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HomeMy WebLinkAbout0211 OXFORD DRIVE - Health 2T 1 Oxford-Drive T T Cotuit F A = 021 029 K i I r .. �0 Or:�Ait :SEWAGE# � q-��r` VILLAF IIdSTA�LEIZ'�:S+tAi�£�3'�t31dE lv4 SBP'T�C TA�`IK CaO.FACII 'l Y'tom) "� • �f 2 t'S fsize) _- SA , PTO:QFBFD€�OOIyiS EtJILGER QR OWi�tER , '` pERi�&ITI}ATE G(3Nd'PL3a1NCE DA"�' Sapi=on Dcstance Betwesn:�c Feet MaxinumAdjusted Grouudwata Table to the Bottom tiaeaching Facility PnvatGIatarSup ply 9+Teli atidlo Facilit)► �Y wails existeei un ata of rovidun 244 feet of let g f it) Edge of wletlaAd and I�eactung f tltty(Lf ally�vetlapds exist Feet within 3IXL`fee f teacEu091 a«it'} 1 i : -G r t lop f lo � rt � � D � C N � a ;ate., Commonwealth of Massachusetts 5 Title 5 Official Ins • � w., Inspection Form hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r W i 211 Oxford Dr Property Address Mike Mulay Owner Owner's Nart�e information is Cotuit �/ MA 02635 7-17-19 required for every page. City/Town State Zip Code Date of Inspection • ti+ I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that] am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes f 1 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7-17-19 spector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form I� wa iF► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is Cotuit MA 02635 7-17-19 required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System is in good working order with no sign of failure. 2) 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 ON ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts , r� Title 5 Official Inspection Fora i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 El ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): ,r .. fa 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 s Commonwealth of Massachusetts ' r� p Title 5 Official Inspection Form Sri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a u 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts f,. Title 5 Official Inspection Form i;i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike*Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 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 water supply 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 2000 gpd- ® 10,000 gpd. ❑ ® 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. 5) 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. I For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. - 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w: + Inl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® Wasthe 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts 1� Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information , 1. Residential Flow Conditions: ,- Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 7-2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form iCl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner----pumped 2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 sue` Commonwealth of Massachusetts ,w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 it page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2411 feet Material of construction: ® cast iron ® 40'PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 A c Commonwealth of Massachusetts ,w Title 5 Official Inspection Form ! ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - " 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 18" Depth below grade: 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: 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 7. Grease Trap (locate on site plan): ; Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ' 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w iMr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. 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.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I p I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not.required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators 34x11 x10 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form p 1cI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field in good working order and holding 2" of water with no sign of back-up into surrounding stone. