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HomeMy WebLinkAbout0017 PATIENCE LANE - Health 17 PATIENCE LANE, COTUIT A= 039 050 I F� TOWN OF BARNSTABLE ^/1,0CMION SEWAGE # 9 VII LACE tlt a- ASSESSOR'S MAP & LOT ~SO .f INSTALLER'S NAME&PHONE NO.�CsS SEPTIC TANK CAPACITY /GW GIC1Sted e s o LEACHING FACILITY: (type) y l/U l l A AYS (size) /D X I�53C-1 NO.OF BEDROOMS I BUILDER•R OWNER ;)6CL PERMTTDATE: (0-JS-ae 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 4 � - 23� 44/1 r10 1, GG r IP 70f 3-70" 3 L O CAT IOa- l� SEW A G E- PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS h off-( R Q t.0 BUILDER ORx1 OWNER o pDATE PERMIT ISSUED �S DATE COMPLIANCE ISSUED 3c 8 No. . �(D v Fee v® THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s� PUBLIC HEALTH DIVISION a TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Migt onl *p!5tem Con5trurtion Permit Application for a Permit to Construct( ) Repair( ) Upgrade(jy Abandon( ) ❑ Complete System 13�Individual Components Location Address or Lot No. 0 f A-T(64C.0 CP4Q C Or"to Owner's Name,Address,and Tel.No.Mtz®L-fl J#GKS®iV .� � (7 F',Otrj Lni C€ L�l l� Assessor's Map/Parcel llwf 39 f o r 50 L 6®r..o c r r,4 OJ_6.,�rs Installer's Name,Address,and Tel.No. .b4D.,j_ Designer's Name,Address and Tel.No. D/l'y"""� ,AP I"$`,� �C. oSi��aLLs d�6S'r Type of Building: Dwelling No.of Bedrooms �'�(S T ^'Lt Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33'® gpd Design flow provided o-9 gpd Plan Date (o�/lzp 6 Number of sheets Revision Date t Title Size of Septic Tank /0 o 0 (rr4L�'."� �S��nl(a" Type of S.A.S. Description of Soil /Ka o dui fA-. D J/ Nature of Repairs or Alterations(Answer when applicable) '"PL'� �LG'a Ste' lvee'' f✓� _Ps+FIc.T�►T'a°'1 e o LrtP®P X2•r�� /� �4rX/j71,,-f6 loan &-,*(, ree7YG %oll*jC Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thi and of Health. Signe Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. P.O06 - 40 Date Issued l0 C$"-0�P-• No. Fee y Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zfpplicatt.on fbr 1h9pbg.a1 �&pgtem Con.5trUction .Vermtt Application for a Permit to Construct O Repair( )� FUpgrade(?5.. Abandon( ) : Complete System ®'Individual Components Location Address or Lot No. (7 'P/4T t En1C:6 L14( C T Owner's Name,Address,and Tel.No. 1-1,4tz t-a —jA u<s oN e.N C C C ,Ft4 E_ Assessor's Map/Parcel. /.Iw if 39 L a r 5 0 (o7-v i T o-r4 O.L 6J$ Installer's Name,Address,and Tel.No. �o✓t BA'°ti"�� Designer's Name,Address and Tel.No. &+-4/e-L- ),o S N 1�V osi-7"1Lt6 Type of Building: / l Dwelling No.of Bedrooms e�.t S �1 0� Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 gpd Design flow provided 3 gpd Plan Date ���V 6 Number of sheets Revision Date Title . F. Size of Septic Tank rO a 9„Crit LCJ.-4 �``rtT�n!(�) Type of S.A.S. `1�F�L T q 71)r 1 t, Description of Soil Nature of Repairs or Alterations(Answer when applicable) q e 3o t 7�/v(W XA fl� /leeT;o `C'n 4 .tt1-P77C /�N!< Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this-Board of Health. G / Signed, Dl` ("_-d'' Date 6 15-- (� Application Approved by _ C> (2 Date ip' Application Disapproved by: Date for the following reasons Permit No. .70 n 0 Date Issued r f-_o c� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT`IF}Y,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by ,.r S�c 5 � �/C��l/y� at / 7 d r t'N( r f / has been constructed in accordance �} with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 6 f/S Q(,. Installer,/_/11C(!S 11, /.7/©uJr,/ DesignerkL#bedracros 3 - Approved design flow 50 snd The issuance of this permit shall of be con trued as a guarantee that the syste will funetio s designed. Date 6Z 4 Inspector No. -)Qd6 -A0 Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Di5 pont *pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair