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HomeMy WebLinkAbout1071 OLD POST ROAD (CT & MM) - Health W Old-Post Road,Cotuit I 1 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: 1071 Old Post Rd. (Main House) Cotuit, MA 02635 Owner's Name: Robert Sachs Owner's Address: �f Date of Inspection: May 23, 2006 Name of Inspector: (Please Print) James M. Ford Hwy ; Company Name: James M. Ford M F, Mailing Address: P.O.Box 49 fix• Osterville.MA 02655-0049 ► .Telephone Number: (508)862-9400 C-3. CERTIFICATION STATEMENT ' I certify that I have personally inspected the sewage disposal system at this address and that the information reporte i 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. 4 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Fu r Evaluation by the Local Approving Authority F 'Is Inspector's Signature: Date: May 30, 2006 The system inspector shall submrcopy f 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 1.0,000 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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: Mav 23, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distributiori box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: Mav 23, 2006 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 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-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FORM PART A CERTIFICATION (continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: Ma v 23, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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 town overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow ✓ 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 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.] 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply 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 L Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: Mav 23, 2006 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 backup? ✓ _ 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: Yes No ✓ _ 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1071 Old Post Rd. (Main House) Cotuit,MA Owner: Robert Sachs Date of Inspection: May 23, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of.bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box;soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 5112197-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 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) Depth below grade: 28" 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: 1500 Qal: Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30 Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage The outlet cover was 12"below grade. GREASE TRAP: None (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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: Ma 23, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: .Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (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 ofpumps and appurtenances,etc.): { . 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required). If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: S flow diffusors(12'x 48'x 2'-per design plans) 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.): The flow diffusors were dry and clean A video camera was used for the inspection There did not appear to be anv signs of failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 r r. • Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 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 enters the building. B �r nT i A c p� a O 3 L3 i