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0923 OLD POST ROAD (CT & MM) - Health
923 OLD POST ROAD, COTUIT No. V" -1)3 Y Fee BOARD OF HEALTH TOWN OF BAR.NSTABLE 01pphratiou _for Yell Congtructtou Permit Application is hereby made for a permit to Construct(t Alter( ), or Repair( ) an individual well at: p�3 018 /06sT Acl Location-Address Assessors Map and Parcel �4w Sul�tua� 2 -23 0 lJ �ogT Owner Address �e"�Nis J Ca•un>el1 108 De 4/,ASS /lA MCA34 p. -e Address Installer-Driller �� Type of Building Dwelling Other-Type of Building No. of Persons >, Type of Well Y POG- Capacity Purpose of Well Lri'YtGa/!ow Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Complia a ha en issued by the Board of Health. Signed S /7 D 0e Application Approved By t Date Application Disapproved for the following reasons: Date Permit No. yy� 03q Issued Date ------------ ----- ------ ----------- ------------------ BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of (compliance THIS IS TO CERTIFY,that the individual well Constructed(y! Altered( ), or Repaired( ) by D e.0'J.1J;s SCai•'-)ti C L/ t Installer at Q�,� 4 /� /ooS7- P has been installed in accordance with the provisions of the Town of Barnstab aoa'�rd gof Health Private Wel Pr tection Regulation as described in the application for Well Construction Permit No. 2AA -� Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. y" ?,.1-63 V �J 1 1 ) Fee I g BOARD OF HEALTH TOWIWO-F BARNSTABLE 2ppricatiou,,.lor Yell (Cougtructiou permit Application is hereby made for a permit to Construct(r/), Alter( ), or Repair( ) an individual well at: -ct Location-Address Assessors M p and Parcel 1I � 23 0IJ Ao97- � �. Q G vj u I J u ti Owner A dress i f —Installer-Driller__ r C, Address \ Type of Building Dwelling Other-Type of Building No. of Persons Type,of Well L/ pJG �/ Ca acity Purpo d of Well Agreeme it: T1he undersigned agrees to install the afore described individual well in accordance with the provisions of the .Town of Blarnstable Board of Health Private Well Protection Regulation-The undersigned fulIJ,er,'gr?s not to place the j well in operation until a Certificate of Compliance hasp.een issued by the Board of Health. Signed; Doe-w��Z7 I _ Date kl.Application Approved By �/ ` q Date Application Disapproved for the following reasons: Date Permit No, � w`� "V� _.—_ --_ Issued — Date e o-----a—tee--e—ore ----------..-....._------------------- ------------------------------ BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(G)! Altered( ), or; Repaired( ) by De���S SC-e*AnJAJC Installer at 9 POST P c� has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well/Protection Regulation as described in the application for Well Construction Permit No. 1k))tj 'Q Ll Dated 510/1-/ r / THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector .- .-.r se r-r-se.eas.r.r�cr-.'a b.Yl"s'9L'IWya sue' .rR.yve.aom---eWs---:+ea- ---oo----w-o•------s-rO--.as -Ae--- ------ews-s- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Cou5tructiou Vermtt No. �/ >� Fee 1 -Permission is hereby granted to D eK.Aj/$ _jAj Al r- (1 Installer ' to Construct(yr, Alter( ), or Repair( an individual well at: No. r-�O.� /Oo s T ni J Street r as shown on the application for a Well Construction Permit No. o?. Dated 4/Vh r Date Approved By ,r' r t` 0 lJ e ✓ ���r.J r�Gu r �ePfj tj Commonwealth of Massachusetts 6;17l. Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 923 Old Post Road Property Address - M'y James Eastman ;] Owner Owner's Name ' information is required for every Cotuit /� Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection 00 Inspection results must be submitted on this form. Inspection forms may not be alter d in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere key the return Name of Inspector Y Cape Septic Inspections �I Company Name 624 Old Barnstable Road Company Address > Mashpee Ma. 02649 tty own , State Zip Code 508-280-3356 S13938 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 05/05/2016 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •'' 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. Cityfrown 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: This home has a H-10 1000 gallon septic tank and a H-1 0 D- Box and a recast leaching pit. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 923 Old Post Road . Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yr 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑. ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 923 Old Post Road Property Address James Eastman Owner Owner's Name information is COtUIt required for every Ma. 02635 05/05/2016 page. City/Town 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. ❑ Z 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 923 Old Post Road Property Address ' James Eastman Owner Owner's Name information is Cotuit required for every Ma. 02635 05/05/2016 page. Cltyfrown 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? ® ❑ 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •°' 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code .Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: In 2015 173,000 gallons were used and in 2014 122,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments sV.,y 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 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: Home owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons gallons How was quantity Drivers Est. q y pumped determined? Reason for pumping: Home owners request 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): i t5ins•3/13 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 M 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36" feet Material of construction: ❑ cast iron ® 40 PVC El other(explain): Dis tance from private water supply well or suction lin e: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 24"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: standard H-101000 allon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h s•'V 923 Old Post Road Property Address James Eastman Owner Owner's Name information is ` required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness ill Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert evidence of lea kage, etc.): would recommend the new owner put the tank p on a maint. Ian with a local septic pumping p p p pmg co. based on the future use of the home.The Barnstable Health Dept has a list of local pumpi ng co Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. Cityfrown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.•' 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection there no signs of solids carryover or evidence of past hydraulic failure Y Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 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 to ryAssessment s SVe,� 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: one ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there was apx. two feet of standing water and there were no signs of past hydraulic failure. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923 Old Post Road Property Address James Eastman Owner Owner's Name information is re uired for every COtUIt Ma. 02635 05/05/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.)- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. Cityrrown 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 r ?c- 13 ,"j, I+ 0 j e>-27 6ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 LO CAT IONLO,4 a3 SEWAGE HERMIT 1110.29e VILLAGE Co&lr 12w I.NSTALLER'S NAME & ADDRESS z2z(,4aw Ay.-4s- - BUILDER 01 OWNER DATE PERMIT ISSUED �5f S3 ODATE COMPLIANCE ISSUED 0 90" D c- i Po Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 923 Old Post Road Property Address James Eastman Owner. Owner's Name information is required for every COtUIt Ma. 02635 05/05/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 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 M 923 Old Post Road Property Address James Eastman Owner Owner's Name information is required for every Cotuit Ma. 02635 05/05/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Ct c / l v t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 J` shingled wall �.. 7�L ��'-[� • s� T T T'T�TY.. . T' "T �slo / e vs 4:1) 1 'T T TT•Y..TL,Y.•T -C T Y""T Y"T�T'T Y'•T'T'Y'T 7'-6" inside shingled wall concrete foundation 4- 8'-0" 16'-2" pw foundation design?? (must be enclosed) fib, .4o,ar nLYc � Scale: 1/4" = 1 ft = Add NORTH SIDE WEST SIDE (FRONT) ® ��• = Remove P D�vC �fi�/� r �Y yy� S 41). f jlpS�Yv r,.� 923 OLD POST RD - MBR & Bath / ) 317107 r N 8�-0" AL ' NEW Scale: 1/4" = 1 ft Closet& FMBR dressing area, Garage under = Add = Remove xsfn 8� 16' 2„ �- SUN PORCH DETAIL -A R shelves w do r foundation line of VANITY area original house r:original #oundatio all under` r _ TUB/SHOWER area r M fi l3r�l OPEN BASEMENT UNDER = � 9a3 0l � 923 OLD POST RD = MBR & Bath 311107 �3 61P05i, VV C6vk , • � FI r , � o 04f o(sf• t6y o, ;Nb i §'3 Commonwealth of Massochusetts A&K Executive Office of Environmental Affairs SEPTIC SYSTEMS Department of ;} PLUS {x: ' Environmental Protection 'septics repaired, replaced, redesigned Complete from permits to landscape William F.Weld Governor v d 540 6706 � 7 Trudy Coxe �• � Secretary,EOEA x'`r David B. Struhs Commissioner ll ", r•r.` SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A sou;' CERTIFICATION'. j�Y•Property Address: 923 Old Post Rd. Cotuit Ida. Address of Owner: Mr- & Mrs.. Robert Covino. Z;pate of Inspection: 3/1/96 (If different) # 28437 Verde Ln. ht,4N Inspector: ame of Inst r James M. Kerrigan Bonita. Sp,rings„_-Fla. 33923. y [ompany,Name, Address and Telephone Number: Y „ p• } - `'•`CERTIFICATION STATEMENT . I certify that I have personally inspected the sewage disposal system at this address and that the information reported mow Is t� r' accurate fi�,ancl 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: ® r � r , + Passes m RECED y' Conditionally Passes E ..,. Needs Further Evaluation By the Local Approving Authority C3. MAR 6 . a+ Fails 1996. ) Inspector's.Signatu Date 3 1 96j The System Inspector shalLsubmit a copy of this inspection report to the Approving Authority within.thirty.(3( days of .m letrng thrs�' ,�tnspection.` 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 � tihe report to the appropriate regional office of the Department of Environmental Protectiori.:` . jq,Ahe original 'should be sew tc: 1ne ?)'stem owner and copies s6-,t to the buyt;, if applicable and the approving iauthont�. . • - , i' INSPECTION SUMMARY: �f s Check A, B;.C, or.D: "'A] SYSTEM PASSES: 'I have not found any information which indicates that the system violates any,of the failure criteria as defined in 310 CMR 15 303 Any failure criteria not evaluated are indicated below., ASS) SYSTEM CONDITIONALLY PASSES: One or more system components need.to be replaced or repaired.