town of Barnstable Board of Health 200 Main Street Hyannis,MA, 02601 Re: Alternative Septic Systemr5 Old"Oyster-Road,Cotuit Dear Mr. McKean: We write to provide notice of our intent to install a Phoenix dry/gravity composting toilet in our residence at 75 Old Oyster Road, Cotuit,and to request either written approval or a statement that approval is unnecessary for the system. We request a response as soon as possible, as we have scheduled the installation for the latter part of March. Below is a description of the system to be installed. The description is taken from a site visit report prepared by the system installer,Mr..Conor. Lally,for George ("Bunker") and Edith ("Dita") Henderson. We are omitting portions of the report that concern other options that are not being implementing at this time. Byway of background,this house was substantially upgraded in 2007-2008. .A new Title V compliant on-site sewage treatment and disposal system was installed in 2007. That system is in good operating condition and will continue in operation. We wish to install the Phoenix composting toilet in one of the two bathrooms in order to reduce nutrient loading to Cotuit Bay. 1 l - - Co p st;n-: T+ ►ile.t _to 1�*i�s.t '' -. rt Prepay d for lunkezr and 01la: Hender5all 75 0 d Oyster Road C hita 44A i'm,pmd by saner LAy PROJECT UNDERSTANDING The project consists ofrenovatlom to i► a house.used seasonally for recreations and"farnily gatherings,The house will be closed up during winter r,onths;,wa-ter , r and leetrlelty will be'(0rAed'off: bathroom _ renovations ar,e expected"to`be compkted by May Ist, p.Srle visit was:corrdcted on ii=on 2rd: to discuss how conroposting,toilets could be. Incorporated into the planned re.novationkP with a focus on the f asibility of a Phoenix Co.mpoWng Toilet System:for the list floor bathroom,Though nota prrior ty, the.:second floor,bathroom was a.1so evaluated fi r future conversiortif opt:ans4.The site;wi ftr was,atten:ded'by, owners Dunker and Oita. HendeirsonR builder,Steve E.!heny and c000r tall w Tl�e fiocus of tine discussions-was on bathroom layoutas itrelates tot sitfng;the:commode,alligning,the commode with the tangy below,and the best;possible options for,L irouti gt',hevent.line. The,pri'mary til f®r co,rrsid`erin g ecological sa n it a bird n, prac ,ces irthi project:it ,participation in the.local effort to stem the flow of harn'rl!ul excess.nu��trients into the:surfbce waters of Cotuit:.Septic systems account for 85 of the,controllab'tel nitrogen irtnoactng the:3;' Bays watershed. Im pie men:in.g;composting toilets is:one way.t*reduce°thatirnpactwhife also, conserwng�potable:water. Below is a surnrmary of site visit discussions,system options,:retrofit conside ti€m, ,,scheduliag, and next steps., 5 FIRST FLOOR, COMPOSTING TO-IIET Q PTIIONS=AND..CONSIOERATI NS, Based on site vi'sitobservations,,i.t:is our;recorcrrnendatior�:that.a l?hsemixdr " ravity, camposting toilet.be utilised:in the:first floor bathroo..m renovation..There,is sufficient space for the tank to be sited in the'basement below,andi.space to:'ld 'te,the coiLnrtode.above.In our opinion;the;Phoenix model'200 is the most ad'vamta eor9s system°fi r flats:particular situa:tiono- due to the collective benefits of high,capacity,ease.of rnaintenznc ,performance record,, optimal water saving potential,nutrient attenuation:capacity,ea:se•of permitttngfregul'atory, l A 2 approval,and project.schedul•e.Ot'Naer system options that are also feasible its,fdr use the first, floor and/or second floor bath roome are i';dentifierC s part eaF thrs report= Phoenix Composting Tailet Overview of System &Maintenance Requirements The Phoenix Compost n,gToilet[s manufactured byAdvanced 1C tin systems.�ACs�yin�M1lhTteftSh� MT�.It..is orte � - of the,most advanced systems on:the rrearket, Witte po.pulariky i'n Rublicfac`ilitie ,; - - , residential, and remote settings alike{ The tarykcomponent is typically�'i`ted be'I,ow - the battiroorm#in a basem. entor accessible , space, like thatoffereri by the'ba.serment at the Nendeirson house, Floor to.celli.reg: l�l height'in the basement Is 78'�the modeli 200 is 68".A.Minimum of•G above the tank helght;ls o;ptirnal for installation They 7W balsernoot milt allow-for an Insulated base far,thet tank to shot .The dry taite.t uses:no water and,is connected to the tank;by a. .2 inchi diane.e�ter chrute_A.foam flush fixture thatwould.be connected'A the tank by a�4'',pipe is also an,opt on,t howvever the group Identified the dry gravity cornmode as,preferable for this; application. Feces.u ri nre,toiletpa parr a.ndflaked pine shavi ngs,are- all inputs,to the system. The top-ttne.shaft incorporates t ,new contributions into the to !1'evel'ofcompost,.whife the lower tines keep layers separated an.d,assist in:lowering; material during removal.The,addition:ofpines s'havings, approximately 1/4 cup peruse..absorbs liquid;, maintains compost structure,and provides carbon:to.the composting process. 4 , The system.is vented using.a small fink wNch maintains negative pressure down t`hroug,h the toilet elirnina ng the Potential for odors i'n the bathroom,The fan al'-sot main twins any aerated,campost,for effect.V aerobic decomposit on,,ands helps to ma:intaih moisture levels througbi evaporation. .46 vent pipe will need to rung from the ba:sernent.near the,tank( - Et to tl°�e ridge of the roof:. 3 Organism rich leachate is recirculated'via,.rnanual:hand pu-m;pi toi support.the,Oom,posting', process.in the event.ofexcess there Isan overflow,outlet that is connectedfrom the bom tt 0 . Front of the,ta n,k to,either se Ode sewer, grey at et or evaborator system.In this.case asm-alf condensate 'ha th rough the sa n.ftaV(line III the basement,: nelearying - 'Maintenance for the Phoenix sy stem is nottime.con su.,. Ing nor,difficult, but,It fsve important.Weekly/Bl,montihiy;maintenance ge-n.er.a,[,!.Yl consists oft urning,-t�h�e..up.pertirieshak vi IsIgt'h zu 46 rn rrOifan,,are, adding ad'ditiona[pinesha inizsifnecessar-y,,O,,nOensurI e"recir .0n.p -7- par on and fun cb'o,nlna,,-in.total abort ieve tto,ten inute.s-,Frequency,oft'ov,d.nema,tn,,t.enLa,ncels rn_,IL --an b e a dependantoni"ym.te use.The torrip lete _a n te n _ce;guWe,ca n -ccessed here: http- ww.com, -W NC -1100 i1W po -,com/LITRA X/manua INA Removal frequency is usedeperid'ant.Basedf on,projected use of the lliornej the--system will 'likely require,removal�approx4mateiyevery'2.to 5 years.Finished -compost is harvested too or the bottom l access door ont he unit,and can be,removed-,f6cfand a P,pticatiort or secondary, composting.The property has ample space,suitable:for ap, i,,,catior►offirtishedcompost,.,onist-,te.. -he,P r,(,,,t [ lllyy 4 ay lof A removal of finished material 'hoenksysterntypica ie rd s 3/1.of ard, , mull like compost. Since this application;on,is exp ectedlo seeseaso nal use;,there:a respedfic steps.to:take;in preparation for th e idle WJ nte r�pe riod.These steps,can,be fo tind on page.s4 ofthe_,above, mentioned use r er manual 4 Re-ttrofit Considerations Fixture location In,order to:alfgn.wrth the tankbelow,the ` enter of the commode will be o%et toward"the shower and further into the room than where the exfsting..f Lure is-centered., Building a shelf'on the;srdes:and"behindRthie commode was discussed, It was ag.reed�this would fill;the; '"r space''behind'the commode as well as bring the eerterof the- NMI wfndow f"rarnl closer to the cente;rof ithel new fiXture.The shelf behind the COMM ode will:also con:c--,eal