O Upgrade ( ). Abandon ( ) System located at 17 'eu,t rl jc. c- �- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this perm t.J /} Date 6A roved b � / `r �G � pp Yam__ Town of Barnstable Regulatory Services sanivsznsr.e. 9 mass. � Thomas F. Creiler,Director i639• rFc A. Public Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date: Designer: 61,f-i%LtZ-4- Jp174,%)s o^j Address: X 3 oS!e/t,41LL6 A-t/} O�GS On 6 /S 0 6 J� ,D Q Gr 60-011, ) was issued a permit to install a (date) (installer) septic system at 17 P,T/65n L 45 4^J Ot &T-u r T based on a design I drew; (address) dated 6 I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by y designer to follow. MW (Desi er's S ature) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form r. Dclo DV6'/'Af7 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, j�ftr(r£L g J o N'lkts Pam/ ,hereby certify that the engineered plan signed.by me dated 61/51 o(o , concerning the property located at CoTui T meets all ofthe. following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and-two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 6(3 B) G.W. Elevation 9 +adjustment for high G.W. = 32 DIFFERENCE BETWEEN A and B SIGNED : DATE: /,._5rZ®6 NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc �. 63 p No._ �.��......� G Fxs...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...--.�w.J-------------_0F..........�� .R..t Ti (- ........................................ An irFation for Uiipnsal Iforkii Tonstrn.r#inn Vamit Application is hereby made for a Permit to Construct or Repair an Individual App y (� ) p ( ) Sewage Disposal System at: ...�,t'�� :t�l :....- •._> ._......._ ..C Q- .Y T------------- - '.l. l�S...........__.....••----------------............-- Lo ion ddress - or Lot No. ......... _._... ti --� c$'�fP�j_.. - °I'3 °SfCV6I l Owner dress Installer Address Type of Building Size Lot.... c.Sq. feet U Dwelling—No. of Bedrooms---- ............. Expansion Attic (� Garbage Grinder ( ) ....&IIA............... No. of ersons__...___.._................. Showers — Cafeteria pa., Other—Type of Building p ( ) ( ) 04 Other fixtures --------•------------------------•-•---------------------------------------------------------------------------------------------------•------------- d W Design Flow.........s�-............................gallons per person er�day. Total daily flow____.__'3_�a_0_..__...................gallons. WSeptic Tank—Liquid capacity_.�pM.—gallons Length: ��. Width.__ _�.`�Q. Diameter.�P __._. Depth_. '..._. x Dispo 1 Trench—No.....1--------------- Width_...._/_'Q_.____.... T6a ength.../✓�A...... Total leaching area._X.,(,P-------sq. ft. Seepae Pit No--------------------- Diameter.................... Depth below inlet-................... Total leaching area..................sq. ft. Z Other Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed by_________________ Vest c®�v�.. ._._........_........ Date...... .......... Test Pit No. 1...�-X....minutes per inch Depth of Pit.....��1..•.�___... Depth to ground wat r.... (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R; - �' ------- 0 Description of Soil....................�. a ..._. v�So,L_ ---�.... ............•----------------------------------------•---------------•-------------------------.----- -----•--•...•---------------•-------------•-----. _ --� -----------------....•------------•-••--•-•------•-------•-•---•••-V W --------------------------------------------------------------------------------- -------------------------------------r---------------------------•---------------•-•-------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agree n : hey'undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with th pro 'ons o i m� 5 0 'he State Sanitary Code— The undersigned further agrees not to place the system in per n un . a. Compliance has been iss ed by the board o health. An I do Approved By-G-- •---------:: ..... --- --- ........................ -•----••- � t/ 9..... b . Date A ication Disapproved for the following reasons---------------••--------------------•------------------•------------------------•-----------•--••--------•----- -------------------------------------••••••----•----------•.......--•--••••---•..............------...........-----------•------------------------------•--------•-•----•-.....---•-- -------....... Date PermitNo......................................................... Issued-....................................................... Date No.. S�.. :.: � Fps..... ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `°J�`�1... OF......... �?P. W..------------------•---._................. Appliration for Disposal Works Tonstrurtion Frrutit Application is hereby made for a Permit to Construct (>< ) or Repair ( ) an Individual P Sewage Disposal g System at: ... .A 1 N :.........!4 .--•-:._.. Coln .�-$-•............. .............•--•-•-•-l_c.l...tia 5-........•.........------..............------------ �•- Loc tion-Addressor Lot No. tt� Owner 9 ress W �2�?.�.�.....Z.....-- 1�...........-'-- ............................ ! ! .t.....VV S� t- .. '�k1�WICk( Installer Address Pq d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.....-3..................................Expansion Attic (� Garbage Grinder ( ) aOther—Type of Building ...&JIA................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------•---------------------------...•. .-------••••--•--•-•----•-----•-----------•-------••••--•-•--••-••---------.....-•-------------- W Design Flow.........-_�_6...........................gallons per person er,day. Total daily flow------- .........................gallons, WSeptic Tank—Liquid capacity.1 f.0*..gallons Length�_�x, �;.�.. Width.. . ."ID'. Diameter_ /4•...._ Depth..5°_$'�.. x Disposal Trench—No..../................ Width_.... f3._.._...... 1 a ength._A//A..._.... Total,leaching area. ........sq. ft. Seeplge Pit No-----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft�....= Z Other Distribution box (✓) Dosing tank v�1�Ut .•-- Date.---•••. Percolation Test Results Performed by................�_C?!�ies't .._.._._....__....�'.._._...._._._._... �"__'`� ..,��_...___._.. a Test Pit No. l._ .....minutes per inch Depth of Pit..../A.......... Depth to ground wa er--- ..... fXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 •--•--....,••----•--------••......--••••---•-••----� --b---.�-----_-r-L-------------------------------------------- •.......... ------------- ---------- OVDescription of Soil------------------ � .----•f-PAA1 M�...t1.M.....�. ..- �.--- --�--------------------------------------•---•-----------------•••--•-••---•- � -••----------------•----- ------......---:......------.....------------.....-------------- !c -�...., W VNature of Repairs or Alterations—Answer when applicable................................................................................................ ---..............................................................-..................................................................................................................................... Agreement Th un ersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the p/rr •isi fs of T TLE 5 of the tate Sanitary Code— The undersigned further agrees not to place the system in o, ti until I f pliance has been issued by the board of health. t: �igned.------.. I� `' `----------------------------- -1 . . ---........ Appl at' PProved By ......:.... Date Ap i tion Disapproved for the following reasons:................................................................................................................ --....