`The system, upon completion of the.replacement or repair, passes inspection. � )ndicate yes no .or not determined.(Y, N, or ND). "Describe basis of determination in all instances If. not.determined", explain why not)... la 'The septic tank is metal, cracked, structurally unsound, shows substantial .Infiltration or exfiltration r , or tank failure a imminent. The system will pass.inspection if the'existing septic tank is replaced with'a`conforming septic tank as: approved by the Board of Health. ,., (revised 8/15/95) 1 # (fib} �-.. One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 t� ice,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION\FORM PART"A «;t CERTIFICATION(continued) t '" Property Address: 2 0 d Po R . n 1 st d Co i 9 .3 t u t Ma. =Owner. Mr. & Mrs. R. J. Covino` `},pate of Inspection: 3/l f 96 BJ SYSTEM CONDITIONALLY PASSES,(continued)' 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): f broken pipe(s) are replaced. . obstruction'is removed distribution box is"levelled or replaced x cr 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):. �t broken pipe(s),are replaced y s a. obstruction.is.removed r`° 44 �] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditionsexist 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. s +' 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH,DETERMINES THAT THE SYSTEM 19 NOT.FUNCTIONING IN1 A MANNER -, WHICH WILL.PROTECT THE PUBLIC HEALTH AN,D.SAFETY AND-THE ENVIRONMENT: t" Cesspool or privy is:within 50 feet of a surface water �:• Cesspool or privy is within 50 feet of a bordering vegetated wetland or a,_salt•marsh.: , " 2)`" SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES'THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC-HEALTH:AND SAFETY AND THE ENVIRONMENT: The wstem has a septic tank and soil absorption system ano is witnm luu feet_to a sunace wafer suNNiy'-or uioutary to a.' f surtace water supply. w The cvste� ha a Septic tank and soil ab sorption"system and is within.a Zone 1 of a public water supply well. r The system had a septic tank and soil absorption system"and is within 50 feet of a private water supply'well. >J r _ Tlie system has a septic tank and soil absorption system and is less than:-.100 feet but.50 feet or more from a private water supply well, unless a well water.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. . DI SYSTEM FAILS: t. I have determined that the system violates one or more of the following failure criteria as defined in 31.0.,CMR 15,303; The basis kj"' . for this determination is identified below.'The Board,of Health should be contacted:to determine what'wil_I be.necessary to correct the failure: Backup.of sewage intahcility,or system component due to an overloaded or clogged SAS or cess ool. M P _ Discharge-or ponding of effluent-to the surface of the ground or surface waters due to an overloaded or clogged, or cesspool. .� a r (revised 8/15/95) Z. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPItCTION`FORM �3 PART A CERTIFICATION (continued) ,Pro err 'Address: 923 Old Post 'Rd.. Cotuit `.Ma. ;:Owner; Mr. & Mrs. R.J. Covino `pate.of Inspection: 1 3 6. •- 9 0) SYSTEM FAILS.(continued): _ Static liquid level in the distribution box above outlet invert due to an overloaded or`clogged,SAS or,cesspool..` a Liquid depth in cesspool_is less than 6' below invert.or available volume isjess than.1/2 day,flow. Required pumping more than 4 times in.the last year NOT due to,clogged or obstructed ptpe(s);J x:. Number of times pumped ter Any portion of the So.il Absorption System, cesspool orprivy is belowthe high groundwater elevation. 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 pubic well. Any portion of a cesspool or privy is within 50;feet of a.private water supply.well F f., `'. Any-portion of,a cesspool ror privy.is`less than 100feet butgreater.than.50 feet from a,private water supply well.with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water.analysis for*. r" coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate,nitrogen. i xv j`E) IARGE.SYSTEM.FAILS: ' k A. The following criteria apply to large systems in addition to the criteria above. . The design.f[mv of system is 10,000 gpd or greater (Large.System) and the:system,is a significant threat to'public health and safety ` - ,i and the environment because one or more of the follo��ing conditions exist _ the system is within 400 feet of a surface drinking water supply r ;the system is within 200'feet of a tributary,to a surface drinking water supply F the system is located in a nitrogen sensitive area'(Interi.m:Wellhead Protection Area (IWPA) or a mapped Zone II of a public w r atesuppi� well ,',The owner or operator of any such system shall bring the-system and facility into full compliance with the..gr6undwater treatment program '.. 4requirements of_3.14 CMR 5.00 and 6.00. Please consult the. local regional office of the Departmentfor further information. rI p 5� ;L ._ yT T (yevised 8/15/95) 3 ?x • r fr SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B k f CHECKLIST Property Address: 923 Old Postd'. Cotuit Ma. Owner. Mr. & Mrs. R.J. :Covino Date of Inspection: 3/1/96 Check-if the following have been done: A Pumping information was requested of the-owner,occupant, and Board of Health. < D - + None of the'system components have.been pumpe'd.for at least two weeks and the system has been receiving normal.flaw rates f°Y during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ; As built plans.have been obtained and examined. 