the,verii't:pipe j ' cornirig up from the.basement "Tank location.7he tarok will,be sited directly land neathth ". toilet,,and'wII11ikelyal[Sri with the,fong:slde para 1 le t toilthe laasermeotwiodow,Thesfde,ofthe nk,w-i,lfbutfogainstthe all and.,the rear Qf""khe tank will:'blrtt.a ainst tlh ,. _ w- - -- 8- hae `sar>lita :fine, f?,lurtabing modiff.cati'ons.The radla,tor will need to be ,..., relocated to the wall abutting the:hint floor bed'roomn,'The copper-cold water Ifrie,as well as°the,twC,271/2.PVC,pipe-s that are in joist.bay adjacent to the toilet line,will need to.be re=located to allow for the`12"chug to wine through the,joilst, bay.it may be advantageous to extend thel current rArI sanitary Line leaving.the.basement to bring,access to the cleandut furtherinto the.room,,1past where-the edge calf the tank MIT'be... Iolst balm: It is likely that they joist in,between�the curren€tollet. flange,and the cold water supply,for the toilet w11t need to,bel bored out 1to.accommodate the 12"chute.: Venting:An opt5mal.route.for the 4" line was d'entifetl to.be from the cornerof'the basement where the.existing toite ,line corn es through the floor,up into the sheIfIbehiind the torl'et�, through the st floor wall into the bedroom closer,.up�thrcu h the second,floor,and enclosed within the narrow roof next to f » the second floor bedroom. The penetration should be-near the fridge so that the:pipe can exteridl approxirnatety-12 to 16 inches and clearthe height:ofthe ridge .A ventcap its provided' with the Phoenix system. Bl`aclm a8S pipe is prefierredi, Electrical requirements. A GR.receptacle.should'be located: � 1 .near thet front of the tank,either above fn the gois.t bay or on the adjacent wail.:Two outlets would sufhce�,but four,is preferable. l:eachate connectiom,Th.e;l'eachate autletfi"tifin on.the fron bottom of'the tank Willi connect to a srnalt oondensatel pump ' t .►-�' wvh1ch,will connectvm,3,(8'tubing to,a barb fitting.threaded into the sanitary line leaviing.the basemient.Typicallya sanitary 5 . art:e-ndi cap. wye Is plumbed in.1,1 n.e,,,with the WYe,lbci*ng,,,up,,threat- . edbatb1stapped Access.,The s ihe door leading into the bulkhead stairs will'l,need toi be;(-e for enough clearance to,get the two ha lvesof the tare int-0 the,basement. Permitdng &..Approval Composting toilets are regulated 1ey two ides an M 1 -r-efer t d_'�� o a fs nMa sachusetts.,110C Ti'tie,5 (on site wastewater disposal r h pitu mbingeode.7ber, na V NO, egWationsl,and state. be local ordinances in gamstable Thai,eff6ctthe.use.,ofcoLm,,po.sting-tdffet-s.Tlhe.Pho niki tem forgen general lose throughoutWassachusetts wherever MtfeiSap oc is approved _.pffes�L- naf Maids of Health('80 K)a re responsible for admv ims tra.d ng 711t[e,55�Tho ugl the P r-poc�for,a P P r a W-- C vary s isnifica"fly from town to to z w the ty ptrcaf m e.c.hanni's s,recur M- ,m- .e rided; is "OP P I[Cartlo"'(0 r ap ef t t.o-,c onst ructawn-alternative idlsposalsystem fssued",S ubmfhedi to the'80H.This should beclarifted it.h;tbeTown,,,of-8arnsta'bfeNleattb,Dlvfs.ioo,,TbePhoe.,nix,pis-,, approved for general:use under the pl'u-MVIM-S,, -,0 d'e-,end hasa product,a-pP oa-1,in-U be b 0 :ry provi'ded'to the:;plumbing inspector if needed':;. The Phoenix 200 composting toilet will be installed by Conor Lally and Ben Goldberg. Builder Steven McEleney may also be involved in certain aspects of the work. The plumbing modifications will be done by licensed plumber Michael Pasic who will handle any plumbing permit or inspection that may be required. Kindly provide us with a written approval for this project,or a written statement that no approval is needed. If you have any questions,please contact us at the contact information given in the letterhead above. Sincerely, George&Edith Henderson cc: Conor Lally Ben Goldberg Dake Henderson 6 J 14 Fee SO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for �Diopozar *p$tem Con0truction Permit Application for a Permit to Construct(Repair( ) Upgrade( ) Abandon( ) ® Complete System ❑Individual Components Location Address or Lot No. 75 CAA Owner's Name,Address,and Tel.No. Assessor's Map/Parcel u-1 —D 11 t` e,-y `� OZ Installer's Name,Address,and Tel.No. 1 Designer's Name,Address and Tel.No. ocgoS�li5 —GG'p��J rim � Type of Building: Dwelling No.of Bedrooms Lot Size Z\j(n30 sq. ft. Garbage Grinder (A Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) SS0 gpd Design flow provided SGZ gpd Plan Date ,SVAC4e �'ZOp� Number of sheets Revision Date Title 5 Size of Septic Tank I sby G Type of S.A.S. W n)b' Ple-t� Description of Soil SVE- ��j E ]JJ 7]S 0 -�11 606 n B-Cl" -9 cNNe9— l6\K V5 (aAyy\'y- SAjjt7 -en(o+1cr-eJ1. 17- /2d" C LA-jgQ 2.Sy (v i V tA-eck - �h ST'ric c 3 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this of Pe . Signed Date Application Approved by Date 3 Application Disapproved by: Date for the following reasons Permit No. ao O-+ _` (-1 Date Issued --------_---------------------------------------- No. .. 1 i� Fee SU TH �COW41ONWEALTH OF MASSACHUSETTS Entered in computer: Yes tPUBLIC HEALTH DIVIMON TOWN OF BARNSTABLE, MASSACHUSETTS '1 io oaY * gten Cott�truction PermitAlication for � I Application for a Permit to Construct Repair Upgrade Abandon pl p. (•�}'' p O pg O O'P1`Complete System ❑Individual Components Location Address or Lot No. 75 61 1k (�5�w-r '�.0�A Owner's Name,Address,and Tel.No. Assessor's Map/Parcel VZ' -Ott ,` C�v� ` - Te-C y A Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ' 1 i Dwelling No.of Bedrooms Lot Sze �,(a30 sq.ft. Garbage Grinder (A i Other Type of Building NQ.of Persons Showers( ) Cafeteria( ) Other Fixtures ,'�+i 5r�/.. I rp Design Flow(min.required) SS'� gpd'-w-Design flow provided gpd I Plan Date SeA r44, %ZM77 Number of sheets 1 Revision Date Title � - al Size of Septic Tank " I sup (oI I ype of S.A.S. &6 fOjW PIE .L Description of Soil SEE E 5 r 4* - o-$�� 60I\W\ Q-1�' t"3 C�ye9 tAyl�S�9 laAw�Y S AD 17— /2a" C lA�� ?_.Sy (n�V tall-e� Sr'�.ni� h SST 41c>LF 3 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: i Agreement: ) r �% The undersigned agrees to erisu�re.the constru(AJon and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this -eard of Heal h. l Signed Date Application Approved by Date 3 ~G�- j Application Disapproved by: Date for the following reasons Permit No. goo-+ 91LJ Date Issued 1'- 1'3-09 ———————————————————————————----------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS . Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired ( ) Upgraded ( ) Abandoned( )by at 7S nl d . has been constructed in accordance with the provisions of Title 5 and thefor Disposal System Construction Permit No. 01fP6-�- - fN dated Installer,,� ���§- fY�s� .1� Designer ,I #bedrooms Q 5 Approved design flow gpd The issuance of this permit shall not be construe as a guarantee that the system Wi I func 1, igned. Date M �d'7 Inspector i —————————---—————— ———————————---—— ————————— No. 1`1 Fee SO THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS i lwigoar 6p5tem Construction Permit Permission is hereby granted to Construct (-'�) Repair ( ) Upgrade ( ) Abandon ( ) System located at 7 S y(J by 5\1r \01a.A , (16,x - 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 [3 ~ 1-� Approved by. r r , Town of Barnstable Re gulatory Services °i69. ��� Thomas F. Geder,Director, Public Health Division Thomas McKean,Director - 200 Main Street,Hyannis,MA 02601 - Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 0S Iozl°`d Sewage Permit# Zml-A 1 .