-••-•-••---••-•----------••------•-••-•-----------•--•-----•---•--......•-----••-••••--•--.........._......••••........•••-•--------•--•---------•---••-••-••--•-----------••---- ................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... (9rdifirate of Toutplianrr THI$_1A TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............. ----------emu G ----------------------------- ------------ ------.....:.--•--•---------..........------------------------•-----....--- Ins aller- at.__..._.....�. -Cc' - '" 'P.2')Ge' .�"---------------•----------------------........--------------... has been installed in accordance with the provisions of T 375 of The State Sanitary Cpc�e s d c ' ed in the application for Disposal Works Construction Permit No...... ...._�...?'"���...... dated---- .... :...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. t DATE.. ....5..:�:�••...-•-�S••-••••--•---•----......-•--_. Inspector----------------- -- --•--•-••---=••-•----•----••------••-••--.......--•...... U THE COMMONWEALTH OF MASSACHUSETTS L.BOARD 'OF HEALTH No .•. FE ...... Disposal/ ork.5 %banotr ion rruti# Permission is hereby granted...../?017....... .........ev....................................................................... to Construct (Y,,) or Repair (� an Individual Sever a Disposal System at No.........�ie. .......fa-�.........1.... �....W 1._ Stree as shown on the plication for Disposal Works Construction Perini No �4�.. Dated._!-j .e. b l f Board of Health - DATE------------- -• ......................... FORM 1255 A. M. SULKI , INC., BOSTON 6, 4's 5 o 00 ,Sri �' cy 26 TURN WhT w 7-1 -� 1 fI creme L ►+ or / a SIG �! 8, o to / SO 1cn u N7<I G "�o / Dl�o r -T-0 0' 3 O d 7 u �.E � I S4A�� �'✓G�r f �' �..'l � Lo . ' r i \ N lS�LN'W S col. , i 1 . y,l �6L91 s o � _ H Of 4f4s ROBERT B. Q � ( ?� ALBERT' y.\X LEGEND ( 1 A• lXIBTINA SPOT ELEVATION 0,t0 ; �� MORSE 'fti � No.1095i ,o o-/.• CERTIFIED PLOT PLAN EXIST110 CONTOUR ---- 0 -� A �:��,,,�- : ,M FINISHED SPOT ELEVATION 6�\�°.:`�''�j; a FINISHED CONTOUR 0S +cr ��q, LQ7 6 s T't► Tip `✓cE f� �E NOTE: The location of any existing underground sewerage, wells, or other utilities shown on t;is, plan is approx- IN imate only as determined from records and/or verbal SA JI A S 140 1.2, W ASS. information. The contractor is responsible for the verification of the existing locations in the field. SCALE, 1 "- 40 DATE -1 I/MIMI /fds �DIQEDGE ENGINEERING CO. INO !�(cK.c-onf` ,., CLIENT: I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. r9� BUILDING SHOWN .ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS 1DR.BY� °� .� . �.NG EER RV �— -- OF BARNSTAB Es MASS 712 MAIN STREET CH. BY, k'/3•E= ' / "ems HYANNIS, MA$S. SHEET- OF �` DA E ZREG. LAND SURVEYOR lk kk lz vi howco1 NY W 222 �` W � % W 14o � o � W � fA Jvoo W � U U1 � 4 •: • o •• o••a yyh p J 2 � �IQ � W 0 q o W� u � otwc i� � . . 2 a ocW � ,m(j . .ono. . . . Q � U 41k OF J V IX Cj �t1 to :\ l V O 0 � IS �1 14 K t 1► I� 1� Q Q Q CD hcdceR�� P 4 V V .O Z.1t- i rW rye 4l g 4 • • �-------_--� . . oho . 23 �. � h ova... ti. . s, S�N Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boson,Ma. 02108 .title Grad Stt t " � D.E.P.Title V Septic Inspector P.O. Box 2119 a Teaticket, MA 02536 WILLIAM F.WELD / (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART A r"CelVC8 � CERTIFICATION APR 2 7 1998 Property Address: 17 Patience Lane Cotuit Map 039 Lot 050 Address of Owner: ® TOwNOF Date of Inspection: 4122198 t, (If different) HEg1 Hp pj, Name of Inspector: John Graci Joanne Bosak I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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: X Passes This Inspection Is based on criteria dented in Title V _ Conditionally Passes code 310CMR16.303.My findings are of how the system is performing at the time of the Inspection.My inspection does _ Needs Fu/er valuation By the Local Approving Authority not Impyany warranty or guarantee of the longevltyofthe _ Fails septic system and any of its components useful life. Inspector's Signature: Date: 4122198 P 9 . The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. 