'Note if they are not available,with N/A + The facility or.dwelling was inspected for signs of sewage back up. .4 +'The system does not receive non-sanitary or industrial waste flow �. + The,site was:inspected for signs of breakout.,. = t. ' J i All system components, luding the Soil Absorption System, have been located:on'the site. ' + The septic,tank manholes were uncovered,, opened and the interior of the septic tank was inspected for condition of baffles,or' tees, material of construction, dimensions,.depth.of li uid,.de th Hof sludge, Ie th•of scum.. � P� 4 P g P °. - + The size and location of the Soil Absorption System on the site has been determined based on existing information or r ` , approximated by non-intrusive methods: ' 7ite iaulit�. o ,r,t. : „ c,.c.,; LL:, ii d 'ferent were provided with information,on the proper maintenance of:Sub Surface Disposal Svstem.. e ,. u n : v P't.revised 8/15/95) 4 vh �< SUBSURFACE SEWAGE DISPOSAL SYSTEM"INSPECTION FORM k PART C SYSTEM INFORMATION r L ;Property Address: 923 old Post Rd. Cotuit Ma.' ':Owner: Mr, & Mrs. R..J.• Covino I �Qate of inspection: 3/1/96 FLOW CONDITIONS' 4. j'RESIDENTIAL ;;Design flow: 330 gallons ",Number of bedrooms: 4 -*Number of current residents: 2 Garbage grinder(yes or no): Y . 71. Laundry connected to system (yes or no):„ Seasonal use (yes or no): Y Water meter readings, if available: n 1 (oq 12L' � f7�l4t,date of occupancy: 9/l/96 +COMMERCIAUINDUSTRIAL: Type of establishment: - �lResign flow: gallons/day £`Grease trap present: (yes or no)_ ;{:Industrial Waste Holding Tank present: (yes or no) KNon-sanitary waste discharged to'the Title 5 system; (yes or no) "<Water meter readings, if available: h, -------------- c last date of occupancy: OTHER: (Describe) "fl:ast date of occupancy: - GENERAL INFORMATION '!P•UMPING.RECORDS and source of information: System pumped as pan of inspection:(yes or no)� if N/A yes, volume pur�lre4 Reason 4or pumping N A ' TYPE:OF SYSTEM Septic tank/distribution box/soil absorption system p Single cesspool 4 rt Overflow cesspool Privy F. Shared system (yes or no) (if.yes, attach previous inspection records, if any) Other'(explain) lAPP,ROXIMATE.AGE of all components, date installed (if.known).and source of information:,:,_1983 (Builder) I Sewage odors detected when arriving at the site: (yes orno) No . (revised- 8/15/95) S . x; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; t PART C , •r p SYSTEM INFORMATION (continued) Property Address: 923 Old Post Rd. Cotuit Ma. Owner: Mr. & Mrs R.J. .Covino pate of Inspection: 3/1/96 .. (`SEP71C TANK+ 3 s } iplan)` ovate on s to Depth below grade: 12 Material of construction: + concrete metal FRP other(explain) 19 ,Dmenstons: 8'6" X 4'10" X - '7" s.Sludge depth: -11, t Distance.from top of sludge to bottom of outlettee or baffle 3 s 8 1 Scum thickness: 1/2 n Distance from top of.,scum to top of outlet tee or baffle:_ '�' q.istance from bottom of scum to bottom of outlet tee or baffle: 30" Comments: '(recommendation for pumping, condition of inlet.and outlet tees or'baffles; depth yofaiquid'level.in relation to outlet,inverf,structural integrity, evidence of leakage, etc.). All rnm=nnPnte ;„ gnnr� 'anal a anrl iTrirkina girnpprr GREASE TRAP: IIT;/A ;'(locate on.site plan) . Depth below grade: 'Material of construction: concrete metal _FRP other(explain). Dimensions $Cum thickness: , y';Distance from top of scum to top of outlet tee or baffler ce from bottom crtl— t„ tOtlnm Of OU!le! tee or oattie: '..•Comments: (.recommendation for pumping, condition of inlet and outlet tees or.baffles; depth of Itquid 4level m relation to outlet invert, structural integrity, evidence of leakaec; etc,(' , +..eq - ":(revised 8/.15/95) 6 'a f N t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {` PART C. SYSTEM,INFORMATION_(continued).: i'aProperty Address: 923 .Old Post Rd. "Owner: . Mr. & Mrs. R.J. Covino �,bDate of Inspection: 96 5. , ; 7-TIGHT' OR HOLDING TANK:_ Mlocate on site plan) NPrk Depth below grade: lvlaterial,of'construction: _concrete metal FRP_other(explain)` ., _ ,;bimensions: }iCapacity, . gallons r a Design flow: gallons/daj 4 Alarm level: Comments: ,tcondition of inlet tee, condition of alarm and float switches, etc.). fir. ♦ ... .._ fl- DISTRIBUTION BOX: (locate on site plan) ,. r , jyQepth'of liquid level above outlet invert:` 0. x Comments: (note ii lec`el cnCl GnJ.v : . i..GC:'„i G' I,d> c: .,J,C,, 6 idence.of leakage into or out of box, etc.) , PbMP CHAMBER:—L[A r (locate on site plan) `Pumps in working order:(yes.or.no) ' -"Comments: t(note condition of pump chamber, condition of pumps and appurtenances;,etc.) r • (revised.'8/.ls/95) 7`, �. SUBSURFACE SEWAGE DISPOSAL-SYSTEM:INSPECTION FORM:; M1 >� PART C SYSTEM INFORMATION'(continued).. ,:Property'Address: "923 old Post Rd N.Owner: ME. & Mrs R:J. Covino t Date.of Inspection: 3/1/96 ,). 