- Assessor's Map\Parcel-�z� i.l Designer:. �Jv��,, gas ���� ��c Installer: Address: T.��,2 C2. ;> �S i56t l urAddress: e-e-a+e::9,1 19 1 /U o o 3 y On 6 9 L l D`7 ' _ was issued a permit to installea (date) (installer) septic system at '7 5 Orr V1 C `(5-k!E2 �OAP Cow ck based on a design drawn by (address) wL w A-04 1&x6AkkL dated 9 OA 02 (designer) _ I 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. 1.ire - 1-5 3. CL : (rC.LA uFze�i L�( vCit m,�v1PC64 CP-'CO j 6 F- l0©,/o I certify that the septic system referenced above was installed with major changes (i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. �x OF MASS 4(lner's Signature) �o� PETER GNP o SULLIVAN �. CIVIL No.29733 1 oP�F'P�cCiSTE�`� ASS/ONA4ENG (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUELT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc LIVIVCi R)UVI UY a: Ml 1;liU1;OOM 11H mm L=LT- i \ -J lJONYHUl1Sli 1:1'1'[.'HliV ll V>11V( R( y Q // S'J,tjl)Y \\ FMUYIFEMMEF _ n 1 \ 11Y PROPOSED FIRST FLOOR PLAN OPTION 3 1/29/07 I ❑ \ I 13li A00.14 BIORM)yl I I I I I - f I I - I � 56 BUIN'MM )Slit' BEDROOM I I I I I PROPOSED SECOND FLOOR PLAN 1/29/07 j< 95 220• Plicyaration of flans and JAecmcanuiaa n u••+ r - , r� . .— � r r• - r r • — 7-nd plans and specifications .for every on-sire system shall be prepared as.follows: : (1) _Every system shall be designed by a Massachusetts Registered Professional Engineer or a'Mass achrusetcs Registered Sanitarian provided that such Sanitarian shall not design a. system designed to discharge mart Chart 2,000 gallons per day pursuant to 310 (JAR 15.203. ; Any other agent of the oWner.tnay prepare-plans for the repair of a system designed to discharge not morn than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are reviewed by:a Massachusetts Registered Sanitarian and.approved by the.apprbving r au . nty;. .(2). .Every—plan submitted for approval must-be dated and bear the stamp and signanire of the designer, (3J Every plan-for a new system or plan for the upgrade or expansion of an e.:ating'-Sys tC n "- which requires a variance to a property line setback distance;must.also reference'a clan j/J/-which bears the stamp and signature of a Massachusetts. Licensed Land Surveyor in ac •rdance with M.V.L. c, 112, § 81D; 4) of suitable scat-'(one inch=40 feet or fewer for plot Every plan for a iystcm shall be plans and one irieft-ZO feet or fewer for demils of,system component ). �.gd.shall include. : d tenon of: ; (a) the legal boundaries of the facility to be served: _ the holder and location of any easements appurtenant to or which could impact the siem; (c) the Iocatiortof rha Z11 dwcIl ng(s)or buildi:tgls)existing and proposed on the farlity - and 1dentifieaddri of those to be served by the system; " • "' - " " : ..:Th iacation of existing or proposed irnpervzous•areas; including:driveways and parking areas; —.. . :(tom location and dirnersions of th'e'systcm (including reserve area),, -• system design calculations, including design daily sewage flow, s.epric rank capacity (req `cd and provided); soil absorption system capacity (required and•provided); and - w Cher systctri is designed for garbage grinder, orth arrow and existing and proposed contours; Iodation and'1og of deep'observation hole tests including the date of test, existing grade elevations marked on each test, and the naives of the representative of the tap oving authority a.Id soil evaluator, „ `rlocation and results of percolation tests including the auto of test and -tha names of e•representative of the approving authority and soil evaluator, . (j} .name and certification number-of-the-Sotl--Evalgator of record; (k) lo.cation .of every•water supply,public and*private, 1. within 400 feet of the proposed system J,ocation in the case of suface water supplies a.-id gravel-packed public water supply wells, 2. within 250 feet of the proposed system location in the case;of tubular public water supply wells, and 3. within 130 feet of• Cho proposed system,location iri the case of private water supply wclas; f the Comrnonweaitht; rivers, borde=' g••vegetated 1 location of any surface waters o wetlands. salt marshes, inland or coastal banks. regulatory fioodway, yzlociiy zone, : surface water supplies, tributaries to surface water supplies,certified vt;rnal pools,private water supplies or•suetinti lines, gravel packed or tubular public water supply wells, subsurface .drains, leaching catch basins, or dry wells; and the location of any nitrogen sensitive area identified'in 310 CNM 15.213 within which portions of the proposed _.._ tern aro located. �) locatzoa of water lines and•outer subsurface utilities on the facili ty; absctved and adjusted ground=water elevation in the vicinity of the system; o) a complete profile of the system; •a note on the plan listing all variances to the provisions of 310 CMR 15.000 sought conjunction with the g1ar.; . the location and,rlevaaoa of one bcrc.'uaark.within 50 to 75 feet of the facility w ch is got si:bjcct to dislocation or loss.dur'ng consavction'on•the facility, r) when dosing is'preposed, complete design anE'spetificatiorr ttf the,dosing system proposed ineluding.but not limited to dosing,charnber capacity rreq iced and.provided),' urap curves and.specificadons, number of d'osi.�g cycles and dept_tt per cycle; (s) when a Recirculating Sand Filter or equivalent alternative technology is required or proposed, a complete plan and sperfcadon for the system,including a ltydtagIia prof le; (�( a Locus pl2n to show the,location of the facility including the nearest existing street; ( the sticet nu,'ribct and lot nurnper, if any, of'the facility; and v) the mater_'als of cons=ction.and the specifications of the system., TOWN OF BARNSTABLE LO°--ATION 7S-nLn 01bl eR SEWAGE # 200-7 L4 14- VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0,77"I'�r')r S fr)w r SEPTIC TANK CAPACITY 1 LEACHING FACIL=: (type) fi (size),�,)Q)( NO: OF BEDROOMS BUILDER OR OWNER QW10eR, Oe 2rgo3 t PERMrTDATE:Q J3_R Q7 COMPLIANCE DATE: ] zIo7 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 S-yo` aoxyo r,rld s tGw«l Ls' 4 7�53� rfori'i• .� 40 G 3- 37` W� 30` 7-W ago 110 TOWN OF BARNSTABLE LOCATION 620 slrr Rd SEWAGE # VILLAGE ����� ASSESSOR'S MAP &LOT021 f1/ INSTALLER'S NAME&PHONE NO. -S-E1MC TANK CAPACITY �x �l® C-,P.S o� LEACHING FACELITY: (type) b4cL IfD�t (size) /D�o�Crr NO.OF BEDROOMS 2 BUILDER OR OWNER PERMTTDATE: COMPLIANCE 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) , �;� �`y Feet Furnished by 1"041, o 6 LJ 9 de sta TOWN OF BARNSTABLE LOCATION �S alb 091S Of Rel SEWAGE # VILLAGE 4 0fif ASSESSOR'S MAP & LOT.DPI —m/� -��kNAME&PHONE N0. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) NO.OF BEDROOMS - 3 BUILDER OR OWNER 6.e4 e PEPadr'DATE: --957 COMPLIANCE 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) I Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by "'?. /7 ,� � �C,...f/ yr� . ., 1� I. � :� M jffL�_ Town:of Barnstable Dept rtinent of Regulatory Services _,q q i Pi blie Health Division Date �00 Main Street,Hyannis MA 02601 rE0 MKt� edme rat:Pd. �OD'•D d Date Scheduled Soil Suitability Assessment for Sewage Disposal Performed By: 5`�1't��an Gn�,ln ' Witnessed Dy' I LOCATIOri & GENERAL INTORMA UN B er-de}-Suvt- e+ Lo cnlion Address i Owner's Name t� 17 r2 l�C I�lf>7c1¢rd 7 0.l c>' O yS b_r ''R4_ Address C r2►'�, Te.r •�• Z o 50mCX1 ,itc rri p_0a y3 " li ' Engineer's Name Assessor's'Map/Parcel: (3 p1 I O F; a Telephone 33 it c NEW CONSTRUCTiON � REPAIR- i� p CC i� v c� I Slopes(%) Surface Stones NoA Z__ Land Use t l�, 1060 ti tt Drinking Water Well SOO �l Distances fruit' Open Water Body Z�=4® LI R . Possible Wet Area'_ g I' R Other A) R Drainage Way, �� , I Lit Properly Lhie ZO (Street name.dimerohnn of hrt, 5T{RTCI: locations of test holes&pert teats,lociit'e wetlands in proximity to holes) V CD N ri EMMA I G7 GJ � i C) . L7 1v��5" Depth to Bedrock Parent tnatutal(geologic) I M i g p/Up NIG Weeping from Pit Face �1a Depth to Groundwater' Standing Water in Hole i Estimated Seasonal High Groundwater CC - fir• - OLA� -- (z,cu 11a t t DETERMINATION'FOR SEASONAL HIGII'WA,TER TABLE ;1n ' Method Used: 1WC,P = �t� c �G.lti�) _ In. f l in. Depth to soil mottles: Depth Observed standing in obs 11ose: n; Depth to weeping ttom side of obs.hole: in. Groundwater Adjusbncnt d.factor Adj.Otoundwatcr Level ' . index Well level Index Well N Reading Date: Ad PERCOLATION TEST Date !2 Time i� Fur Observation -Z 3 Time at 9" j Hole g --�—--.- Time at fi" Depth of Pere ;9 z rj_(eq��efl Time(9"-6") _ f j Start Pre=souk Time Q ' End Pre-souk Ions, Rate MInAnch Zrn i s Site Failed: Additional Testing Needed(Y/N) Site Suitability Asscssnient: She Passed — i Original: Public Health Division Observation Hole Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the i Barnstable Conservation Division at least one(1)week prior to beginning. 0:1 iEALTI mP/PERCFORM I Ef P OI3SE_RVA.TION HOLE LOG 1I01C it Other�_— Depthfium Soilflorizon SoilTcxluie Soil Color Soil (USDA) (Munsoll) . Mottling (Structure,Spews,Uuuiders. Surtkcr,(In,) rh��°t°r�nav �e.dravcll _�. 5 Q �oye' i DEEP Omit RV e ON HOLSoil i-LOG soli Role# _other Depth from Soil HorizonSoi Texture, SDA) (Munsell) Mottling (Structure,Stones,BuulJcrs- Surface(in.) � ' lenc iZ0 � 5 � z,sy ply • E I DEEP OI35ERVA ION HOLE, LOG Hole#�_ Depth from Soil Norimn SoiTexturc Soil Color Soil Other Surface(in.) (USDA) (Munscil) Mottling (Structure;Stones,Boulders.Consistcncv %Grnyci) LLA ' -33�t �i Lt✓ I ' 3 i2 C, Q k L DEL+'P OBSEILVil Othe ATION HOLE LOG s�ii0le it_�.r Suil,Tcxluro Soil Color Depth from Soil Ilotizon (USDA) (Munscil) Mottling (Stricture,Stones,Uuuldcrs. Surface(in.) , n i ci c %GtBvc `1 i i i Flood Insurance Rate Man: Above 500 year flood boundary No Yes Q Within 500 year boundary No l Ycs 0 Within 100 year flood Boundary No . Yes DeptholNaturall bccurrin `Pervi'uus ateriai. f� Does at least four feet of naturally out, pervious material exist in all areas observed throughout the area proposed for the soil absorption%systerri7 V l'_ S_ arnot,What is We depth of naturally occurring pervious material? certification 1 have assed the soil evaluator examination approved by the 0 1 certify lrat on ( 0 (date) P ysisAy�ss p trio cons1stont Willi Department of>;nvirotnu utaI Protection andcelat tile describcdin 31ve t0 CMR 1.5.017..Ecrmed.uy the required training,expertise and expericn Dale l�(z- Signature Q:I ICA.LITIMPIPLRCrORM No.--------5-;,7• / — Fn$............. ... THE COMMONWEALTH OF MASSACHUSETTS BOARD = HEA T ................ ......G ....,OF........., ..... .............................. Appliratiun for R-opuua1 Works Tonutrnrtiun Prrmit Application is hereby made for a Permit to Construct (, ) or Reair ( an Individual Sewage Disposal System at .... 'zE '�r,�...... a.;� � ------- --------------------------------------•-..._. Lo tion- ddre J or Lot No. r— ............. .. - •• ��c- ......................... ..................................... --••--------....---•--..........................--. Owner Address W ..--=-- � ------------------------- Installer Address Type of Building Size Lot---------------.............Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building ... No. of persons............................ Showers a YP g ------------------------- P ( )' — Cafeteria ( ) Q' Other fixtures _________________________________ _ WDesign 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 ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1____-•-.._______minutes per inch Depth of Test Pit.................... Depth to ground water..................... GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------------------••------...................--•--•......--.............................................................. 0 Description of Soil........................................................................................................................................................................ x --------------------------------------------------------------------------------------•------------- ; --- ------------- x Nature of Repairs or ¢�terati s Ans r w n a licab .. ............... .....�'..._. Q. ? ..._.__.......... U P i PP / Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with' the provisions of TIT IL- 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 Application Approved BY, . "M 79, Date Application Disapproved for the following reasons:----•----------•..............••-----------------------------•-----••-•-•-••-••......-•-•-- -••--........--•--- ...-••-........-•••........•-•••-•-----•--•-•-••---•-----•••--••-••••••••-----•---•----•--...------••---- Date PermitNo......................................................... Issued-...................................................---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ...........OF..........4j ................f............. Curdifiratr of (pomp innrr ,. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Re aired by--- ------------------ ..................................... ....................... ;iali -- stalle X ' 7_/ has been installed in accordance with the provisions of T _ r of The State Sanitary CoSJ,e as described in the application for Disposal Works Construction Permit No.. . .._...� _7............. dated-...'_.__7:77.`_7_77.................... 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 � HE H 79 } . ...........OF.........�C.?1. .. . ---- °`� No........ � FEE.. ...... Disposal Works Tuner ion rrmit Permissionis hereby granted.......................................................................................... .......... ----- ............. to Constr 'i Re a divi al SewViIs sal S t) p� P (at No. = ( = = ...Q... - ----.--- - ------------------------- --- Street as shown on the application for Disposal Works Construction Pe No.. ._. __.._.. Dated........._69....7..I:............. —.......................- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - ne. ("' Fims THE COMMONWEALTH OF MASSACHUSETTS BOARD H EA T )4 -�-- ....OF........... . :.. . . ......... Apphratiou for Diopuiial Works Cfuatitrurtiou Prrutit Application is hereby made for a-;�Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ..................................................... tion- ddre or Lot No. .........: -_-----.. ...... .............•-•---•--..........................._. Ir^ .. .y Owner 41 Address W `'�Y 044 -••-----•-----••------- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder .( ) '4 Other—Type of Building No. of persons---------------------------- Showers — Cafeteria Pa . Other f-xtures .------•---------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................. Width................ Diameter................ Depth................ xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-_________-_-__---____. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------------------------•---------...-•--...----••------•---...-••--................................................................. 