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HomeMy WebLinkAbout0114 PEPPERCORN LANE - Health 114-PepP ercorn Lane Cotuit -- — A— 004— 009— 001 J t \ \ Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well --�� Street Number: Street Name: 114 PEPPERCORN LANE Please specify well type: Building Lot#: Assessor's Map#: Irrigation 004 Assessor's Lot#: ZIP Code: Number Of Wells: 009 001 02635 City/Town: Well Location BARNSTABLE In public right-of-way: GPS (7,Yes r No North: West: 41.59655 70.45229 Subdivision/Property/Description: Mailing Address: W click-_ here if same as well location address C _ Property Owner: Street Number: Street Name: DAVID MUGAR 114 PEPPERCORN LANE City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02635 Board of health permit obtained: f Yes f^Not Required Permit Number: Date Issued: W2021018 04/02/2021 Massachusetts Department of Environmental Protection Bureau of Resource Protection-Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock uger Choose Bedrock,,---..,,-. WELL LOG OVERBURDEN LITHOLOGY rFrom(ft) To(ft) Code (Color Comment Drop in drill Extra fast or slow Loss or addition I stem drill rate of fluid Medium Sand FYBrown �'Fast r Slow S NO � Loss Addition - 20 30 (Fine To Coarse S Brown Slow t--_�!� — _ __1 YES NO � Loss Additon WELL LOG BEDROCK LITHOLOGY 1 Drop in Extra fast or Loss or Visible Rust Extra From(ft) To(ft) Code Comment addition of Large drill stem slow drill rate fluid Staining Chips P Cftoose Code , 1�'Yesi 1�Yes=YESNO Fast Slow Loss Addition ADDITIONAL WELL INFORMATION Developed 'Yes C No Disinfected G Yes C`No Total Well Depth 30 Depth to Bedrock Surface Seal Type None racture Enhancement f 'Yes t:=No CASING E Is Casing above ground? — --- ..._..__.._...........--- - --- .....__.._._...__...-- _....._...... ..........----................--r--- - --..._.....__...__....._..._..._.__.... From To Type Thickness !Diameter Driveshoe 10 I 26 Polyvinyl Chloride _j Schedule 40 -!nj r Yes SCREEN From To Type Slot Size Diameter 26 30 (Stainless Steel Well Point 0.0124 - � WATER-BEARING ZONES FDRY WELL_ From To Yield(gpm) 11 30 12 �� PERMANENT PUMP(IF AVAILABLE) Wire Constant Speed Pump Description � Horsepower Submersible 1 Pump Intake Depth(ft) 25 Nominal Pump Capacity(gpm) 20 ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) 1(count) Placement I Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Choose Material Choose Matenal �� i—Choose One WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 05/11/2021 Constant Rate Pump 12 01:30 # 13 00:01 11 WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 05/11/2021 11 (12 ''''.... ................................. COMMENTS e WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. WILLIAM Supervising Driller DESMOND, DrillerURQUHART Registration# 299 Monitoring[M] Signature THOMAS,E DESMOND WELL Firm DRILLING,INC. Rig Permit# 0551 Date Job Complete Os/21/2021 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. it ENMOTECH LABORATORIES,INC. MA CERE NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1.800-339-6460 FAX(308)888.6446 Client Name : Desmond Well Drilling Location Address: PO Box 2783 114 Peppercorn Lane Orleans, MA Cotult, MA 02653 Lab Number: DW-211906 Collected By: DW D Date Received: 05/12/21 Sample Type: Well Well.Specs: Irrigation 30'/11' Location Source Da1e'Cullected''" Tyne Collected Comments A OSM1/a1 _ 12:10` Analysis Requested Units Recommended Limits Analysis,Result Method . 1)ateAnatyzed Analyzed By Total Coliform CFU/100mL 0 0 SM9222B 05/12/2021 KF Q 13:30 pH _ ?H units 6.5.615 6.55. SM 4500-H-B 05/12/2021 SD Specific Conductance° umhos/cm 500 133 EPA 120.1 05/12/2021 SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 05/12/2021 SD Nitrate-N mg/L _1010 0.63 EPA 300.0 06/12/2021 SD Sodium M M� N mg/L � + 20.0 20 EPA_20_0.7 05/17/2021. KS . Total Iron Y^ mg/L 0.3 0.09 EPA 200.7 05/.17/2021 KB Manganese mg/L 0.06 0.186 EPA 200 7 05/17/2021 KS Comments: Over a lifetime,the EPA recommends that people drink water with manganese levels less than 0.3 mg/L and over the short term,EPA recommends that people limit their consumption of water with levels over 1.0 mg/L All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the beat of our knowledge, Water meets EPA standards and:Is suitable for drinking for parameters tested. + Date 5/17/2021 Ronald J.Saari Laboratory.Director BAL=Below Reportable Limits "See Attached Page 1 of 1 � aCertlficatlon is not available for this analyte for potable water samples,. it No.-GD / Fee 60ARD OF HEALTH TOWN OF BARNSTABLE ZIppYication _Jor, ell Construction Permit Application is hereby made for a permit to Construct , Alter( ), or Repair( ) an individual well at: l y 6?70 e CO" La", Gbtl" -F Location-Address Assessors Map and Parcel f P�e- r Et i l ctl l lq I�P'rcorn ,(.Ofil�if f�/l t 0�(0 5 Owner I I Address OCzErn nd, (aX11 Drdlljra , Installer-Driller Address Type of Building / Dwelling V Other-Type of Building No. of Persons Type of Well LA I � L4 D JOVC, CapacityPurpose of Well l 1�YCGICp- 101� Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certifi ate ofCompliance has been issued by the Board of Health. Signed Date Application Approved By / 1 Date Application Disapproved for the following reasons: hh Date Permit No. �- Issued Date --------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed W, Altered( ), or Repaired( by te-'Z-,MO V)C - W-e l D r 1 1LC�1 L (� Installer at �—1 ►"'gyp ��n C'DIZLI t has been installed'id accordance with the