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 sue` Commonwealth of Massachusetts r� Title 5 Official Inspection Form ��I' w: c�l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): 4 t5insp.doc-rev.712 612 01 8 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 4 :� Commonwealth of Massachusetts Title 5 Official Inspection Form Jw! i ;Yii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k 211 Oxford Dr ._.r' Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 J 6 r 6 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 y� 4r, Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r W 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' _ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts r� P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T,; >" 211 Oxford Dr Property Address Mike Mulay Owner Owner's Name information is required for every Cotuit MA 02635 7-17-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 _ TOWN OF BARNSTABLE —'LOCATION 9I1 6)(Fw SEWAGE VILLAGE l ASSESSOR'S MAP & LOT _ INSTALLER'S NAME&PHONE NO." 'vS SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) �� f['?Cffi NO.OF BEDROOMS BUILDER OR OWNER Y 'vim PERMITDATE: 0 COMPLIANCE DATE: b D 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 ��� � �' t `. A ` 1. ._ � �'__ � � ... _ • n� t � \ __ '� Mw .. � ' �` Y � �p r � ` � , .� � � F �1 l , No. l D Fee 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprtcation for Miopozar *yztem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) O Complete System XIndividual Components Location Address or Lot No. ®)CrU ql_� Owner's Name,Address d Tel.No. Assessor's Map/Parcel �` Installer's Name,Add r'sand Tel.No. t� Designer's Name,Address and Tel.No. l� p�� -UN-i�!t� f! Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 7 3 gallons. Plan Date 1 ��`=6 Number of sheets Revision Date Title Size of Septic Tank s : �(3—#—IV Type of S.A.S. Description of Soil 'L1r !�'��"'�"'J S/ �✓�.lC S Nature of Repairs or Alterations(Answer when applicable) €J -� C., �a pazr- oldper-fvd, Cop Date last inspected: .SIGNING ENGINEER MUST SUPEs Vi--% INSTALLATION AND CERTIFY IN WRITii'S Agreement: THE SYSTEM WAS INSTALLED IN STR CT The undersigned agrees to ensure the construction and maintenance of the aforeZe'scribed'on-site sewage disposal system in accordance with the provisio of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d s Boar ealth. Sign Date jjs �6 Application Approved by Date 14 G LJ Application Disapproved for the following reasons Permit No. Date Issued q O --------------------------------------- i AA No. c L ~� Fee V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS = ° Z0pYication for Mizpoal *pztem Construction Permit Application fo a Permit to Construct( )Repair( )Upgrade( J,, Abandon 0 Complete System Xjndividual Components Location Address or Lot No. ��� C>YFUl2 Q10�,I VX Owner�'s]�Namfe,Address �and �Tel.No. Assessor's Map/Parcel aq CCU 1 u� !, Installer's Name,Address and Tel.No. -. Designer's Name,Address and Tel.No. p Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 0 gallons per day. Calculated daily flow `1 gallons. Plan Date 1�- y7—bi Number of sheets 1 Revision Date Title N Size of Septic Tank act S t 1— Tt"7l,�-? Type of S.A.S. Description of Soil r. r/1 rM C y1 "—A � S��✓� Nature of Repairs or Alterations(Answer when applicable)- pt t ,�V J 5� C, . Date last inspected: f 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 Board ofje�al�th. Signed' ) g' r ///(� Date I? Ca Application Approved by . _�• Date Application Disapproved for the following reasons Permit No. n('X3q —� / Date Issued `i G . --------------------------------------- Act,Jl b (Irr,�,t ��-big�/ THE COMMONWEALTH OF MASSACHUSETTS �U II „k. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by at l �( ' } /` c! 1 sP i) I i has been constructefd in accordance with the provisions of TiNMI& he for Disposal System Construction Permit No. 7 n t/- d t� dated !f ut-1 Installer .