i�e 1y y j a /)( 31( 3 3a Iy y. 33 al 10 f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Main House) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: ✓ 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) 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: According to the design plans on file, no ground water was observed at 14'below grade This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected 11 l 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: 1071 Old Post Rd. (Art Studio) Cotuit, MA 02635 Owner's Name: Robert Sachs Owner's-Address: Date of Inspection: May 23, 2006 i Name of Inspector: (Please Print) James M. Ford - Company Name: James M. Ford L «� Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 r t Telephone Number: (508)862-9400 ' CERTIFICATION STATEMENT - I certify that I have personally inspected the sewage disposal system at this address and that the information reported;; below is true, accurate and complete as of the time of the inspection. The inspection was performed based onY_ny �3 training and experience in the proper function and maintenance of on site sewage disposal systems. am a DEP '} approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system] ✓ Passes Conditionally Passes Ne s Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: May 30, 2006 The system inspector shall sub 't 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 L Page 2 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1071 Old Post Rd. (Art Studio) Cotuit, M.4 Owner: Robert Sachs Date of Inspection: May 23, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1071 Old Post Rd. (Art Studio Cotuit. MA. Owner: Robert Sachs Date of Inspection: May 23, 2006 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 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-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1071 01d Post Rd. (Art Studio) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS.or cesspool ✓ Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow _ ✓ 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 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. This system passes h pp y p q ty y [ ys p s s d 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.] 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above). Yes No the system is within 400 feet of a surface drinking water supply 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1071 Old Post Rd. (Art Studio) Cotuit, MA Owner: Robert Sachs Date of Inspection: Mav 23, 2006 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: Yes No ✓ _ 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1071 Old Post Rd. (Art Studio) Cotuit. MA Owner: Robert Sachs Date of Inspection: Mav 23, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 1 Number of bedrooms(actual): I DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,.if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 1018197-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page Tof 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Art Studio) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 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) Depth below grade: 21" 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: 1560 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30". Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measurinz stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.)' Tees were present. The liquid level was even with the outlet invert There did not appear to be any sizns_of leakage GREASE TRAP: None (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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 1071 Old Post Rd (Art Studio) Cotuit, MA Owner: Robert Sachs Date of Inspection: Ma v 23, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete -metal _fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day , Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if presentmust be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,anyevidence of leakage into or out of box, etc.): The D-box was level. No solids were bresent: PUMP CHAMBER: None (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.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd (Art Studio) Cotuit. MA Owner: Robert Sachs Date of Inspection: May 23, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) 9 ) If SAS not located explain why: Type leaching pits,number: . ✓ leaching chambers,number: 2 flow diffusors 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.): The flow diffusors were dry and clean A video camera was used for the inspection There did not appear to be any signs of allure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 f - Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Art Studio) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2006 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 enters the building.. r� 13 . `�` 3 �9 Sl 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1071 Old Post Rd. (Art Studio) Cotuit, MA Owner: Robert Sachs Date of Inspection: May 23, 2.006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high groundwater 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) ✓ Checked with local Board of Health-explain: Topographic and water contours inaps. Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:' You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 20'+1-to ground water at this site. I This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There.have been no warranties or guarantees,either expressed,written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected 11 Y ��L/� Fee/`�'"l2'�J No.� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z[ppfication for IDiopo.5al *pgtem Con6truction Permit Application for a Permit to o t )Repair( )Upgrade( )Abandon( ) N�Complete System ❑Individual Components Location or Lot No. Q�Q O s OwDW' Name,Address and Tel.No. — U,( Joan L.ArnPC Assessor's M /Parcel �a t,�a.rn n �Iamfk6h o toi3� o8-Vcoa-1�15 I ttaller's ame,Address,and T 1.No. Designer's Name,Address d Tel.No. pyPiCK , i�eh �i�u.I E., 5'wee�SEP- PP d�-j'' t'je- Boa p,b� pox 6& tLoI , MOIL-rM t< A d�(o73 �•It -o272 E.� KAQ.,ta6� 41tA - oato'45 5o%- y,32- Type of Building: Dwelling No.of Bedrooms Lot Size / ? sq. ft. Garbage Grinder( ) Other Type of Building pr•� �i Lta l o No. of Persons `�I'' Showers( ) Cafeteria( ) Other Fixtures Design Flow Z-b b gallons per day. Calculated daily flow Z 0 CD gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Ei00 Q A Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) :3 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boafd of Health. Signed L�� t ` Date 10-Z Application Approved b - Date -"e•' �`�� Application Disapproved for the following reasons Permit No. r Date Issued 9® '" No. 7 Fee Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS !t 9 �.. 