0 Description of Soil........................................................................................................................................................................ x V .....--------•-----------------------------------------••-•----------------------••------------------•-------------------------------------•----------------------------------------•-......------•-----. W ----------------------------------------------------------------------------------------------------- --- U Nature of Repairs or terati s Ans r w :applicab ... .. ........... d --------------------------•----------------------------------•--------•--------------- Agreement: The undersigne3 agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f.. the provisions of TITLL 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 ---------•--•-------------- ----------------------------------- Application Approved BY l. l.%... (v ' '` �� '-------•--- Date Application Disapproved for the following reasons:................................................................................................................ --------------------------•-----•••-•-•---•------------------...••--------••-•--•----------••-------•--•----........._..--•------------------------•------------------------------------------------•--- Date PermitNo.......................................................... Issued................................... Date f- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... P 1............OF.......... j 4 ..........*..................... Tntif r,att, its �it�tt�t�tMYtr� THIS IS TO CERTIFY T$at the Indivddual Sewa e Disposal System constructed or Re aired by -•--- .--• -•_. sta11 a has be-eV,installed in accordance with the provisions of T ` of The State Sanitary Co described in the application for Disposal Works Construction Permit No.. ......f _7............. dated-------9.1�k--71................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE.---•----•----•-•-•..............•----•--...................------------..----.. Inspector...................................................................................... THE COMMON;YtfLTH OF MASSACHUSETTS 6 BQARD HE H - .............. 4 No.......�.�.j7.._ OF FEE.. ............... Permissionis hereby granted-------------------------------------------------•-•------.............................................. ...... .......................... to Constrijct le�and>vi�ual Sewa >s sal S st at -�f i�... J�' . --...__.....! --d._ -1.�' ek ......... & Street ��rr as shown on the application for Disposal Works Construction--P No. ,=._ _...... Dated......��`f0.`?_:,�'............. ........ •--• - ........................ Board of Health DATE------'=--------•-------•---------------------•-•--------......_....----•--• FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE 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: 7r Old Owlp— /Qel C,o "/f, A417 Owner's Name: gktt. Linfell Owner's Address: 7S Off c c fl Date of Inspection: 6-111-06 Name of Inspector: (please print T&411 9? Aa Ufa Company Name: jo4 pal o ock,4"'. sf,-wi'e o Mailing Address: j$ a/a L.> 57�ea� Ale,,-et,ks A/Z%/s, M)V 6716 q$ Telephone Number: Sob y:2$-777 9' CERTIFICATION STATEMENT K. t�3 I certify that I have personally inspected the sewage disposal system at this address and that the informationtreported 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 = s Needs Further Evaluation by the Local Approving Authority , Fails 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 inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT VOR VOLUNTARY:ASSESSMWNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: `TS Old Dys-ttv Pcl 6"-,- , Owner: ge oso e/ Date of Inspectio : 6-/y-06 Inspection Summary: Check A,B,C,D or E/ALWAYS completAN of seawa.n. A. System Passes: t/I have`:not found,any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurafly unsound,exhibits substantial infiltration or exfiltration or tank faihm its imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance. indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break-out,or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are t:eplaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 Wines 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 s Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART X. CERTIFICATION.(continued) Property Address: 7S" Owfir Owner: ¢ltti A 3n Te IJ Date of Inspectio C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOTtFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION.F0".-`- PART A CERTIFICATION(continued) Property Address: 7.1" old ovife, Rot co H 1 Owner: Ae&g e / Date of Inspection: /i/'4k D. System Failure Criteria applicable to all systems:. , You must indicate"yes"or"no"to each of the following for all inspections Yes No V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 1/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool r/ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow L/ 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. L/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. L— Any portion of a cesspool or privy is within a Zone 1 of a public well. r/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. r/ 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 falhuv criteria are triggered.A copy of the analysis must be attached to this form.] NO (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 it design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary.to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large.system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: —1c! Old (&.s' g RJ Co T.t /lfdJ Owner: T IJ Date of Inspe tion: i(—A—O•d Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No i/_ Pumping information was provided by the owner,occupant,or Board of Health 1l 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? V1- _ 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? tom_ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? /0 _ y- 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? V _ 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 1. 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(3)(b)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR . OLLNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 75" ®lel OG,f Owner: AI -- Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#'of bedrooms): 330 Number of current residents: 2_ Does residence,have a garbage grinder(yes or no): 0 Is laundry on a separate sewage system(yes or no): 1�i [if yes separate inspection required) Laundry system inspected(yes or no):_ Seasonal use:(yes or no): Alo Water meter readings,if available(last 2 years usage(gpd)): 10o v� 9�01 y Alo p�P 2 ' ��y , 3;��1� Sump pump(yes or no): Last date of occupancy: Bch COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): evd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records )/ Source of information: ALn vf�ffy�ny`/�+i'ly Was system pumped as part of the inspection(yes or no): If yes,volume pumped: /oc'y gallons--How.was quantity pumped determined? Reason for pumping: as,au fe., o� �v,sr� �� �.:��c6,��,� TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system Single cesspool i Overflow cesspool L td,r —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attat:ha 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: -- GpfSYJL'O� D(/yr Lf.� I.