� Designer r � 1 The issuance of this permit shall not be construed as a guarantee that the system.will fu' lnctiontas�designed. Date 1 1 �l�t)� • Inspector --------------------------------------- No. ,����i 7 �'�--- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopozar *patent Construction Permit Permission is hereby granted to Construct( )Repair( )Upgr de )Abandon( ) 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 provisions or special conditions. Provided:Construction must be completed within three years of the date of this-pepm t. Date: /O Ll Approved ���"- January 13, 2004 Hunter Engineering 7 Weeks Pond Drive Forestdale, Mass 02644 (508) 477-8268 Re: 211 Oxford Drive Septic System Inspection To Whom It May Concern: Please be aware that I conducted an inspection of the newly installed septic system for the subject property and that the system was installed in conformance with the approved plan. Very truly yours, 4 John P. Hunter, P.E. TOWN OF BARNSTABLE � . . . (� SEWAGE #�JIJ LOCATION ✓�l/ D VII.LAGE ASSESSOR'S MAP &LOT �� _C INSTALLER'S NAME&PHONE 7NO.SEPTIC TANK CAPACITY ' (size) �tcf6K- LEACHING FACILITY: (tyP �`�` � NO.OF BEDROOMS 3 BUILDER OR OWNER ' PERMIT DATE: p COMPLIANCE DATE: 0 Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leachig facility) exist Edge of Wetland and Leaching Facility (If any Feet within 300 feet of leaching facility) Furnished by 6 Syr 5�, �1 - (?L7" At � ad TOWN 9F BARNSTABLEN�:�°�a �..LOB:%ATION ® I vsr SEWAGE# --"VILLAGE Co u' ASSESSOR'S MAP & LOTA) 'a►� INSTALLER'S NAME&PHONE NO.. SEPTIC TANK CAPACITY <Ta 914 LEACHING FACILITY: (type) / (size) ,a QIU L NO.OF BEDROOMS BUILDER OR OWNER £S W P— I i lu� d'1 PERMITDATE: COMPLIANCE�j ATE: Separation Distance Between the: 3 J�/ j Maximum Adjusted Groundwater Table and Bottom of Leaching Facility a 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 o J " W SL3 -_ P c t � � IOU- W Commonweafth of Massachusetts Executive Office of Environmental Affairs CIV' Department of - L, AR 1997 Environmental ProtectionEALTF;Q�Pt William F.weld OF BARNSTABLE _ Governor Trudy Coxe Secretary,EOEA David S. Struhs 1 Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: o� X Address of Owner: Date of Inspection- 97 (If different) Name of Inspector: G-ondow /aUm V-5 Company Name, Address and Telea,�r ne Number: Oc ZrAN an0FAA/ CoN l 'r?a.�x soS- h��8 - 5�y� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the local Approving Authority _ Fails Inspector' Signa ure: Date: e System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. .The original should be sent to ine,system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Aj SYSTEM PASSES: 1 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. Bj SYSTEM CONDITIONALLY PASSES: i One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances.' If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 V. Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0 ®)(::!Fo";' 9f F,,f pN Owner: 1 T^,� AI sf WO?'Pit Date of Inspection: BI 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): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ' obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soli absorption system and is within 100 feel to a surface walet supply or tributai y iu a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The 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• �. DJ SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) g Property Address: a. l xI� O' 1 U Owner: chi Date of Inspection: E D] SYSTEM FAILS (continued): °` { Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day Flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.f,_: Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of,a public well. Any portion of a cesspool or.privy is within 50 feet-of a private water supply well _ Any portion of a cesspool'or,privy is less than 100 feet but greater than 50 feet from^"a°private+water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable; attach copy of well water analysis for coliform bacteria, volatile organic compounds,,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems-in addition