4 INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion.f 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not'metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127197) One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Patience Lane Cotult Map 039 Lot 050 Owner: Joanne Bosak Date of Inspectlon:4122fgg _ Sewaae backup or.hreakout or hioh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: ..broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 t fi 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: i 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 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: 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. Yes No _ Backup of sewage in 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 cesspool. SAS is in hydraulic failure. (reyleed 0427)97) ` i SUBS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Patience Lane cotuti Map 039 Lot 050 Owner: Joanne Bosak Date of Inspection:4127J9s D]SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. of or privy is within 50 feet of a private water supply well. — — Any portion of a cesspool p vy p , 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: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: , Yes No - the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall 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. (revised 04127)87) - • r C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 17 Patience Lane Cotuit Map 039 Lot 050 Owner: Joanne Bosak Date of Inspectlon:412219e Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x _ The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected' for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. " x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is unacceptable)(15.302(3)(b)J _ , r (revised 04127797) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Patience Lane Cotutt Map 039 Lot050 Owner: Joanne Bosak Date of Inspectlon:4122J98 FLOW CONDITIONS RESIDENTIAL: d/bedroom for S.A.S. Design flow: 9-P• ' Number of bedrooms: < Number of current residents: t Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yee Seasonal use(yes or no): No Water meter readings,if a_v ilable:(last two(2)year usage(gpd): _ rda Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a , Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER:(Describe) roe Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ' System was last pumped In Nov.of 1997 by ABCO System pumped as part of inspection:(yes or no)Na If yes,volume pumped:0 gallons Reason for pumping: nla TYPE OF SYSTEM rt x Septic tank/distribution box/soil absorptions system- Single cesspool r " Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: 1986 c Sewage odors.detected when arriving at the site:(yes or no) No r (revlesd 04127197) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 17 Patience Lane Cotutt Map 039 Lot 050 ¢` Owner: JoanneBosak .c r Date of Inspection:4122198 SEPTIC TANK: x (locate on site plan) Depth below grade: 5,. - Material of construction:x concreate_metai_FRP• Polyethylene_other(explain) ' If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H5'T^w4'10., b Sludge depth:r Distance from top of sludge to bottom of outlet tee or baffle: ze•- Scum thickness:u A Distance from top of scum to top of outlet tee or baffle 