2pplication for Diopoai *pgtem Construction Permit Application for a Permit to oft t. )Repair( )Upgrade( )Abandon( ) U'(fomplete System O Individual Components CJ Location Addres or Lot No. a t Q o 5 KQ, OWQU'$Name,Address and Tel.No. tolto i T t Joh _A (,t n1� �+�m nrn G•-c>.n E / Assessor's M /Parcel `k P M I d h me O l�13�o K G�;-4 I� ler's ame,Address," d Tel.No., D signer's Name,Address d Tel.No. (k`r't ICI< , u�ller, rJu� 1-L peel "III \.)e• �0� PIC:, Qax 5�� SPArRIok-rl,l Mn - C� (�?3 - �1 -c) 21Z l< , Nve uatc ,Cola , oa 5 Q,- �l3z S3c1 Type.of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Rr� Zf uq I o No. of Persons I Showers( ) Cafeteria( ) l Other Fixtures Design Flow Z C�b gallons per day. Calculated daily flow Z a Ca gallons. :. Plan_Date Number of sheets Revision Date 5 e` Size of Septic Tank k S00 A Type of S.A:S. Description of Soil Nature of Repairs, r Alterations(Answer when applicable) i tt: Date last inspected: l Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described qn-site sewage,ydisposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is Bo d of Health. 401 Signed G� ut 1 Date- Application Approved b Date Application Disapproved for following reasons '� ,1 Permit'No. �— Date Issued ~ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS l � s Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( tl-Repaired ( ) Upgraded( ) Abandoned( )by �✓��'-�-/�f1" L' at Z4 V tj77-,r 'F5-- has-been nstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. "' 5`5ated^.11P 0 2W 7 Installer Designer t I t/ 1 / �l. / The issuance of this a sha Ve,llconstrued as a guarantee that thets/stem--wwiilllt function as-dest ne . / Date I Inspector t r � V �� ------------------------Fee =�'No. 9/ '� THE COMMONWEALTH OF MASSACHUSETTS PUBIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpaai Opgtem Construction Permit Permission is hereby granted to Construct( Rep�ai )Upgrade )Abandon(. ` System located at 14 Z I 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 tws 4t. Date: /z�- Approve y� �_ a' r TOWN OF BARNSTABLE LOCATION �d'l I OIt PUT RD• __ SEWAGE # VILLAGE (o r ill ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME &PHONE N0. _ �r tx.lt ell I Oh f�'' Camr,ta ny SEPTIC TANK CAPACITY LSc�d n� LEAC8]NG-FACILrTY: (type) Flow fl i 11C tx.'d r,_(size) NO.OF BEDROOMS �T t1,10 BUILDER OR OWNER PERMIT DATE: 10 3 -q? COMPLIANCE DATE: y Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �� Feet Private Water Supply Well and Leaching Facility-.(If any wells exist on site or within 200 feet of leachingfacility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Qn"C �IIL' g 1 - t.. ri N h V C� Q Q Ctl 44 � a r— - 4�� CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, t'A Tk1 CY, hereby certify that the application for disposal works construction permit signed by me dated ID- Z 4� concerning the property located at CIA P05T 01CO- UjAg meets all of the following criteria: ✓• There are no wetlands within 300 feet of the proposed septic system ./ There are no private wells within 150 feet of the proposed septic system a/• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase in flow and/or change in use proposed / There are no variances requested or needed. SIGNED . �L_� �� t Aur DATE: 0 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. ,Q RT ST'v 8 Ca � 8 TOWN OF BARNSTABLE r. LOCATION /07��/ O�Cl PArr RC1 SEWAGE# VILLAGEOTi1_ ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY SW LEACHING FACILITY:(type) 01' POW ► (size) NO.OF BEDROOMS OWNER SAJIS PERMIT DATE: 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) Feet ` FURNISHED BY ,L n Cn&n + � �AGk B �� . . � ' , �, 13 t is` a.i a 3 �9 S 1 MAte) H ovsc, �I TOWN OF BARNSTABLE ,LOCATION 0'7 Q 1& POsi 2 SEWAGE# C)'� "VILLAG.E C M& ASSESSOR'S MAP&PARCEL 0 -J41 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY /SC*LEACHING FACILITY: (type) A70W /JI'l"h//y'y.