to the criteria..above: The design flow of system is 10,000 gpd or'greater (Large System) and the system is a significant threat to public health and"safety- F and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply ` the system is within 200 feet of a tributary Mto 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 wells r The owner or operator of any such system shall"bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. • A r "a s . f (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: dt - Owner: Gh71Rl Date of Inspection: ' 31��9� Check if the following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. VA s built plans have been obtained and examined. Note if they are not available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow VThe site was inspected for signs of breakout. /All system components, excluding the so have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility o Nnc. (arid occupants, if diffc-c-,t from owner! were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y SYSTEM INFORMATION Property Address: Owner: Date of Inspection: f ' FLOW CONDITIONS , RESIDENTIAL: Design Flow: gallons Number of bedrooms: ,J Number of current residents: �1 Garbage grinder (yes or no):-90 Laundry connected to'system (yes or no):Y S Seasonal use (yes or no): NO �/ Water meter readings, if available: OJr G 0 Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: Rallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: a GENERAL INFORMATION PUMPING RECORDS and source of information: 0 UV N& System pumped as part of inspection: (yes or no) If yes, volume pumped. I h gallons Reason for pumping. _jN N5 rRW U SX 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: -s7F+m �ti /�/� r✓ �S y`' Sewage odors detected when arriving at the site: (yes or no) N� (irevised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Q �� Owner: C h,4a�ss uJ.CI1 l N&T0 Date of Inspection: SEPTIC TANK: t/ i (locate on site plan) Depth below grade. Material of construction X concrete _metal _FRP —other(explain) Dimensions: Q00 CLAINS Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:/ Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: 611 d Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and tlet tees or baffles, epth of li, uid level in relatio�t outlet invert, structural integrity, evidence of leakage, etc.) -rAtj a i ► hN L Q TZ p.' GREASE TRAPAJO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom ni srfim t- bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/:5/9S) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: cJ.�' 6-0JV& Owner: w r, 1 N O DD C6�An � Date of Inspection: TIGHT OR HOLDING TANK: N� (locate on site plan) Depth below grade: Material of construction: ®concrete metal FRP —other(explain) Dimensions: Capacity: QalIons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribc,ie- i, e^_:z' ev�de^ce of solids carr\•nver, evidence of leakage into or out of box. etc) oX IS UN N_ a AWL WA PUMP CHAMBER:— (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition.of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION (continued) Property Address: OYTSORJ Owner: (Z k AFt l£,5 �u"I N� 0 I'J Date of Inspection: 31oh SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: ote conditi of soil,;�s,iggns of hydraulic failur , level of pond ingg, condition of vege ttion,etc.) Vr� �1E(L NS ECIi8ri UUoRk-'ru 'HROPLIS IV N O 1 U' CESSPOOLS: (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 groundwate,. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: NO (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C JSYSTEM INFORMATION (continued) Property Address: Q�/ ad Owner: G h AR J&,r w� �' ri Date of Inspection: 1 �57 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' j ✓ J )Ajq k 3y ao (D."?,-)ox y8 ro 0x50,Ad 1R tU DEPTH TO GROUNDWATER o Depth to groundwater: 5 feet :9'ROM method of determination or approximation: (revised 8/15/95) 9 s No....... ..�r.._...... ! Fxs............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF `HEALTH .........T t .