6'". s Distance form bottom of scum to bottom of outlet tee or baffle:g How dimensions were determined: Measured j Comments: (recommendation for pumping, condition of,inlet and outlet tees or baffles,depth of liquid level in relationto outlet invert, structural integrity, evidence of leakage,etc.) ' Septic tank and all components are structura5y sound.Recommend pumping system every two yearn for maintenance r, GREASE TRAP: (locate on site plan) - ' rd� w ' Depth below grade: nra Material of construction: —concrete—metal FRP_Polyethylene_other(explain} •� ; Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rva Distance from bottom of scum to bottom of outlet tee or baffle: nfa :. Date of last pumping;v_ Comments: r tees or baffles,depth of liquid level in relation outlet invert, structural integrity, (recommendation for pumping,condition of inlet and outlet to e p q evidence of leakage,etc.) + rda BUILDING SEWER: (Locate on site plan) ; Rh Depth below grade: rz. Material of construction: cast iron x 4g PVC :_other(explain} — g, Distance from private water supply well or suction'lineS­ Diameter. nla_ A. i�vaemments: (conditions of joints,venting,evidence of leakage,etc.) e jvr , (revised 0Q7)97J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Patience Lane Cotuit Map 039 Lot 050 Owner: Joanne Bosak Date of Inspectlon:4127199 TIGHT OR HOLDING TANK: (locate on site plan) ,. Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: rda Capacity: ria gallons Design flow: rdagallons/day Alarm level:_wa Alarm in working order?_Yes No Date of previous pumping: e Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: pia Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: ' (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_ves Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.). rda _ (revlaed 04r17i97) '7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Patience Lane Cotutt Map 039 Lot 050 Owner: Joanne Bosak Date of Inspection:412219s SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: n1a — i . Type: leaching pits,number: 1000octagon leach pit leaching chambers,number:rua leaching galleries,number: nla leaching trenches, number,length: rda leaching fields,number, dimensions:n1a , overflow cesspool,number:rda Alternate system: we Name of Technology:_rda Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) , -.each pit and all components are structurally sound and functioning properly.System never had more than 2.5'ofwater In a. CESSPOOLS: (locate on site plan) Number and configuration: rya Depth-top of liquid to inlet invert: rda Depth of solids layer: n1a Depth of scum layer: Ma Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n!a inflow(cesspool must be pumped as part of inspection) n1a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n1a PRIVY: (locate on site plan) Materials of construction: rda Dimensions: n1a Depth of solids: rda Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda -. - (revised 04127)971 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 17 Patience Lane Cotuit Map 039 Lot 050 Joanne Bosak 4122198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) �hA O e AC pave 9 of ae (revised 002719T) ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 17 Patience Lane cotuit Map 039 Lot 050 Joanne Bosak 4122198 Depth of groundwater 12+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health, Check FEMA Maps Check pumping records R Check local excavators, installers A X Use USGS Data ' Describe in.your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts � t . (revisedOUIT19T) page IO 0[ 10 t i I'��Tr� � Y S � :,'=_ -)6u riCN a0*x SE r HCRE',DO-3 H 10 ;(-A REMiT,aBL_ COVEN 4"SCH 4000?LE? LATERALS per, DISTRIBUTION BOk TO MUT --- - / SHALL BE SET LEVEL FOR A TWT DAM REQUIREMENTS Of 31004P FEEMUM O THE CONNECTED TO 15.232 fWATERTIGi' TNESE _._ 5rK Perfoec Ry: 4naCsii CONSTRUCTION E"C: EACH DISTRIBUTION LINE 171.3 r/A / N0. OF OUTLETS 4..SLDW�' 6" w1TH SOLID SCH 40 PVC PIPE * Junes Wi = 94 5'. NA« 1-----`-- - __ Date: ;:., .. _. _ _ USE{✓ � CRUSHED STONE 0=3/4" 9 (FND� 9) - - - 9�9 ° o DI.A STONE TO BE TP-1 (ls.. = 91.9� 13 as a f1 /99 - �T481.t LEVEL BASE DMPACMECHANICALLY r s 9 i .0Y1,3 2 roam 5At CrpLA L1D) f 94 6 Bw, ;vR5/ . -oamy sand A Z- , 5 - - . 