� uroxJ (size) NO.OF BEDROOMS OWNER SAG, PERMIT DATE: 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) Feet FURNISHED BY �nrp��liur, �' Fps �r nT A c D` a O B 3 ► 18e �y 3 3a Iy Y 33 a► TOWN OF BARNSTABLE LOCATION 1071 . Olt Pair R D• _ SEWA E # JJ S `�.'MLAGE�_cartL)4 ASSES 0'S � OT INSTALLER'S NAME&PHONE NO. T Mu l Ch#1 4; Comra ra nv SEPTIC TANK CAPACITY 5C1C3 n LEACHING FACILITY: Fln�, IN C ca.. _ (size) 2 x NO.-OF BEDROOMS Am 15+UA10' BUILDER OR OWNER—, Zfoln PERMTTDATE: 10 3 'q? COMPLIANCE DATE: D' Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Pak t t.�46:^' STuo�o A � �T C A -C i 8'1�� R - SJ = 'yitZ�� -�== si Lill Q-� "'_ �' TOWN OF BARNSTABLE LOCA MIN L-nf-Q i SEWAGE # VILLAGE�,QtQ 1 L, ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. U e rile !ciao D SEPTIC TANK CAPACITY LEACHING FACILITY: (type (A) An I) IttU5b1 5 (size) NO.OF BEDROOMS rt.. BUILDER OR OWNER (TOh17 PERMTTDATE: I' D- 9�COMPLIANCE DATE: , --Y l l Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 h�2 Z1616 r,nl cs eG _ ' e 7 07- 3r Q6 � 7/9 `9 No. Fee & "TFI� COMMONWEALTH OF MASSACHUSfETTS Entered in computer: l� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zloprication for Migozaf *p.5tem Construction Permit Application for a Poe in t o Constr}lct(vj�ep ' e( )Abandon( O Complete System ❑Individual Components Location Address or Lot No. Lip T 6 • 0(.0 loobT Owner's Name,Address and Tel.No. Ct,. 0t)4(,g. 6 Gc�TV LT lcma Lq MPl? Assessor'sMap/Parcel 910,emir' Zoe D , X 0 2— 141494IL+T04,Me, Ot93CP Installer's Name,Address,and Tel.No. `; 6. ®�� Designer's Name,Address and Tel.No. CSog�g3z'85�J9 j,/ Y /� fit► $tAif-s-Lbe.9-1PL,S e- ® �1 01 N A" c N t M A. Type of Building: Dwelling No.of Bedrooms Lot Size 3261593 sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures // Design Flow gallons per day. Calculated daily flow — to 6 �/ gallons. Plan Date OJ. 11.0 L99(p Number of sheets / Revision Date Title _RZOIkSEQ &Te 'RAU OF LAt�Cb 19 CR�nQXQSTAOM . MA+ Size of Septic Tank /600 Type of S.A.S. PILOT DIFy5.gd1C Description of Soil 1,1�ea PUq� 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 Titl En ' onm tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issu s alth. s . Signed Date Application Approved by 4., / Date Application Disapproved for the following reasons Permit No. 9 Date Issued TOWN OF BARNSTABLE LOCATION L-�t � SEWAGE # � VIIa AGE .t'� .1 1 G. ASSESSOR'S MAP& LOT INST-ALLER'S NAME&PHONE NO. _ SEPTIC TANK CAPACITY LEACHING FACILITY: (type� �)��1 tlS -15 � _ (size)Sl NO;.OF'BEDROOMS BUILDER OR OWNER PERMITDATE: I ' ? COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Furbished by � 9 S - O 04 £�= 9 7 1 9�i=�d .�.-.-r � �- "'r'"�. -.+. yi � �.t,Tf..l r. • ,,�i• ,,,,,rc.�•,-....._..... M_.je..T� �Q�� yT'..-{r+ D97 ... t No. Fee lob{ / COMMONWEALTH OF MASSACHUSETTS Entered inconiputer: L-4 Yes PUBLIC HEALTH DIVISION -.!TOWN.OF BARNSTABLE. MA6SACHUSETTS Yicatton for ig ogaY p!Aem Con.5tvia tion Vermtt' Application fora Permit o Construct( Repair( )Upgrade( )Abandon( ) L] uo �et S Ny 2t e m ❑Individual Components 174 � `Location Address or Lot No. �T • Oi, l�0`JT �� Owner's Name,Add tress and T �,�8 .1(Q j C cYru 1 r ECHO LN1 M 75 Assessor's Map/Parcel. n , t' r Installer's Name,Address,and Tel.No. S -0-3 f DesiPAgn�`s Narne,lAddlr�essran�-Tel.No. 4n gqolett Ale- 14 A V-w " Type of Building: ? Dwelling No.of Bedrooms Lot Size 328 509 sg.ft. }Garbage Gri er Other Type of Building No.of Persons "' `- 'Showers'( ) Gafeteria( ) Other Fixtures :Design Flow ! w gallons per day. Calculated daily flow -- 41 b ! gallons. Plan Date--Al 0 a149& Number of sheets Revision Date "~--- Title 090 lsr o 5t Try �U aF IA40 I N 01AP 0►�Tt�at--1-.9 t4A r Size of Septic Tank /5C.1C 1 Type of S.A.S. jFjM i . Q F1)S6C*)IC Description of Soil X/ i � � 1 Nature of Repairs or Alterations(Answer when applicable) ti 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-Aa nme tal Code and not to place the system in operation until a Certifi- cate of'Compliance has been issu d^ s ° lthSigned DateL7 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued / -�-s 1�7 THE COMMONWEALTH OF MASSACHUSETTS ' r BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(X)Repaired( )Upgraded( ) Abandoned( )by at l•>�- � L�1—�t-I- / ��-A)m6 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7 M- dated Installer '?68 A,vc�I r Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. R' Date In � � `� Inspector t ——————————————————————————-—— -- ———---- No. 7 7 Fee ego _ THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Mi6pogar *pztem Construction vernit Permission is hereby granted to Construct( epair( )Upgrade.(. )Ab ndon System located at:. 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, rovisio�sxor-special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: 7, :=- �/� �� !� a Approved by G� i i -� Town of Barnstable P#_ 90/"; v Department of Health,Safety,and Environmental Services �,►�, Public Health Division Date 2-7_549' 367 Main Street,I lyannis MA 02601 BARNEMABLA - 'rtn Date Scheduled 9-ZV I==I Time /A'(A i :" Fee Pd. yc S Soil Suitability`Assessment for Sewage Disposal Performed By: Witnessed By: fEr2V C�rr.v.�iw4v LOCATION &6ENERALINFORMATION Location Address / n Owner's Name wi tv -C,A.�.�,_e3 Po e3o�G ZC>8 Address /H,oH,ic ror% w�/� 0193G Assessor's Map/Parcel: - -Engineer's Name- NEW CONSTRUCTION REPAIR Telephone# 4/3 Z- OY3 9 Land Use Slopes(%) 3 S Surface Stones Nu Distances from: Open Water Body y k3Q ft Possible Wet Area ft Drinking Water Well /y Y ft to evey Drainage Way >7 1 ft Property Line > `' ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests;locate wetlands in proximity to holes) Z>� VIA, J. qZ.2 Parent material(geologic) 2v22 P : t to trc% t' t' `f., ` Depth to Bedrock O rt rt'i ys Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMrNATYON FOTt SEASONAL;HIGH>'WATEtt TALE Method Used G.t?ovivL�,G✓iJ'i2 lvc7T c�wcG✓IY�ul� Depth Observed standing in obs.hole: in, Depth to soil mottles: '`''• in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment n. Index Well# Reading Date: Index Well level Adj.factor Adj.`Groundwater Level_ : PERCOLATION.TEST vate`I z:y l�Tirrie...I/ ov Observation Z r Hole# , Z .... Time at 9" Z-r-s—a Depth of Pere yZ :Sy Go r 7Z Time at 6-03 `ZJ 1 3' Y. Start Pre-soak Time© 01 0;0y Time(9"-V) o,',Zg:> Z.S End Pre-soak Rate Min./Inch 2- Site Suitability Assessment: Site Passed_ _ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-� Copy: Applicant DEEI' OBSERVATION'ROLE LOG` Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes.y` u O �c L�pr^ Spw� p 1Z L �,; S,.rt>ro G✓LAld✓ Loasa .o /yiAsr�✓3 ye t�i22/'p/3t.8 n e :. stivt3;' �A►vb� q.✓r O� 2ddoYSvC3 3c�� � aatc SN )� 6 Si.,,6�a�ie,.t,.✓ LwS� . ... DEEP OBSERVATION HOLE:LOG H6 e# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulderes. Consistency.%Gravel) 71.—�G3 Piw4 /VO Spw.n O/ram Sz. ti c1,10�W 1-GCS Z3 7 a �tsa o►' d 5.��a Ca/ /•Low'. ; DEEP:0)3SERVATION HOLE LOG Hole#. Dcpth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.).. (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. % DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil'I'cxture Soil Color Soil Other Surface(in.) -:` ( SDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Man: £dry fl Above 500 year flood boundary No_ Yes x Within 500 year boundary No X Yes Within 100 year flood boundary No Yes - .