�0..........OF...... �@.s` 'A...5. G----------------------- Appliration for Dhipoti al Works Tnnitra rfion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ qq t a..J Owner AA'' :_®.a.....__... 7 n. o.'r.tq No. -ry �ocatiVd!��O.l�.0�-4-��------� ���- �o�,------�� L.!.{.-�t t•��-'--0..4.���. , Address a ------------------------------------- Installer Address /+ �O Type of Building Size Lot.-._.--Q)_._-...........©..Sq feet Dwelling—No. of Bedrooms.........-�............................Expansion Attic (AO) Garbage Grinder (NO) p, Other—Type of Building ._I___ ......_..... No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- Design Flow.............5.5......_..............gallons per person per day. .Total Wx 1° daily flow........._3 � ...........gallons. _ W .. . 0 VWSePtic Tank—Liquid caPaclt 1nU0gallons Length idth.. ^�. +Diameter._.a A-. Depth.5.1.1®. Disposal Trench—No. Total Length.....................Total leaching area.._............._.__sq. ft.Seepage Pit No----------1---------- Diameter....... Depth below inlet.... -.... Total leaching area..5_O.z....sq. ft. Z Other Distribution box ( j ) Dosing tank (► d �/ '-' Percolation Test Results Performed by..JA E ._ �_..HI`N -�.�'.E L �....... Date_.f aTest Pit No. 1------%.....minutes per inch Depth of Test Pit......�_z_+ Depth to ground water........................ f= Test Pit No. 2.....2-......minutes per inch Depth of Test Pit-------11...... Depth to ground water------------------------ a ------ •-- t rt-------- ---- f- ----- - - - q �I', r O Description of Soil---- I---------(�j � .a..-.. �.CI�Q-1 ------ Z" �i ;---- u.4t�_j x U •---•---Z-- � e_ ►.v� ---�-� .........................'� 1�11...--fed-Iu!'� ld x -----•--------------------------------------•-----=---------------------------------------------------------- A _ U Nature of Repairs or Alterations—Answer when applicable___-N _ ___________________________________________________________________•--_-.---__. --••------------------•---•--•------------------------------------------------................----------------------------------------------------------......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIli LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued by the b and of hrlth. Signed-. `� �.• �. l Lt - .............. ..... -..... . � Date ^ A. hcat>JJJon Approved By. .. .. ._ .......................••-•----------......... ----- -•------ -------- --- �_ 99 Date Application Disapproved for the following reasons:----•----------------------•---•----............................................................................ Date PermitNo......................................................... Issued-....................................................... Date • J S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------....I.C�t�-ICI...-..-..-.OF...... ,.-E Apptirtttion fnr Disposal Works Tnntrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ _ ..... - .�........ .?.�..! ` ���.. ... _1/ ...... .......................... ........................................................ ocation-Address or Lot No. ----._._.. •----_..... Owner Address W Installer Address d Type of Building Size Lot-4--a I_j ._Sq. feet U Dwelling No. of Bedrooms.___.__-.__�....._......................Expansion Attic (yp) Garbage Grinder (NO) p.l Other—Type of Building __&JA_____________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ _ _ W Design Flow_____________.:!_.?......................gallons per person per day. Total daily flow-------------%_ 0............................gall'ons. WSeptic Tank—Liquid ca acrty S a90gallons Length_� -_,a _ Width- _:_.)_i . Diameter-_N_/A-__ Depth_5__-__�_p_. x P Pit No__________ _____�Diameter______ ___ ...____ Depth below inlet_.._=�t��" _.__. Total leaching area__�?_��'�_-__.._.sq. ft. Disposal Trench—No. .____ _.__ Width....................pTotal Length____________________ Total leachinggarea_______________....q ft. Z Other Distribution box ( I ) Dosing tank (No) _ `-' Percolation Test Results Performed by-_:--S_A YU. _�___j....AIN_! 1 c_......................