5Y6/4 Medium sand 8 0' *� � 6 6. 9 �- _ -_. _ f - . - _ tiff 'observed GW ESHWT. � .,. .C—/ 6 0 9 9 0 �l��/�� &,4 ?'off 5 YSrEm S iN& TP-Z (!L . _ (96. 419719 h' o fr51-/1^4 Ir • �' 1/2 4a,T 6 VENT 3 9� l000 r,c r�►�►tiLor''� - -( 95 . PK , t5l3 Loamy sand JAsNEO STo�f (ya r,o_re 8 ; 8% . 4 ' ;ti 6/4 Mediurn sand �r"No cllpac:tv s:csw)r)Idw Chamber - - / �99 10 Tp-,z ( i 99�5 q..ScN4° i ---..___, ._.___.-.. ._..__._ � ..��/ � .._..____._._ --~a.�s:�.ewa.rw.■ • g I�>:I L.r�I►T or�5 ii t 6 i� D a<�� �P �F c.N�,r.�n o �a t e: _ .:::e JL ILI q Q 7 kn JG=- ----ass AY 00*0 ! � Ioo ��isti.v�* No�SE Perc Dep- .. . 4 - "_ ..< _ PI ( 94 . 6 to 93. —.. 6AKA6E 9' < _ Mr-- ; 95. 7 94 . _ d Q 6iE = 4,b f - _ - c BCi ' 0 3.6 � 0a TMTOR;: I o Inv. '3ut _ _ 93 . 3 ; �$ L t .� rM s if� �' �YE�- A Inv. In = _ _ :_ _ _- _ 98 . 3 !E4t.P,, f r '10.. * . ow x Inv. Out � _ - - :. 98 . 0 6AA 4CL 94 . 66 �r 5Ey Pi�x v £ 314 p t r w Al ?4 �� S't' a-+• (,v ASr;ED S 7'oN E n I. 94 . 5 0 rs 92 IJfII,rT'ES (� Bottor.I (avP�•x� got,:or, - _ 87 . 4 to the Title V ( 310 a-.,. ,._ Hea Regulations . �6f9n 2 . �herF ar- . _ wT_ fir_:^- : put__c wells within 150 - _- _ -opcs eaching area . _ _ -- 00 7 _ ..� �. _ .:� � . _�-:'-_ _-� , �.�� _ _s ac- :._-.:in 1-00 feet of a wet .:' - .. - - = - "- �^ _ . ' _ems' = 1 - _ve r front . ZK°^I `AN 98 Of ..T-- 3 . Ex,st ^ ��_ _ . __ �. _ t,� - -- = an--i anew 4" SCH 40 PVC r es E NCE J. 3 < g sep� tan�c I - - - f 4 . Nc changes Gy_ ,;e ~e {_e' ,, w ,-ut the approva' - — Prep se e __ - _ -- _ - - - - �e= -:r. - _ r :se with ^C _ SEP7 SY r SE�T1 0-4 ,. . prep�reO: � - - -=e°,T _ , _..-`/-r-_ j �-Ap-ed Plan Plan r i9�35 FFE" /0�-9" The SeT, a crcperty line Sur Je` . IV " . �0� -` i x f • " � `se r� P*'' v -^ q sve� _ a_ _wing _rom existing structure vENr �on,L r2 ryclt ND v14� / PC+cY 'u`rvoaw oc ac W_�1 be -- - t - a C C S'v'St- _ ri0 &I<4 of exiting the - ANv a ONE4 ^TFo� �; � " _ p �ingi -� ..l :.ons-r;:.. }' NN' a Si _ a�- e -h shown on the -1_ /00)LI i,.JI'r rr✓ (p 'Oo 0►' (rjLA ,�E ?/Oe� �'� �� >: : '�3rvv `as„ ?eS_ Z;er. 34?y' - ` _ - - L \�a_ra�eJronhectedotcf new 71 `"� j .�.:' ,a.r sepr _ JOE 9 s �F*i ST/AJ(r) its, 9S 3 ,* 28 L �,,-� 3 Bedroom (existing..� � � c s POMP c sE__ i 10 GPD/Bedroom X 3 sec:�� - z 3i rercolat_on Rate < _ _„a 4 _ c The design of `_fir _c ___.^_.� 7_e�a -S _'J Sed on -he GAEAT� r" orig pprcvea et -G e $FE= 9R,6- A , , o,✓" a f;-�, _ _ �i.�>` a-�'� ,s�ANO i 3 Bedrooms! , per _ _ _ ---. requirements . 4.bpp E� S r/N b I - - PROPOSED LElI►CHI?1!G orFOoJ �® -0 � n" POINT sr P QQ arC/B n t 1 c - >Epr(c TilNK j)-go�C ,� T �,`• _ - ^� = ' ltrator . _60a - �c" �-- �e Area _ 7 "' r' ,. .r.. Bottom Area: 300 _ _ X ' - = _ _ _ • u NEW o co`��1. � �OTV�T_ '`"'' / ,:,, e a>� `; Total _..eacf?_ny - o.,r�£r Pvc TEE- AND f q INF,c rRArvaS 3o't_ 1 /o'w x � H I , i Ma p$�. vim% ESN�r aotT;jM TP-1 LltL." 111= /ll p4a 9 No'�'� S'.:BS77RFACE SEWAGE DISPOSAL SYSTEM I .Ee., / :- Patience Lane, Cotuit j y p `�ice, S 1 P''1 SCALE. APPROVED BY: LHAWN br DATE. _ . . Jarael 8 Johnson REVISED a Pracwtz /l1 O+fl� p+io o# .10 or;o p�40 0+Sa C+ I70 0 r>v v+9� /+oo /�v /+,a v i.. c v P -w -ar-__ _:.- acr. 428- 4 !oz hDc 02635 FIO(T . I JD Q Si 9_<'Ott :NC (508) 477-9909 DRAWING NUMSSR �. L:- ? 3rz 83_ MA 02655 J-2094