__..... _. . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in"all areas observed throughout•the area proposed for the soil absorption system? 8.5� If not,what is the dept Vof naturally occurring pervious material? Certification I certify that on G-/b—95' (date)I h"-0s9e6th'e s6il evaluator examination approved by the Department of Environmental.Protection and that the above analysis was performed by.dtne,consistent,with Ic the required training,expertise and experience described in 310 CMR 15.017. e, Mi l Date Signature , ,_,-.._..._.. _....-.__. ...,_,..-... ._...... ........ .... ._,_....._,. -......._...-_..,_.....+,.-.a._...._..._.-....::r. - ...r,.._..-_.-....-._,..-.a.+yrr...nr....._.,r -„{ .._. ..+wu•.n.-, _.a.-...,....,W+.,^+^«.._"4iN^..,^---w+-•—.-,W _ _ ."„°"'.a°„ -+ i k d- •_ 1':"y. a :r :.. ,`n. . , „ Z` F# x / w , ! Poij f :• vs e. FOUNDATION , 4 y /fr /li VO `E"Pt 0 I'M�1. , .�I--I 1 8" E.,4� � �'`" ' y , i t, 1 , � . _ P STONE (0P EQUAL_ MINIM0,1, ,�'� _._ � _ � � 1 � � 3 TC` i � 2 CLE � � t. L. n . Y,,... PITCH 1/4" PER I= T. a '._ _ r ' , _ . .. . ,_ 10 �f MAP LE'v 1 ,9. - ._ ,._. _ - , p Fv. r w i #a .s NM *.. y 1 „ I _ A T JF Sol ZONE WELL k n^ v N`4DEX �'?T, TO BE W�,TE-P TESTED (�ED -�F � D �� tv�'N./INC+-f. ., SE EY � v " ^ 1 _ in ADJI.,+S ____ _R i_._A ' ION RATE 45 : � P OBSER��'�.-ICN HO --- 1 �, � � RIL � w,C.��0 � . ELE� �: fir HO, _ , �PT�C TANK � ;TT��N4 �-� �-� Hc�L1=� 0� p_�SG� PROBABLE WATER 7 A�..� c.l.,.EV. � l�..za _ „ _ <` 9 3 0 - , r I'\0T TtJ SCALE SA LE Z/F t� ' / ., ,,..,_ ,, .\ \_i - ,..... C���►���'[f p►1 ." ,x* ,a'�k,, vac .`*;-,. me ON, ,oil -71 ca �� 5 /"X / OL / Of.., �- �, 5 ,✓,! .'r Ar.'¢`v' er4.�..tw r r e xv . --._ ''✓� - . , `--''' ,/ /� , �7 ; " 19 r ! ' -----.-- --'�` ,' s` � A/0 WAT ER A ' ' ..; ` `° NSH - gTERl .LS S� O E.P. Wt ►►RK lP ANU M � Nr TO D _. ALL aNlA c ti ,�► ,� -- - : ' _ �, TITLE *5 AND THE TOWN OF � :�� .�m` ���__ P .ES :ate RE.G(-k- NS POR THE S�� - AC,'E SPOSAL f SiE JAvE. 2. CC 'HERS —0 SA�7APN/ �� T5 S�-iA L 8E Ol.��T TO ly - 12 C� ` A i 3. E X S TI ''N: FN L. GR�DESSHALL REMA1�N E"SENTIAL!� THE SA. .4 OF - '�' T � � T+Y ARE, � BE CAPA3LE ,.. - 4. A,LL C�OINEN i S OF HE SAR�T�Y SYSTEM SHALL 'w!THS� A,ND H-10 LOADING �.NLESS Y ARE, UNDER DER OR -C 10 F T +OF ' RI v`E.S OR PARKING AREAS« H-20 I OA.D#\`G SHALL. BE '�; o �` _ / USED UtNDER OR WIT4N 10 FT. OF DRIVES OP PAR�`ING AREAS. ANY A ,SCINRRY UNITS USED TO BP!+NG COVERS TO GRADE SHALL- , _. h f .,� � ._-7h'l t. a •-�/� � ./ f � 'r / f ,,._ _ .... , ,,,r .� !" ,y. �"r. RE J r Af : --, �-` ► �` MINAT! HA, BEEti �,IAC.E AS TO COWI LIANCE VIITH , � ��ESIGN � ,�� 1..aL-,_ TION. �. / _ �' ,� W . ._, ,. �'�., - _ �, ;��,` ' r . -,..-- ,�'' ��,' A�`,� .� DE`FDI=- C� RF,. : R�CTION�s A • i 1 G t�RBAOE +DISPOSAL UNIT .UD _ v , _ r, +C AV!A Af�kv REPLACE U UITA,ILE IvIJD T ~Rl 'f_ Off' ,- -�: / j/ !�� LEA: G SYSTEM .AND BACKFIL_L WITH C'EAN S { •ID, „ T ( TAL rT!MA k ED FLOW 1/D_GAL./BR./CAY` X __ _. Bk.; _S�P-_ GAL /JAY c _ _ .. SEE f / tRE-(�UiRED'SEPTIC TANK: CA�f:'A­l"IT � l ec� _. GAL. �, �`-._...... ACTiI,AL._ SZE OF SEPTIC TANK %4�._ GAL. S o, vLEACHINGAREA REQUIREMENTS .-�,A•, AREA ©_�� GAL./S.F. � © % i , ��� , �D� `' `�s',f- /� ';-'�� Pig �, � r�rt JF'�SEC� SITE PLAN O� ' �.��C 1�'� . I ►307TOM AREA +?� _ GAL./S.F. � /�'v �' � � � LE-ACIANG CAPACITY (BOTTOM �- -IDEwrALJ _-. GAL./DA,Y ,'C� X 1 A. .. , _ 604 LEGEND B� RNST ABLE• MASF\CHUSET- S �?�?' _ GAL./DAY RESERVE LF AC1-iING CAPACITY —AR'_3 FOR SCALE DAB E �JOV. 11, 199EXISTING SPaT ELEVATION ©X00 A-- �, "i , TPPEP f- EXISTIt�1G CONTOUR ------ - --- FINAL SPOTELEVATION O-AOb ,-,, �'� f �b}-?