� �- �Y A •C_:_-�C_g�_ DaieJYLA�(... , � - 1 aTest Pit" No. 1...... _......minutes per inch Depth of Test Pit------[Z_t....... Depth to ground water......................... f= Test Pit No. 2.....v.......minutes per inch Depth of Test Pit.......l-_G______ Depth to ground water________________________ a ------- . i•-----, f.. ---•-......-------•;2-t-•--;---....--• O Description of Soil_..-�--1........ '� -f'r... a---•-..`_ 1`� �'`! r�l ----- l `� 1+�_:__ a _1 x , 1 ` .. I I '`<!t1'�'l--_��_�?_!l ----_-•---------- ` �n - � 1`� 1.__`..... - ---------------------------•----------------._.._-•-----------..._._._-----_.._...-•-•---------••-•----•----•-••---- ---------------•-------•-•••---•'•-••-----••-------•--••-•-•••------------•---• ;�U Nature of Repairs or Alterations—Answer when applicable--- V�_________________________________________________________________________________ ••------------------•---•-----.._..-----------•----------------------------------------•--•.._....•-•---•..._._...•-------•--------••------•-••••--•-••••-----••••---•••---•••-•---•-•.....-•---•-••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....................................................................................... ............Da.-........-.... �' Date A licafion A roved B ^-�-- A'_..L-�!j � -�_ PP PP Y ------- ----•--............................... ------ -� Date Application Disapproved for the following reasons:............................................................................................................... ....................................................................................................................................................................................................... - Date PermitNo......................................................... Issued....................................................... Date �1 '60Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.....................................I............................................ �rrti irtttr ofWontplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..............................................................-•----_._--__----•-•--••-•------•--------------------- Installer at------------------------------------------------------------------------------------------------------------------------------------------------•----•-•-•-- has been installed in accordance with the provisions of TITLr, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-:__ _______. dated_.------ r- ____. -t_� ..... __ THE ISSUANCE OF THIS CERTIFICATE,SHALL.NOT78E CO STRIDE® AS A Gt A&ANTEE THAT THE SYSTEM WILL NCTION SATISFACTORY. DATE............ �3 .......................................... Inspector... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A'?�^ �::.(c 81... f FEE-_.� .: DisposalWorks' Q.ttnstrnrttinn Vvrrmit Permission is hereby granted............................_...............-------------------------------•-----•--.-.------------•----•-----•••--•--•-....__-----_-._._.. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.............................................................................................................................................................................................. Street as shown on the application for Disposal Works Construction Permit tNN}o.." f:6.61jD'ated_________ ��-1.G-�1•..__. Board of Health DATE---------l !.i---gs............................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -A zq r0 >_�#pT-ION v� SEWAGEJERMIT N0. C, V I I L A G E `INSTA LLER'S AME i ADDRESS '` R U I L D E R OR OWNER eA DATE PERMIT ISSUED w DAT E COMPLIANCE ISSUED �'�]5�9.5 • jib ' • 7 pi i BENCH MARK: TOP OF FND. T (SAS) SHALL.BE OLD If�IJ r ELE.='�„� � G S • I 34.25' LONG MANHOLE COVERS TO EXTEND TO 11,0' WIDE WITHIN 6' OF FINISH GRADE 1 10" DEEP -i j Z. \N OF 4f4 y BAFFLE REO'0 P Laws lcal , �► � JOHN P. qOy c EL 4-5 •�� NEIA7 (oA_.rlv -1 o= HUNTER USE Zoo _ CIVIL '� 44.,30 .o D.B. 2' PEASTONE TOPPING o No.36445 0 E x 15T: W 45• - 9 �� aW CAP ENDS GENERAL NOTES: `�c�SZEQ I' A 6• row _ " __ Cz A[LCQIJ 3' `�—3/4" DOUBLE WASHED — ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM. �_- (�C� EL=.4 Zg STONE ALL AROUND SYSTEM PIPE SHALL BE EITHER C.I. OR C � SCHEDULE 40 P.V.C_ — THE BOARD OF HEALTH SHALL BE NOTIFIED 1 1 -3104- ( O 11.5 31.25' .5' PRIOR TO BACKFILLING OF SEPTIC SYSTEM. 