1 SOIL ABSORPTION SYSTEM (SAS): t (locate on site plan, if possible; excavation not required, but may be•approximated by_non-intrusive methods) ;.; Of,not determined to be;present;explain: ' n e• ;T eY a>YP leaching pits, number:_l ~ leaching chambers, number, leachrrig galleries, number, €�k' i leaching trenches, number length: leaching fields, number, dimensions: p, overflow cesspool, number: a ,Comments: (note condition of soil; signs of hydraulic failure, level'of ponding, condttion:of vegetation,etc.) ,f t, V CESSPOOLS: A ` � u .;(locate on site plan) Number and'configuration: ; ;,Depth-top of liquid to inlet invert: %Depth of solids layer: (:Depth of scum layer: s t,D.imensions of cesspool:' ulvlaterials of construction: Indication-of groundwater: jt�_° :t�•inflow (cesspool must be pumped as part of inspection) • ' Comments: (note condition of soil;'sighs of'hydraulic failure,,level of pon•ding,,condition of,vegetation; etc.) .` _. . - PRIVY: N/A . (locate on site plan) Materials of construction: Dimensions: r' %;t,Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised `8/15/95) $ Y 10 n SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,.',Property a Address:� � Owner: C,5Q pate of Inspection:�,I (a� -SKETCH OF SEWAGE DISPOSAL SYSTEM:, n . : V 'include ties to at least two permanent referenc landmarks or benchmarks locate all wells within 100' T. N - - - #. Lid } gar ` r �\ ,DEPTH TO GROUNDWATER 'pepth to groundwater: a feet method of determination or approximation: 0;S � , E�c�•J Sv Rt- t^ . (revised .8/15/95) 9 . LO CATION�u n SEWAGE PERMIT NO. V,F L L A G E �Q T I N S T A LLER'S NAME i ADDRESS S U I L D E R OR OWNER QZ DATE PERMIT ISSUED 1� ' /J-^ -� DATE COMPLIANCE ISSUED _ � 0 o ✓ o � � � '' o' ��f i .., a L 5,V , No............ ........... .. THE COMMONWEALTH OF MASSACHUSETTS _ BOAR® OF HEALTH ......;7/—? A✓......_.....OF............ 1 Appliration for Di_gpoii al Mudg Tomitrnrtion Vami# Application is hereby made for a Permit to Construct (,�() or Repair ( ) an Individual Sewage Disposal System at: . GP>.... PEST .......F 2............._... c!!. . G......... i7 L ation-Address or Lot No. !.. ......•••--•••-••--••.............Q................ •--••-----•-.....................••. ......••••---•----•••--•----•-•..................-- Ownez Addr fj 'Ili G G�-------------------••-. Installer Address U Type of Building Size Lot.42,.:5_G.0...Sq. feet Dwelling—No. of Bedrooms..............3........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No.. of persons............................ Showers — Cafeteria dOther fixtures -------------------------............................ W Design Flow............a�a..............._....gallons peiVE =,arltpere�i'd-tay. Total daily flow.................3 ..!Q.............gallons. WSeptic Tank—Liquid capacity/5 gallons Length/?!::!'2..... Width6..'©... Diameter________________ Depth... x Disposal Trench— No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......1........... Diameter... Depth below inlet._._�...El: Total leaching area..._ZG sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.--7.. -......r_,_Ez) Date........................................ Test Pit No. 1---Z.Z-__minutes per inch Depth of Test Pit__ Depth to ground water......:-.............. Test Pit No. 2... .Z...minutes per inch Depth of Test Pit._J4.51' _... Depth to ground water........................ s f . i, O Description.of SoiLT-,=—5T---- �-•-----------------z-•---......----- ................................_'..�__�.-���ir+.-----".. ........��.............................. r J 4......... rs W --•-------------------------------•--------------------------------•------------------------------------------------------------------•------------------......._..--------------•--------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T`:,- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been jjsued by t e boa d of health Sign ---- ...... -•-•----------•----------------------• _ �_ 'r-l......--••----•-••-•--•-. Date Application Approved BY ` ............. ... -l _ = Date Application Disapproved for the following reasons------------------------•----• ------...... ........................................................... ----------------•---...---•---------------------------------•---••-----------------..........-----------------------•---------------•--------•------------------•----••---------------------•---..._.._. Date on Permit No_____________________ .. Issued: .......C�J �^ - •-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /.o1�c/s✓ /-5 T3L OF........ f��2..... T/'� ....... ....................... ;,, Kir i n for Bi�pu�ttl orkfi Tomtrnrtion amit Application is hereby made for a Permit to Construct (X or Repair ( } an Individual Sewage Disposal System at• .. Gam. 5.T .Ro�D A, Lrl- C.=a 7"1... 7i9Y. G2�S Address or Lot No r�GYPn ti i _ ............. ..... .....................................::_._.... ........... �F j �/t tN -t /t`3�E fret /�l BAddr /t�..... ........ 6�' .�. � a ................ ..............................t...___......_._......_.......................... ...._.... .-• -------_._._.._......... Installer Address Type of Building j�.rooms 3 Size Lot.4 7__45Q��..Sq. feet U Dwelling—No. ofBed Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of-, ildiheY ......................... No. of persons.............................. Showers ( ) — Cafeteria ( ) Q, Other fixtures -------- '------------------------ W Design Flow..............Ilia....._ .._._gallons per.perse per day. Total daily flow.................... ..............._.33 G Ions. 49 P q p "y ,�UOg ..s, P /.. x Disposal Trench—No............ .Width___ ._.. Total Length.................... Total leachingarea.... . W Septic Tank—Li uid�ca aclt allons en h/�'.U._. Width_�.....