�Pk�'S `b ��ac�,�i� ov�'v-°>''�vVd 3�•t trP�YS Were sewage odors detected when arriving at the site(yes or no):/ 6 1 .. Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75" Old 0z a±e po/ Owner: At, �Pf„re Date of Inspection: Pb BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) /1l7N.e_ Depth below grade: .Material of construction:_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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): } Thy✓@ i4 A CB>S.!'lvoz W A bGic,4i2/� /DUO y41 GREASE TRAP:_(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.): 7 a M1 Page 8 of 11 OFFICIAL INSPECTION FORM-NO *6 UNTARY ASSESSMENTS `FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM: .. PART C. . J . SYSTEM INFORMATION(continued) Property Address: 7s O!ol 7ui_t Owner- gef ken tell Date of Inspection: 6--/y D TIGHT or HOLDING TANK: (tank must be pumped at time of inspectio tate aj(ta an site plan) Depth below grade: . Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: ' Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N19 (if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.k l Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION(continued) Property Address: If 19/01 4 s';il 1Pll Owner:_ ,�t9y sr,T/. Date of Inspecilon: 4'-I V—ab , SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number.' leaching chambers,number leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: _ I overflow cesspool,number: / innovative/alteraative system Type/name of technology: Conunents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): IV �l�ta�.e/ �¢r.?�Q/ cat �a!/vm o'1r DraGcrs�' ✓170Ogcr � 1Psrt�,�pi�` CESSPOOLS: �s (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: / Depth—top of liquid to inlet invert: /.I Depth of solids layer: 6- B" ' Depth of scum layer: 3" Dimensions of cesspool: 6'.x S' Materials of construction: Lec re:•4, /ol- Indication of groundwater inflow(yes or no): Comments(note condition of soil,sij of hydraulic failure,level of ponding,condition of vegetation,etc): -- C�sS,QDG1 aGnntrKy7c?cl RS /�7rf af� /h� �c /�✓sy-.i�/uc�ff Zyo�:n 50Car.�� CU:sc����GN /t�A Si /JS nr �.Ly(lu i(j 3s 'rC, ��L tl%i t3 GTt/�G't /.Fi�' � wr7 •futir•�-u♦-n ,nvp Ir4 . PRIVY: (locate on site plan) Materials of construction: Dimensions• , Depth of solids: Continents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 0 Page 10 of l l OFFICIAL INSPECTION FORM--NO1'FOR�VOMNTXIlY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAY:SYS'I' A INSPECTION FORM ' PART--C • SYSTEM INFORMATION(continued) Property Address: 7r ©Icy D ti• Rof Owner: Date of Inspection: 6 -iy-06 ,�. ,• •.. ; a�.y:; . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate'all wells within.100 feet.Locate where public water supply eaten the building. . s eo7— ,f . I U d - jig, .3" 6PI,r, 10• :4 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7f—D/J v s fee Acl Owner: gr# 4 �- Date of Inspection: /c—/V—06 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water N Z feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) v Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: iNupf 4 4- B o H You must describe how you established the high ground water elevation: rOKn,;1 WCY/l Y 1;2./-' pfti �n c1YauY� wa r L1/,3' �7`)��! :!� L.Er..c.�,pi / �- ec?SS�ov�i i f�;''. ..�! A�o '+Z �t'v6�v,`Y vYu�?r ' • C? C,vrd,�� �o G 11 r t COMIdOINWEALTH OF iY1AaaACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE r Secretary .ARGEO PAUL CELLUCCI IQ1,�jID STRUHS Governor 'Co sioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 7 �ile, Name of Owner Qh C'U!_u; Address of Owner- < 6 O Date of Inspection: S—/�� 17, n ^� Name of Ins /7. ji �� i Inspector: (Please Print) a CO/�'/� /r/�� � 9`99 I am a DEP oved s em.s�.ins °°�� rwartt to Section 15.340 of Trde 5(310 CM 15.000)_ Company Name: h G.I/o �t'/t Q S•Yv�G h� �� Marring Address: /�Z l(/v ar.,tS furs ehs i� SGr, Cr���fg �► Telephone Number: SV q_g! i-"� rS� 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: _asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority .s Inspector's Signature: -V( Date: The System Inspect.'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 revised 9/2/98 Page IofII � A �� Printed an Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM c PART A CERTIFICATION(continued) Property Address: Owner: G, Cehy<ll Date of Inspection J-J�-99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: L/ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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(s). 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 PART A CERTIFICATION(continued) Property Address: 7s.old ci er Own : .Zjk li ll Date of Inspection: 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 the public health, safety and the environment. w , 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 MANNE R WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT.THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH 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 facility 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 . revised 9/2/98 P2ge3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: fro��! Dy��i� Rd Cori' 44. Owner: G, Lotio% Date of Inspection: s-iz-9g 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 exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an 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 1/2 day flow. Required pumping more than 4 times in the Last year NOT due to clogged or obstructed pipe(s). I Number of times pumped_. I r privy is below the high groundwater elevation. Any portion of the Soil Absorption System, cesspool o p y 9 • _ _ Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the welll has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: C i Date of Inspection: " S=✓�-99 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. Y _ None of the system components have been pumped for at'leastIwo weeks and-the system has been•receivin 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. y _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. 4 • /� _ All system components, excfQdirrg the Soil Absorption System, have been located on the site. v _ The septic tank manholes were uncovered, opened,and d the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth q p of sludge, depth of scum. T / he size and location of the Soil Absorption System on the site has been determined based on: v _ 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 proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C t p SYSTEM INFORMATION Property Address: Owner: L, Loh J�l� Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:�g.p.d./bedroom. Number of bedrooms(design):. `_J� Number of bedrooms(actual):_✓ Total DESIGN flow 330 Number of current residents: Garbage grinder(yes or no): ISO Laundry(separate system) (yes or no):A!O; If yes, separate inspection required Laundry system inspected ( es or no) Seasonal use (yes or no):iz ,.'A r• Water meter readings,if avaf)ilable(last two year's usage(gpd): / !q I lhN�. pr14 Sump Pump (yes or no):_..!10 Last date of occupancy: cCC iaJ) COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: qpd ( 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: System pumped as part of inspection: (yes or no) U04 If yes, volume pumped: t9 gall � �? Reason for pumping: rj j.