20 MIN. — SEPTIC SYSTEM STRUCTURAL COMPONENTS USE FIVE (5) INFILTRATORS SHALL BE CAPABLE OF WITHSUKNDING A SOIL TEST LOG PROPOSED SEPTIC SYSTEM WITH �4.0' OF STONE 0 SIDES 8.3 H-10 LOADING. UNLESS SPECIFIED OTHERWISE PERC RATE=< 2 MIN/INCH NO SCALE & 1.5' OF STONE 0 ENDS SEPTIC SYSTEM UNDER DRIVEWAYS SHALL NO STONE AT BOTTOM COMPLY WITH A H-20 LOADING. — THE DESIGN AND COMPONENTS OF THE SEPTIC DEPTH A g •,'? LEGEND: _ _ _ SYSTEM SHALL BE IN COMPLIANCE WITH THE l.2 / EXISTING CONTOUR - - NOTE: jbT7o�l TTT i-lU�£ STATE OF MASSACHUSETTS SANITARY'CODE .. 5 LOAMY SAND IOYR �! WATER SERVICE W—W— PRIOR TO INSTALLING THE NEW (SAS) THE TITLE V. AND SHALL BE IN COMPLIANCE WITH �jb.. 45,E TEST HOLE Q CONTRACTOR SHALL PUMPOUT ALL LAA-6,►"fil �lk'�) c 3(o.p THE LOCAL BOARD OF HEALTH RULES AND GAS SERVICE —G--G AND BACK FILL WITH CLEAN MI_DIUM SAND ;;-{F-��P+T ARE ENCOUNTERED IN THE c,� REGULATIONS. --Cl MEDIUM SAND 1D'YR I BENCH MARK QBM (SAS) AREA THEY SHAM BE Ri=3dOVED N O vi i�� 03564V'—J — THE CONTRACTOR SHALL BE RESPONSIBLE FOR LOCATION OF ALL UNDERGROUND UTILITIES AND 144• �, ICI O W A9L� �nJS SHALL NOTIFY DIG — SAFE PRIOR TO 2 f — CONSTRUCTION. �. NO GARBAGE GRINDER _ DESIGN CRITERIA: I i - �.. / .l i DESIGN FLOW 3 BEDROOMS AT 110 G.P.B. DAY 330 G.P � / D. REQUIRED SEPTIC TANK- ExtgT1�36. L000.:C�Il40114 To Mpg SEPTIC TANK PROVIDED (NoN9E) �;/ / / J (' N DESIGN PERC RATE <2 MIN/INCH i , SIZE OF REQ D (SAS) AREA = 330/0.74 = 446 S.F. i \ , / I SIDEWALL 75.12 S.F ( ; �,��ti BOTTOM �2)�0.83)(34.25)+(2)(O.83)1[111)= 11 (34.25) = 376.75 S.F. _ SIZ OF r ; / E LEACHING FACILITY PROVIDED: 49.0 ? f 376.75 S.F. + 75.12 S.F. = 451.87 S.F. jQ �:V 334.4 GPD 1 EFFECTIVE DEPTH: 10" iz 0 I EFFECTIVE LENGTH: 34.25 EFFECTIVE WIDTH: 11.0' A�_ / HUNTER ENGINEERING Ia ,K 16 Ia VE NC.F 0 r ' FORESTDALE,7 WEEKS N MA OI2644 ` (508) 477-8268 j `\ I i, I /!✓ , SEPTIC M REPAIR � PROJECT. ---------- -- ------- ! �+ FOR ! ---------- -f-i - AS SHOWN P'4 d21V6 0 X FO - .r su� N owun,er .!P H MAP 2 1 / LOT Z 9 �s„ OWNER: A(G-► AEL }A IAI C. A Y �, i ; , 'LIB oxFoiLl� I �tivt _ . 0 vKASS 02(- 35' M a r s h , 1/ Edge of w /p ` ' — e_t 1Ond `/0 r \ in 14'2ine \�O O �E l e . 74 \\ \ r LOT 14 L \ 5,U\s�F. `-N 3p Spike in II pine \ 40 Elev.= 43.6 L 0 T 26 _ 1 \ r rn 0/ o \� =iProposed \ 2� N/HOUSE' \ \ /��/!/N \ i 3 4'-2 / 4 5' 6 id om.x 4'deep t_.._- \ LEACHING PIT DST. ;IOmin N with4ft.ofwashe 1 �:5 x8' 27' stone all around. � 1000Galt 2,4 --- -- 48 12+�.•' . :. SEPTIC �ProP:ct \ j TANK � G Ii, \ RESE• E TEST L O T 24 HOLE#2. �\ TEST > HOLE#I 3 \ `'` I12'+ c a 0 a' o; CL e F6\ Pine Sapl!ng `I• BENCH MARK N.E.Corner of Elec. Pad EIev.=45.32 Stoke set ;:` 12 5.00\ Stake set — 7/24/85 Changed size of leaching pit . R.S.J. FORD( NOTES: 0 X a (Privte -40'wide) D R ( V E DATE _ DESCRIPTION Drawn by Checked by R E V I S 1 0 'N S 1 . ZONING DISTRICT: R F. 2 . FLOOD HAZARD ZONES : A II ( EL. 11 ) 8t C PLOT PLAN 3 . ASSESSORS MAP NO . : 21 - 29 OF PROPOSED SEWAGE DISPOSAL SYSTEM 4 . HOUSE NO . : 211 PREPARED FOR 5. THE NORTH ARROW IS DERIVED FROM RECORD PLANS C H A R LES 0. W E L L I N G T O N OR DEEDS . THE NORTH ARROW SHALL NOT BE USED FOR ORIENTATION FOR SOLAR HEATING PURPOSES . FOR LOT 25 O X F O R D DRIVE 6. REFERENCE: SUBDIVISION PLAN "KINGS GRANT" PL. BK. 271 PG. 56. IN /� 7. CONTOURS AND ELEVATIONS FROM ACTUAL ON THE GROUND INSTRUMENT SURVEY COT U I T BAR N S 1-�- H B L E , MASS. BASED ON THE NATIONAL GEODETIC VERTICAL DATUM . 8. PERCOLATION TEST NE P 44 13 . SCALE: I = 40' DATE: J U LY 10, 19 8 5 holmes and mcgrath, inc A. civil engineers and land surveyors g-URGMAPO0"t 200 main street IL falmouth, ma . 02540 DRAWN: R.S. J. CHECKED: �A 6 JOB N°85293 DWG.N236-3-29 I SHEET 1 OF 2 GG SOIL TEST BASISIS OF DESIGN -< Finish grade above and ajacent to system shall slope a min.of 2% away from system . - ---� /� !