�1._ Diameter_____ -_---- _ lle t p � ,_f7"De i below >nlet.._6...eET... Total leaching area.... sq. ft. Seepage Pit No �.. __.:. Diameter pti g `�sq. ft. Z It Other Distribution box'(X' ) ;Dosing tank a { Percolation Test Results .Perfoi rs d by._s�[__>a,2F_ �o _.._ `�'�M___.____. Date........................................ a Test Pit No 1__ Z_„muiutfs per inch Depth of Test:Pitt.14 y_ Depth to. ground water------- ............ Test Pit No.2.L ancU Dp of Test Pit....!............. Depth to ground Water _____, r,� ......................................... = -- ---- - ------------- �. O j Descr�tion of Soil 7. 7_.. Z <� - r� i'"' �� - =1�� W --•--•-------------•-----------•---._._. .... .. ''... Ut Nature of Repairs or Alterations. Answer when applicabI------------------------------------------------------------------- W=k.-•--------•---------•-•••....-••---•-- ...---------------------------------•••-•••••-•-•-•-•--•-••------ --------------------------------------•-----------------•---......--•-------- Agreement: o The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with f'1T�'1'•-� the provisions of T ' , 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance haZbeen ' sued by t eboarof health.WSign � ----------- •.... " � .............•Application Approved By--•-.•• •---•--. ................. -------------------- ----•----•••• --- Date Application Disapproved for the following reasons:--------•-----------------------------------------------------•---......-------------------------•••••......----- x , -•--------•---•--- ---------------------••--•-----------------•-----------•------•---------•...................••-•---•-•----••-----•-•- ------ ----------------•--- i t ---------------Date PermitNo......................................................... Issued_............................ Date ¢ THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 4 Y SNP , ................. ...................... OF..... ; ....... Trrtifir tr of Tom' Banta THIS TO ERTIFY, That the, Individual Sewage Disposal System constructed (° or epaired w at-- ........................................................ ----.........................--------..............-•----------....•........------. has been installed in accordance with the provisions of t ' ,.j o Tie State Sanitary C4, !e,.ay#sor in the application for Disposal Works Construction Permit N ......................................... da.ted_:.------------- OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM"WILL FU TIO SATISFACTORY / DATE............... . ..•--••--•--••................. .-------••-•••-;*-----. Inspector < +` THE COMMONWEALTH OF MASSACHUSETTS- BOARD OOHEALTH . ....... ..........OF................................................................................... No......................... FgE........................ �onothtdion permit Perm> sion ereby gra ted . .. -------- L-•.0 to Constr t or ep [ Indiv' ' al x st t f ' as shown on the application for Disposal Works,Construction No !. _ � = - / , _ t ..................................................................... ........................%.._ ...... Board off Health DATE.............. FORM 1255 HoeBS & WARREN. INC.. PUBLISHERS - - WIWI D 1 t T. o/°° / w �T 7, O /007PUTUf?E EX!-�AiV S�oN. cq /O T. . L EA CH//V C> ? P1 T ( 1 so sr �0 ✓ . �o,Nh�2 � m p 46 70 (, m I • \ 7 5T Ai 2 2/. 72 J -LO-7- ..EX/ST/i\/G' AN.D :c/%/�IL �2.9,DE'S ? • HIASSACyGs�T rfR��0�' 606 6 �A; j� Ear' LEGEND tnhv EXISTING SPOT ELEVATIONS LEVA IONS O,A C'✓. EXISTING CONTOUR- - - 0- - - - FINISHED SPOT ELEVATIONS 0.0 FINISHED CONTOUR-0 PROPOSED PLOT PLAN APPROVED BOARD OF HEALTH 1-?-z9--RA,1 s7-,,AgaLF . MASS. DATE AGENT (lor /7- Agv S o2FS I CERTIFY THAT THE PROPOSED R. J. O'HEARN.. INC., RLS, RS BUILDING SHOWN ON THIS , PLAN 1348 ' ROUTE 134 CONFORMS TO THE ZONING LAWS EAST DENNIS , MASS. OF 8A2^/s,74- a ,G, MASS. DATE : a /a 'q G SCALE: G JOB N 0..80- 72 O CLIENT: 10) E REGISTERED LAND SURVEYOR �L 9 DR. $Y • �/� Si a,E�T _� OF L SOIL TEST INVENT ELEVATIONS NOTES: DATE OF SOIL TEST INVERT AT BUILDING 255 FT. ALL WORKMANSHIP AND MATERIALS WITNESSED BY 5k;2 F 77,/yl INLET SEPTIC TANK 25_, FT. SHALL CONFORM TO D.E.Q.E. TITLE 5 PERCOLATION RATE -e Z MIN./INCH OUTLET SEPTIC TANK 24. S FT. AND THE TOWN OF )3/1/0n/• RULES INLET DISTRIBUTION BOX 2-A FT. AND REGULATIONS FOR SUBSURFACE OBSERVATION HOLE I OBSERVATION HOLE 2 DISPOSAL of SANITARY SEWAGE ° ELEVATION = Z 5 ELEVATION= 2 S OUTLET DISTRIBUTION BOX z • 3 FT. _0 _ INLET LEACHING PIT 0 0 FT. I La.q� �a.qm BOTTOM LEACHING PIT /S'•o FT. sa�� s�So,� DESIGN CALCULATIONS , ! svl3 NUMBER OF BEDROOMS 3 GARBAGE DISPOSAL UNIT . . . , , . v� s TOTAL ESTIMATED FLOW (1CLGAL./BR./DAY x.-_? BR.)... 33 U GAL./DAY �og2s4. mac, Co�2s� To REQUIRED SEPTIC TANK CAPACITY. . . . . 6 O GAL. Mao s� MF� ACTUAL SIZE OF SEPTIC TANK TO BE INSTALLED... . LEO O GAL. LEACHING AREA REQUIREMENTS • SIDE WALL AREA O-ZEGAL./S.F. BOTTOM AREAL_ GAL./S.F. LEACHING CAPACITY ( BOTTOM +SIDEWALL ).. ... . . . . . . . 5 ¢9 GAL. 3•/41 x 5x -:5 x/,a + .3./44xa,< /6?ar z•,5 20 RESERVE LEACHING CAPACITY. S�9- GAL. TOP OF FOUND. ELEV.= ZB, T Mir/• CONCRETE 4 SCH. 40 CLEAN SAND COVERS PVC PIPE CONCRETE MINA PITCH COVER 1/8 PER. FT. `ZF1OFA1,q 2% MIN. PITCH a��P sr9�y 3 12 MAX. o RICHARD G i ' v Iz 4 N 2�� LAYER OF 1/8�1 1/211 °;�;E 94 �+ FLOW LINEp WASHED STONE o � FGIS-T 4" CAST IRON �� � � ° o � 3/41- 1 1/2 C'8 7V^1 1)7 SgNITA PIPE - MIN. PITCH G w WASHED STONE 1/4" PER FT. DIST. PRECAST LEACHING BO X X � °- o BASIN OR EQUIV. D w D vl w n U- b 0 n o LOT 6_0 /moo SAL w _ /�i92�/S'Ti9 �3G� MASS . SEPTIC F� �� cr , TANK /o ter. �ir�. ,r,,••� R. J. 0 HEARN, INC., RLS, RS 191 MAIN ST. (RTE 28 ) WEST DENNIS , MASS . PROFILE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM JOB NO. 7Zo CLIENT.