�L ,d, mT Crl"�i TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool J/ Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,it any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: `.37 Jvs Sewage odors detected when arriving at the site: (yes or no)�I�O revised 9/2/95 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7s oi�! ©ys •-R�( cow, G. Owner: G: 1>ti1-el/ Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: 2 Material of construction: cast iro 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�ppIan) Nnet 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: Sludge depth: $ o I • Distance from top o sludg,to bottom of outlet tee or baffle: 3 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: How dimensions were determined: mf4Sar:r� 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.) OF «SS oo s�rviH .. s►S ,�s, ,,v�' .�e =Th Pac .�; GREASE TRAP: (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: (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 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART C r J C SYSTEM INFORMATION(continued) Property Address: 7J ol'^ 0j'S eo-RV , —./5k Wu Owner: Lr , e"-TzP Date of Inspection: 99 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: st uction:_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:_A10 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (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.) revised 9/2/98 Page,8orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM(INFORMATION(continued) Property Address: er own : G/ Date of Inspection:',?�� .5 SOIL ABSORPTION SYSTEM(SAS) (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: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,•signs of hydraulic fpilu a, level f po din d, p soil, coroition of vegetatioP, etc.) loci L1ii<wfo L?y.� a� Aa l%v o rr7�f /0017 c�cx/r`c?�'C 45Af CESSPOOLS:_ (locate on site plan) / Number and configuration: Depth-top of liquid to inlet invert: /'2 Depth of solids layer. $n Depth of scum layer: 3" Dimensions of cesspool: ,�—�- Materials of construction: Co�'lcrf Indication of groundwater: yy�- �/� inflow (cesspool must be pumped as part of inspection) /��D -1 7'7 10l[/ 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 9or11 i y , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: tis 0 let dy J. J.,- RV4 CO I-; M4 Owner: G Jo,,fe Date of Inspection: s-/�-g 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) 13 s��� ealiPv 26 t3etr+�pgrr�1� / 3 OvBr�'�v� �a4t� •R�tiy yRya� 1 f. 7,0r �yuele revised 9/2/98 Page 10of11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -}. SYSTEM INFORMATION(continued) Property Address: Q I� Dysll�' �Ot �O r. Owner: c—. �I2 K Date of Inspection: a NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked �t Groundwater depth: Shallow Moderate Deep 0:2 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater J/;2 Feet Please indicate all the methods used to determine High Groundwater Elevation: F Obtained from Design Plans on.record Observed Site(Abutting property, observation hole, basement sump etc.) LL Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records % Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ypN vLpi I�Yq/.�Y' Cerh/pc+r •f/��f/!s/�r h M& �i7 r p�l f r roc4nr� fir Ato A.-. o LGac`,�� —C P sSjJoo �v y�-vtineA revised 9/2/98 Page 11of11 No....../....�7'.....u gy V;FRii_ ....... APPR I) 8l1 HE COMMONWEALTH OF MASSACHUSETTS "� OA RD OF HEALTH L ;tgned Date TOWN OF BARNSTABLE oil Appliration for Diopoottl orlto Towitrurt"ton ramit v1, I Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .. .......... ......................... -- .... i L on•1 res or Lot No. .. . . ..... ..... ....... ...... .... ........................ •.... .. W Ow er .— /fit � Addr Installer Address e of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms----;------------------------------------ Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons------------..------------.- Showers ( ) — Cafeteria ( ) dOther fixtures ..........................................•--.......--------...........---------------- -----•---........'-------........•-•--•-•-•-•------•--'----.. W Design Flow............................................gallons per person per day.. Total daily flow-.------------------------------------------gallons. WSeptic Tank—Liquid capacitv------------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........................................ a Test Pit No. I----------------minutes per inch Depth of Test Pit.--.--------..-----. Depth to ground water.................--..... fst Test Pit No. 2................minutes per inch Depth of Test Pit--............--.--. Depth to ground water.........--.........---. P4 ----••-•-'---••••----•--•-•----•--•----•-----•-------•-•-•-----•--•---•-•-'----••-•--------------------------------••-.....--'-•-•---•---..............--•-•- 0 Description of Soil........................................................................................................................................................................ x U •-•-•---...•-•••--••---•-'----------•••-•--••----•--•--•--•---•----•-•--•••-'----•-••-•-----------------•--------'•---•---••--------------'-----------'•---------------------------...--------'-------- VW •-----------------------•---------.....••--'-----•------------------------------•-•---------.............------ - 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compha e has ben issued y the board of health. / Signed .. ............ ............. ... ... ..... (p --- ----- Date Application Approved BY -----"-------------------------------------------------------------- --�..--l..y.�.Q.S�-------- Date Application Disapproved for the following reasons: ..... ............... .............................................. . . ............ . .............. ......... . .................. .. -- . "" . .-- " .. .. ..................._.................. -- .........................4........ . PermitNo. ---------TV-� e3�--/----- ---"---"--"--------- Issued ........................D... ....................................... Date .... "fare ---------------------------------------------- -------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ce>r#ifi ate of Tomplianre THIS ISQT0 CERTIFY, That he Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ......................... ....... ......L. .. . - -"" --------------------- / y� Installer � at ...................._..........61.1..........U.... .. -------"--"-W------------ has been installed in accordance ith the provisions of TITLE 5 of The State Environmental 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 -------------------------"--------------•------...._------------------------------- No......Z. 3 l y FRs...�.....�.........." THE COMMONWEALTH OF MASSACHUSETTS - � /BOARD OF HEALTH 1 TOWN N F O O BARNSTABLE 1� Appliration for Uivi-pnitti Mnrk.6 Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ................. VA..6.k......................... --- ye&�....................... L or Lot No. `.._�' `lion- Yrss r . Ow cr � D'� Addr ss Installer Address Tl le of Building ' Size Lot............................Sq. feet Dwelling—No. of Bedrooms.____.�-_____________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ........................:--- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures . .._.. W Design Flow............................................gallons per person per day. Total daily flow-------------_..............................gallons. WSeptic Tank—Liquid capacity_-.--_-____gallons Length________________ Width__--__.________- Diameter._.-.._--------- Depth................ x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........ ---------------•---•---••---......-••••-•---•--•-•-••-•---•----.. Date........................................ i Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f.Z,i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a •-----•-••-------•-•....--•-••-••---••••--•••-•-•---•------••••••----•••......-••••--•-•----._............................................................... 0 Description of Soil........................................................................................................................................................................ x ------= - �1-- . ------ U Nature of Repairs or Alterations—Answer when applicable.----- 2 -�-e_- -� '..' ----• ---•••••• -•-- ........ .........••-----------•-•-•••--••-•••...-•-•----•-••-----•-•-----------------------•-------•••...•••--••••-•-...------------....---•-•-•....._..---........-------•-•--•••--•......•............._...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia to has been issued by the board of health. Signed -- � Dace Application Approved By .............� �9.- -- '.." , .......... - .................._..... -- -- - .. .. _-.�..--e¢ ---..... Application Disapproved for the following reasons: . ..... ................................................................... . ..... . ......... ------------------ ------ -------------------------------------------------------- ----------------- ----------------------------------------------------------------------------------------------- ........................................ Dace Permi: No. ------� -................................................... Issued ............................................................ ------ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gelt#tftrate of Compliartre THIS IS iT0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( i) by ..........._....... - Q-Y.-��� ------------------ 7 V.. Installer �y 1 at .--- -- ------6.�-�.----------?' i(l � ... -- ----------------------.�s...... r..�:_►,> . ..... -...... ............................ . . . has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application :or 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 c TOWN OF BARNSTABLE No....f y'. .3.J tj FEE---3• ........ Disposal nrkii TAno rudinn Vrrntit Permission is hereby granted_...___._._. -....... ......................................................... to Construct (, or Repair ( ) an Individual Sewage Disposal) System '7'� � i A- ) e"- - .......� z '=:.........•--•....--•------•--•-------•------•---••••-•••..............at No.... )._ rj r ' ......... -Street ey as shown on the application for Disposal Works Construction Permit No._7y::,1�:`_1Y. Dated........f�.�..�.�-•-.....!-. l.................."-'----...... ( B DATE................ -�..----��- ` oard of Health/ FORM 36508 HOBBS Q WARREN,INC..PUBLISHERS I I_ ASSESSORS REF: ZONE: ryr a s 1 • Map 021, Parcel 011 RF d Area (min. 87,120SF (RPOD) P PA.ta,.s4a �. Frontage (min) 150' P.am.seo Width (min) - SEENOTB6(TYP.) satsttmJ thopo.eatPbt Sett s: a ` " •' OVERLAY DISTRICT: Front 30 AP - Aquifer Protection District Side 15' Rear 15' st ao r, d "14•T� :. I�Gaasm Hs1 Tapes 516t Septic Teak Plow 0aers FLOOD ZONE: A � ,.....; :+. »mot Zone C Community Panel No. to P-°t�-Tides°e�b #250001 0018 D °� (See Note 7 t8) `sor�t�r.tee a:' w July 2, 1992 Mit,-FOOMhUM -sw s �a TM HOW Location Ma� DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM 3toc�atssss Nor T0SCALE PaTA 1"=2,000f' .B.(bwod�avMq Nr�ckl Roderick ghaW S James a �_ •- o PERC TEST: 11,873 1 4•' 95.04 PERFORMED BY:JOHN O'DBA,BIT-SULLIVAN RMEMUNG , � �`��• . 217,6 WITNESSED BY:DONNA MIORANDI,R.S.-70WN OF BARNSTABLE AUGUST 24,2007 ce/»H '_ _ No TEST HOLE-1 EL.54.0 TEST HOLE-2 EL.54 a TEST HOLE-3 EL.Sao TEST HOLE-4 EL.54.0 -'4'• LOAM LOAM LOAM LOAM t5' $idwrd--•- \ �I 4" 33.7 8" 533 12" 53A 18" 52S 4 PROPOSED PROPOS YELLow13H BROWN N YBELI�OYW�I31H BROWN /F YELLOOYR 5/8 WISH BROWN t D-BOX S'A \ LOAMY SAND 23 LOAMY SAND 33 513 LOAMY 0 38 \ C LAYER 2.SY6l4 CLAYER2SYN4 CLAYER2SYd4 C LAYER MYN4 \ LIGHT YELLOWISH BROWN LIGHTYELLOWISHBROWN LIGHTYELLOWISHBROWN LIGMYELEJ WiSHBROWN t `�\ NO in: MED.SAND 44.0 MED.SAND MED.SAND 1 MED.SAND 44.0 ` 'i1"1-3 ERV~•\\ NO GROUNDWATER ENCOUNTERED 39" PERCI= 50.9 33" PERC•IESST 513 NOGROUNDWATERENCOUNTERBD 4 OO� RES 25 GALLONS IN 6 Ma4. 25 GALLONS IN 10 MIN. 5 t 12W Q MRM 44A 1 <2 MKIN 44.0 1 -2 NO GROUNDWATER ENCOUNTERED NOGROUNDWATERENCOUNTERED 1 TH-1 ¢ \` t 5r' oo_ • \ _�,�a fir. � \ 5Rt 7+ AN rews o.a. 1 \ � 1 t -\�410 w R-51.3' P"3t" >< o T z t ` \\ c� EXIS77t4d PITS TO * _ \ oo- o _. BE REMOVED OR PROPOSED o \• 4 ( �' a P ABANDONED PER SEPTIC loop. t -• 71 TLE TANK ,tt <• \ 75 \.\ Cross Section Of Leaching Bed 1 Sty W/F 00* too Dwelling \ Not to State t \ \ ! S •\ cx+ \\ SEPTIC NOTES DESIGN DATA t \ 1.Location of Utilities Shown on This Plan Are Appro&At Least 72 Hours Single Family-5 Bedroom Prior to Any Excavation For This Project the CMtrBCt0r Shalt Mob- . °i.`2 (' d ..... ..::: clys \ With NO Garbage Orinder the Required Notification to Dig Safe(1-888-344-7233). At �s : ° ':;:::.; ri:: Dail Flow w'•::::.;•::• :: � \, Y 2.The Contractor is Required to Secure Appropriate Permits From Taws t g0 '':::. \` Agencies For Construction Defined byThis Plan. t "d ' ' Septic Tank:S50 GPD x 200%=1100 GPD ........ �o� : �'�' \` Use 1500 Gallon Septic Tank 3.Install Risers to Within 6"of Finished Grade(3 Required). Le end. 4.All Structures Buried Three Feet or Mole or Subject LEACHING AREA to Vehicular Traffic to be H-20 Loading.It is the Engineel's Z� \ \ 550 GPD/0.74=743 SF Required Recommendation that H 20 Always be Used. r 1 �\,o. �• Bottom Area=(20'x 38�=760 SF 5.Septic System to be Installed in Accordance With 310 CMR 15.00 dt Deciduous Tree Bottom 248 CMR 1.00-7.00 Latest Revision and the Town of Barnstable t-------_ _. -Sh _-.-_.__•-----•--•- --•---- -•- --•1370;yarcr'----_\> `` 760 SF Total Provided Board of HealthRegniations. � , 6.All Piping to be Sch.40 PVC,and Shall be Marked wid,Magnetic Coniferous Tree 21•0' �� Lot 4 Marking Tape or a Comparable Means in Order to Located= 21,630-+SF Once Buried. Light Post 7.Inlet Tees Shall Extend a Minimum of 10" • Iron Pie F a S 89 2 '30" 165.00 Below the Flow Line. ID C8/DHp- Concrete Bound 135.48 CROW8.An Outlet Tee Shall Extend 14"Below the Flow Line, ►i/Drill hole 5w NIF and Shall be Equiped With a Gas Baffle. ® Catch Basin N/. Momas J. Seguin It {} Utility Pole Helen C. Gately Trust Zoos OHW- Overhead Wires � -S...I.....• Underground Utility Line - -25- - Elevation Contour 'RTLE. Site p/a n P ED BY.• PREPARED FOR: NOTES: Plan 1.) The structures shown were located on the ground by Proposed Improvements Sullivan Engineering, Inc. CapeSury Geor e 8 Henderson 11 ca�enf�nal survey methods on or between 25/JUL/07 & zg g� g 26 JUL 07. (?p At PO Box 659 7 Parker Road 11 Craigie Ter #2 rn Osterville, MA 02655 Osterville MA 02655 2.) The property line information shown hereon was compiled from 7Jr Old Oy Road (508)428-3344 (508)428-3115 fox (508)420-3994 (508)420-3995 fax Somerville MA 02143 available record information. 3.) The elevations shown are based on approximate mean sea level �l as shown on the Town of Barnstable GIS mapping. p Barnstable (e0tu►f) Mass. 4. This plan is not for recording and is not to be used.for '►� Draft: JOD Field: WHK/D WB 20 0 10 20 40 80 ) p g DATE: SCALE: # Review: PS Comp/Draft: RRL construction layout or deed description purposes. September 4, 2�0� ��=�� Prof. # 27017 Drawin 9 # C704g1