„1 DATE OF SOIL TEST MAY 2 , 1985 4 diam. cast iron or Schedule 40 PVC pipe (install with tight joints.) --- TEST TAKEN BY JAMES J. ANNICELi_ I. NUMBER OF BEDROOMS 3 (EQUIVALENT TO_3ZQ_G.PD. -F- 20'minimum distance ( building to edgeof leaching system ? RFSULTS WITNESSED BY JAMES CON._,xj PERCOLATION RATE 2 MIN./ INCH. 2. GARBAGE DISPOSAL UNITS NONE . _ __._ �-10`min. dirt. - GROUND WATER NOT ENCOUNTERED 3. LEACHING CAPACITY REQUIRED�Q__G. P D. 4. SIDE AREA 158 SQ. FT, `-BOTTOM AREA 154 SQ. FT 1 5, TOTAL AREA PROPCSEO 312 SQUARE FEET SOIL LOG 6. PROPOSED LEACHING CARACITY.-__549_ G. PD, s First Floor i N° I N° 2 7. WATER SUPPLY: TOWN SYSTEM Ele_ v= 50.00 Access cover , -set at finish grode - } REINFORCED CONCRETE 1.f�11TS �� � r Depth Soils Elev. Depth Soils Elev. I 8, PRECAST, 0 F ' 0' 49.7 0' 48.8 vF - _ _ Poved driveway FORH -20 LOADING aQ -�.��--r-.� 7 ii.`.\ /ii�� - -.. �-;�- -4 :f TZ 3�"�-:� �44:_S -S -� - -f ;.-L---t-4Z.f4-S.�T2�: { A4.-f :"4:T...- {-_.i':3zz ::F:� I LOAM, LOAM R ovcble cover 12'max " + I ,UBSOIL SUBSOIL - ^� =0.02 cover 2 -I-- s=0.G2 �' i a+I s=0.02 = Removaa�e Clean 2 c 477 3 45.8 �i i i MOTES ` -- ------ - -- ---.. ---- --- o L - - _.__ leve � '. �� I -- - 2"layer of DIY' 8 f 0 0 ' - H- 20 _ �n a) �o.� o o 0 o o 0 0 ' washed stop e. I. NO CHANGE TO THIS SYSTEM SHALL BE MADE UNLESS G t �I SEPTIC TANK _ } N DB4X rn �` o� : G l 00 o a o G'','. oe c Q k M ediu m j MedI u T) ' 1000 GAL . .I �I ' Vol ooe o 00 » / c T ,� 1 : 4 SAND SAND APPROVED IN WRITING BY HOLMES AND MCGRAs H INC. ---' ,<' ��' _ - _ �,, r 3.6 Effective �,.y, a� at ep t h av. 2. A COPY OF THESE PLANS SHALL BE KEPT ON SITE w _ w� w �� ,�, �� �� o # oft _^Oo odr .o I Foundation y yl >� y / °o- o u+ a. Design b others �` �1 c� laa�) Precast concrD to a o DURING CONSTRUCTION, g y I - a> LEACHING : IT 'o 3o00 12 37.7 I 2 _ _ 36.8 E1 =41.2 3 . A COPY OF THESE PLANS SHALL BE FURNISHED TO ` - --- - CONTRACTOR INSTALLING THE SEWAGE DISPOSAL SYSTEM. I j-4ft. 6ft.diam.- ,�.4ft ,� 4. HEAVY CONSTRICTION EQUIPMENT SHALL NOT TRAVEL " 4ft of�' prec/stwashed stone 4.4' PROFILE all around precast p;t providing an OVER DISPOSAL SYSTEM DURING OR AFTER CONSTRUCTION. effective diameter of i4ft. N c t to scale. 36.8 bottom of test hole) 5. SEWAGE DISPOSAL SYSTEM SHALL BE CONSTRUCTED IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRON- MENTAL CODE. 6. BEFORE BACKFILLING THE SYSTEM, THE CONTRACTOR , SHALL NOTIFY HOLMES AND MCGRATH , INC OR THE BOARD OF HEALTH AGENT TO INSPECT THE SYSTEM AS CONSTRUCTED. . t All outlet pipes from the distribution box shall Outlet beset level for at least 2ft from the box. Knockouts I^ - j -�- -� INLET IOUTLCT cJ f All access Manhole covers for Septic Tank; ; p 0 Distribution Box and/or Leaching Pits set �„ ! �;;�:, ` -- - more than !2"below finished rode shall be INLET i + I OUTLET , „ d -- \ raised towithin 12 of finished grade. Outlet --I-- -y- Knockouts i I Metal frame & cover or concrete cover (-Metal "T's" where required. ----- �_ _,_ 2'-0" f�- l'-2" -� 7/24/85 Changed size of leaching it . R.S.J. 11C DAT E DESCRIPTION C R I P T 10 N Drawn b Checked b Concrete block masonry I I Y Y STEEL REINFORCED PRECAST CONCRETE "# or o. o ,T -- �- _ = a ncrete cover .6 - A _ 2 Conc::cover'°��- R E V I S 1 0 N S Brick masonry I�3 Removable covers 3"-j �+ [ice 0 o c INLET l;. .:. :p . .. I/2" -:�� INLET -� -� i a I V. L T PUN DETAIL SHEET Outlet ' ;b Outlet INLET 8•'•3 min.clearance required p i 3„ ,-INLET `r :a e - ;t 1 l OUTLET Knockouts °;° 2�m� s„ Knockouts OF PROPOSED SEWAGE DISPOSAL SYSTEM '-+�- _ 2 min.inlet to outet 6 mm. x I 1 Liquid level-� PREPARED FOR ' 14' UTLET ( "min. -- �__ ° ,� ,Q' I� min. -_ min.. _ �,min.-- - -- CHARLES 0. WELL1 NGTON --C: _ a � 8 ':� - FGR LOT 25 OXFO ( ; D DRIVE T - _ t1 -� 0 E - - -_ TYPICAL DISTRIBUTION BOX C OT U I T BA R N S T A B LE M A S 3 1 LO --- a - - --- --- SCALE 1 1 - it-oil CT J __ kale" As shown Date' �JULY 10, 1985 �����" J 4 �A holmes and me rath inc.- / _---- civil engineers and land surveyors8 6 srrise 1 �--- ' 200 mai n street falmouth , ma. 02540 , TYPICAL 1000 GALLON SEPTIC TANK _ SCALE: 3i8" _ -0" Drawn By R.S.J. Checked BY lq�,43 jAi ► ;. = JOB N2 85293 DWG.N23£-3- 29 SKEET 2 OF 2 NE