�v _AMF'E` FINAL. CONTOUR — APPROVED: Q�,�'�RU C�J� HEALTH _ _ P)Ak L E. SWEETSER.PROFESSION)v L LAND, S�. R% EYOR, s SOIL TEST LOCH T IONj UTILITY POLE -{�- a r f8 Wei iAMSBt` RG �!'�+'E.—E�} IARWlCf-�l.Mr� 0264 '5 )432-853Q TOWN W TE;R ! W k- TE AGENT CATCH BASIN ® , �A ' 1 C?1- 01� , .. • :< arw.- fir, .. -.:,;. -s. ,`. ., roc= n'-.$ mde•.'"` 'gi'. „ Ar+w.•««,�. � , .., . ".-. .0 .. -:.'. '. - `a.. .: ,. .. .a Oar • ...: - g 3 6 TOP OF FOUNDATION R 000 <° BAxTER K ELEV. -� ROAD COVERS �o 4" SCHEDULE 40 PVC PIPE CLEAN BACKFILL MIN. PITCH 1/8" PER FT. LOCUS NORTH - - 2" PEASTONE \BAY 6" MAX. 4" CAST IRON PIPE7H .m 1111, +_ - -�,�-���-��� ���-���-���.,�,li�,�i���,����I ICI���III��I 3/4" TO 1-1/2" CLEAN WASHED STONE (OR EQUAL) MINIMUM --7-� TEE - - - - PITCH 1/4" PER FT. - ELEV.= FLOW LINE 10'• ELEV. _ _ -- JMIN. _ � . - : O LOCATION MAP 'ELEV. -z---- 2,p., ELEV. _ _Z ? �_ iu'' LEVEL . 'ELEV. - _moo-S_7_ -_.._- vovovovovo 6" CLEAN .y : - ; - ' - ; - ; _ : • _ ys_ • - ELEV. . - DISTRIBUTION GAS BAFFLE WASHED � SOIL TEST STONE WELL _rA1A -- B 0 X _ ZONE �� DATE OF SOIL TEST --____-- av�QQ�Qv�c pvpvww0�7pv0�Ov�QQVOvw i-' t- .- — —-- , f.a WITNESSED BY TO BE WATER TESTED � INDEX_tw ---- -- -=-Y--- ADJUST_r_''f' PER, T iON RATE -- z___MIN.iINCH. -. OBSERVATION !--iOI_E 1 i���0 GALLON ELEV.= `_ __ DEPTH HORIZ TEXT COLOR MOTTLING SEPTIC TANK BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. _ _1 _`___ ' SEWAGE DISP0SAL SYSTEM PROFILE I NOT TO SCALE 77 .94' ,ter � .z WATER AT EL.=--q--- �� OBSERVATION HOLE 2 % - ELE✓ =_-- �__ DEPTH HORIZ TEXT COLOR MOTTLING SCALE 1 -30' i r1 �'1 / - < ` CY n �tii s /S? WATER AT--=-- EL.=_='__ -_- NOTES: - 1. ALL WuKKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OFF - ______ RULES AND 41 �6� REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 41 �� 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 12" OF FINISHED GRADE. JJ° /9 . --- _ 3. EXISTING b iND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME. y` - 4. ALL CO,',APONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF I I r WITHS T P.NDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 F T. Ol'--- DRIVES OR PARKING AREAS. H-2'0 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 5. ANY MP,SONARY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. i _- - 6. NO DETI=RMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DESIGN CALCULATIONS �22, 45 ' - i RESTRICTIONS. NUMBER OF BEDROOMS 2a � '�- - -'�04 4i �--�''J EXISTING ZONING AND/OR DEEDED E GARBAGE DISPOSAL UNIT _� ��_ 140 DWELLING 7. EXCAVATE AND REPLACE UNSUITABLE MATERIAL FOR 5' AROUND TOTAL ESTIMATED FLOW �8 LEACHING SYSTEM AND BACKFILL WITH CLEAN SAND. (----GF,L./BR./DAY X ---- BR.) =,o �rc: ,,, : . _ zc__ , GAL./DAY �02 �o RE:UIFED SEPTIC TANK CAPACITY � -��=_ GAL. ACTUAL SIZE OF SEPTIC TANK _____- GAL. LEACHING AREA REQUIREMENTS io `� SIDEWAi-L AREA ____ GAL./S.F. PROPOSED SITE PLAN OF LAND IN � k BOTTOM AREA ' ____ GAL/S.F. � O - �- LEACHING CAPACITY (BOTTOM + SIDEWALL) ----' GAL./DAY - LEGEND: BARNSTABLE, MASSACHUSETTS RESERVE LEACHING CAPACITY - GAL./DAY ,a ,r. . � '• EXISTING SPOT ELEVATION OX00 ' , ��G"� � i ; _ - AS PREPARED FOR SCALE DATE SEPT. .1 EXISTING CONTOUR �_____-- 00 _ � `' b FINAL SPOT ELEVATION Ox00 _ h� JOHrJ LAMPE 1" = 60' - REV. - - APPROVED: BOARD OF HEALTH x „� FINAL CONTOUR ---- SOIL- -TEST -0CATION- - : PAUL-_ E. SWEETSER.PROFESSIONAL LAND SURVEYOR UTILITY POLE - _. - _ _ - P.O.BOX 565-EAST HARWICH.MA'.02645 (508)432-8539 TOWN WATER W -- W ., � - � . FILE NO, '' -` - SHEET OF CATCH BASIN ®� Df�TE: AGENT 1401-01 1 1