�n����.✓�,w�� NOT TO SCALE DATE //BG SHEET Z- OF Z- f' ION t S EWAGE PERMIT NO:a�®. LOCAT /o� � VILLAGE , 60&l r I N S T A LLER'S NAME a ADDRESS BUILDER OR OWNER DATE PERMIT 14SSUED /ftyC ��, F3 C DATE COMPLIANCE ISSUED t No......49 - D /�• Fps. . .... s • THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ....................OF.......................................................................................... Applira#ion for Bhipao al Works Tomitrurtion rumit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: 57 ..-------- -•---------------------------- ----- ............................ Lo rot No.. . ZZ, a a r�f �n .. ... ... ... ... . ... � ddre ..�t ?'!!.L�f ........ Installer Address L/ d Type of Building Size Lot .A Sq. fe�jt U Dwelling—No. of Bedrooms.... ....... ..........................Expansion Attic ( ) Garbage Grinder (74 Other—Type e of Building �°.............. No. of ersons............................ Showers — Cafeteria Pa yP g -------------- P ( ) ( ) a' Other fixtures .--•----------------------------------------d -------------•------ W Design Flow............. ...............gallons per person per day. Total daily flow............... .................gallons. WSeptic Tank—Liquid capacity Z gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width_....j....__.._.:. Total Length......... __y.... Total leaching area____.._..._...c.�....sq. ft. Seepage Pit No.__../--_._--_-___- Diameter..._. .__._... Depth below inlet:......L......... Total leaching area.Jl.C...:sq. ft. Z Other Distribution box Dosing,tank ( ) Yater -0" Percolation Test Results Performed by..,./ ��...._...�tY�fi��1�........................... Date...._. `/ 'd_._...._....... ... .1.4 Test Pit No. 1................minutesperinch Depth of Test Pit.__.._............._ Depth to ground ......................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------•--- �y•------------•------...------......------.....-•-------........_................._........................................ O Description of Soil �... L�.f�� ._, .---•---•-•--------------------- ------------------- x W •-------------------------------------------•------...----------------------•---•----------•-----------------------------------------......-------------------------•---------------------------------- i U Nature of Repairs or Alterations—Answer when applicable......:...................:.................................................................... ............-........................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iTL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation u tiI a Certi sate f Compliance has bee :issued by the board of health. Signe � Lam......................... ��RE ---•----- •. ate Application Approv By----•- � ................................••-- .� ......---------- r Date llowing reasons:_...---•--------------------•---•---•---...-----------...-----•-----------------•---•---------••------•--....... Application Disapproved for to .•----•-••-----•-------•..........................•......---•••......----........_..__...-----•-----•----------....._.............••--•-_....._..--•-•-............................ -•----------.. Date PermitNo............... ..... .... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' . .......-----V---.....OF.......................................................................................... Appliration for Diipoiittl Works Towitrurtion ramit Application is hereby made fora Permit to Construct (Y or`Repair ( ) an Individual Sewage Disposal S stem �' ................................................ ............ -**"i* Lo t V •` br j��No. ^T ............... ..... -•--^- -------• jf ... O ner�� Addre Inst911er Address Type of Building Size Lot...... ..! (� .�_�.L.- d .Sq. feet a Dwelling—No. of Bedrooms------------------------Expansion Attic ( ) Garbage Grinder (tA aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfi ....................................-....................................................................... ............._...._.......--- 'r4j WDesign Flow............................................gallons per person per day. Total daily flow.._........._......................._.......gallons. WSeptic Tank—Liquid capacity/ J�.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.................... Width ....... Total Length.._..___._ ._t.__. Total leaching area............ -=--sq. ft. Seepage Pit No...../r............ Diameter.._..e� :_..._. Depth below,inlet......L......_.. Total leaching area. � _._sq. ft. Other Distribution box ( Dosingtank ( ) Percolation Test Results Performed by..Z;-.Z......0./�i �''./j............................ Date......Vater .E/`s'.d................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground .___........_.._..__.__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ ...............------..........- ---------------•-------•----•---•-------•---•----••-••--•....---.......................................................... D Description of Soil....../ ��.. ....'�0.....L'- lC' ........ -W40ve.-------- 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`ILTI-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in opera on u til a C rt�-cate •f Compliance has beeZissued by the board of health. i ned .... ------•--_.... ..... -c f / to Application Approv` By--------------------------..==' •••���1� ....----- ������ Date Application Disapproved for the following reasons:------•----------------------------•---------------------------------------•--•-----------•-------......---•-- --•-----•-•------------------------••----•--•------------------------------------•--------------------------•-----------•--------•---------------------------------------------------------------------- Date PermitNo.......................................................- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 ..........................................OF........................:............................................................ (9rdifiratp of Tootptiattrr t THIS IS TO C IFY, That the Iiddiivid al Sewage Disposal System constructed ( ) or Repaired by .....+� g. = at .....................................................-............................................................................. has been installed in accordance with the provisions of TI'IrI Wes,,}5 of.�Th State Sanitary Code as described in the application for Disposal Works Construction Permit No.._......-'�...`______________________ dated................................................ THE ISSUAN OF THIS CERTIFICATE SHALL"NOT BE CONSTRU A GUARANTEE THAT THE "'SYSTEM W L F TION SATISFACTORY. � f y ti t DATE....j.............. .. .....................•--...._........---••- ._,Inspector... --------- ----------........-•--•------•------------._............._........ T,HE,COMMONWEALTH�OF MASSACHUSETTS BQAR-D}OF� HEAL-T,H / . ......................................OF.... ............................................ .........................:.. No............ '.�-1 ''� -FEE........................ '�tr�ion ti� Permissi is hereby granted------- ---------------------------�------- -- ---;----------•---•---•-----------........................................ �_3 to Consti �R'epaU( `). n I ua ewa isposyseo ./' Street as shown on.the application for•Disposal Works Constructi -ernut No._ ..�...... Dated.._.__._ ... :��....... lX ` -40P Board of Health w ATE ........-' ........................ ----------------------• FOR 1255 HOBBS & WARREN,.—INC.—PUBLISHERS� Q I _ 1 JJJ SITE PLAN 7- YPICAL PROFILE SCALE EL 36,•5 NOT TO SCA L F_ 18"STD. L T. WGT. C.I. MH COVER 4"C t PIPE 4"BIT. FIBER PIPE TIGHT JOINTS � - ,-�� +--•---•------ OUTLET L E VEL7 FLOW LINE ! O �TO .F�S�T JOINT/ OWEL L/NG � I io" - /4 I ( I - _ �' o C. TEE �' 1- _ STANDARD PRECAS' 74 ------� I z B o I CONCRETE 15� `.vAL LON I'. ( i 5EPT1G TANK DISTRIBUTION BOX I TO BE INS TA L ED ON �. LEVEL, STABLE BASF.. I i SEPTIC TANK 1 TO HE INS TA L L EV ON t F vEL , STASL E BASE L.oT 52 T 4 ` s 0� 2„ - ,/8 TO 1/2 WASHED PEASTONF ALL AROUND FREE OF IRONS FINES LEACHING PII T p BASF_ TO BE L E VF1 9 h ANC DUST IN PLACE BRICKS MORTAR COURES .3/4" TO l-1/2" WASHED CRUSHED AS RE.OU/RED TO BRING STONE ALL AROUND FREE OF COVER TO GRADE 24 C./. MH COVER IRONS, FINES 4' r DUST IN PL 4CE- : ; A NO FRA ME ---- - a I T 49 4 A L�ACHINC Pl T SEC TON— ,✓' LOT 5% INLET ' FLOW LINE -r PIPE -- --- - -_�_ I I. CONCRETE TO BE 4000 PSi 28 DAYS OD /' \ �• i - 6„ 2, REINFORCED WITH 6'' x 6" NO 6 GA. W W.M. 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER / I �Y y Ls ,, DEPTH REQUIREMENTS. D"''� `---` _� `O j OPENING WITH 4- 1 4. NUMBER OF PITS REQUIRED — / 8�3L G. ,' 00TER L'IAME TER 8 �y04. � � � 'P, _ vi � NOTE EXCAVATE TO ELEVATION ...�a_OR LOWER AS I-V4 INSIDE DIAMETER cou r>ooQ o.� ° 3 REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH PIT REPLACE EXCAVATED MATERIAL WITH CLEAN f I GRAVEL TO DESIGNED GRADE , I 4c 1 7 L MIN. ' EFFECTIVE DIAMETER j (NOT TO F.-YCEED 3 TIMES EFFECTIVE DEPTN) ,•..• - ..1..- •• WATER TABL E SOIL AND -f IESC. DATA GENERAL NOTES PERC. RATE C ? MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD TEST BY: a;5f&19,erc/, IA-IC• le/-.s RS PRECAST 9EINFORCEC CONCRETE UNITS. WITNESSED BY ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF 'THE STATE ENVIRONMENTAL CODE , TEST PIT GR EL 3O _ DATE '__-_.z,-A;,� MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF TEST PIT N0. 1 TEST PIT N0. 2 SANITARY SEWAGE EFFECTIVE I JULY 1977. 0" -------- ANY CHANGES TO THIS PLAN MUST BE APPROVED Br THE 7a/�-Su•y�ca/L G�LL� BOARD OF HEALTH. 4 AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE CGWAti BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. meo. 7"0 CcWAtl& sr9nw PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED OTHERWISE. l2 •rVD ,�.E'ivO w.9TE� EL• �t3.n DESIGN DATA BEDROOMS 3 DISPOSAL � EST. TOTAL DAILY EFF. 330--GALS, Z_EGE' V� O SEPTIC TANK _ 50:= GAL SIDEWALL AREA 2-5- GAL./SO. FT. �,�/ [� /� BOTTOM AREA __ / GAL./SQ. SEWAGE DISPOSAL SYSTEM Cx00 EXISTING GRADE LEACHING REQUIRED_ 205 • 57 SO FT.T. ZONE'- FINISHED GRADE ACTUAL LEACHING AREA SQ.FT. FOR Oo� INVERT ELEVATION ' �;►OIviE`�TIC '�tiJ-,TER SOURCE Tow.y w,gr�� _ PROPERTY LINE �`.. +K- * 4v` ��� oF - ��.� „�� T' _ la�'ic%rf7� _ >pSS— y PLAN REFERENCE _ t,* , lk.-tw,K; �. f` SCALE' AS INDICATED DATE : 5 � MEAN HIGH WATER INDICATED MARK DATUM YLARw ;6. t ram, r �', G� HEigeiy. /r((fr• eLJ! _ MARSH Y �� Y .. �• „E E: �{ ,. ,J ;-, WM. M. WiQRWICK B ASSOCIATES L90X 80/ - NORTH FALMOUTH MASSACHUSET TS 02556