provisions of the Town of Barnstable Board of He lth Private Well PJ ion Regulation as described in the application for Well Construction Permit No. �, 4� Dated / THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector L No. �� -` / ©e Fee j BOARD OF HEALTH TOWN OF BARNSTABLE a 2pplication -1 r �Cougtructtou Permit Application is hereby made for a permit to Construct A), Altei() or Repair( ) an individual well at: � Location-Address Assessors Map and Parcel % Owner Address ,E-,rA0nr - (, XII 6r lirk-1 , Iric , P,0,6QX- 27S,3 , ter (PO 1� 02b�3 Installer-Driller Address Type of Building Dwelling V Other-Type of Building No. of Persons Type`of Well W4 iC ' �' Capacity 4 Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the } Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to lace the .i g g g P well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed J� `� •'j ZAP Date h Application Approved By�_ -��--- -- ---� - T�c�" Date Application Disapproved for the following reasons: ! _: \ ,r Date Permit No. a) c-)-1 Issued `7 Date `*+ BOARD OF HEALTH ., TOWN OF BARNSTABLE Certificate of Compliance e • . THIS IS TO CERTIFY,that the individual well Constructed( Altered( ), or Repaired( by Installer at j)Pc`rcpf n La !�. has been installed'iri accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection 'Regulation as described in the application for Well Construction Permit No. Dated 41/6V-4-1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector .--- - -- ---------- _ _ -_--_-_,- .---.. ®_a�4--------------- ------- BOARD OF HEALTH j TOWN OF BARNSTA/BLE Vern Congtruction Permit I No. � -� _.'"�f Fee _ . Permission is hereby granted to Installer to Construct O, Alter( ), yor,�, Repair O an individual well at: i Street y J as shown on the application for a Well Construction Permit No. WC= �"M Dated Date 416,6' / Approved By .. ; r7'1PROPOSED , ;• � :,ty ui.r .4 5140' T7LlTY PL ATFORM 1 Lawn 1 l,r n J S1l t ' .�, C ... v.,Y /�' � ..� _,, l it ��: . .. � Emeter \ ` � S°ntaH nurkl». c1rco "� '`f i * _ �i Emater Pf�OPOSED -G .` `� O Trans ` ,'tee .ti _'} - , ✓ .. GARAGE \� \ SL f AB EL. 10.5 611 l.. Lawn ts1; E�\ ` \ `` To art +b ,•� ,. �,,,tiJy1�1°� / y `af .��5' tI w y4 '`.y` sl " I ,�•.,,1 \ � �/�f� �ef` Gd!'t7�r? �j'r ,//''''`,�"�-`,cam,.!\\`f/i,' t. ;� , K,•, i , f ` °1, .r `� ;� DEMOLISHE J.� t ;'S _14 � \ try PR© OSE. PfZO�'OSED I i \ "0 8E� t _r •4. �� 57.5r± X LLING�'`-_� PAVED � TH-i f OLISHED ` i. o F.F.EEt�. 13 i{t DRIVE 3. .... ROPO%lrDD RESERVE. C.: EXISTING S TIC TO BE P01 CD PROPOSED CA TCH BASIN —t . ,�. o ROf'OSED X town PRO bSED hh pit ` { ?6 ... 1 P:"4 X r�:p rw'(�r�. :a .,�, Q a+"rr AlVG 11.2 P� QED MA I �- Poop S 36 FE p • , one Line�.. ' •,, �� .o. SEF TlC TANK ` Lfat 32 PROPOSED1� % 8 ,.62fF to DRYWELLS j 12' PATIO 1 10 PROM TI�=3 F D ROO r t � R+UNO E x & DRIJ AY J goy-Commonwealth of Massachusetts vo9- o01 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Na information is required for every Cotuit Ma 9/22/2020 page. City/Town State Zip Code Date of Inspection 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. Important:When filling out forms A. Inspector Information 1# /q 113 on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. P.O.Box 151 r� Company Address to Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number 1 B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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 3. ❑ Needs Further Evaluation by the Local Approving Authority. 4. ❑ Fails 9/22/2020 pector's Signature Date The system inspector shall subocopythis inspection report to the Approving Authority (Board of Health or DEP)within 30 ng this inspection. If the system has a design flow of 10,000 gpd or greater, th ' Sp system owner shall submit the report to the appropriate regional office of the D Theshould 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owners Name information is required for every Cotuit Ma 9/22/2020 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 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 ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityrrown 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 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 Commonwealth of Massachusetts �w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `,� 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityrrown 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 '/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 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. 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 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? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f c Commonwealth of Massachusetts h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 7 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 770 Description: 2017 plan design 7 bedrooms Number of current residents: 3 seasonal 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts r� ,? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 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: none Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityrrown 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 b system operator under contract P Y Y Y p ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2017 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 30+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. CityfTown State Zip Code Date of Inspection D. System Information (cost.) 6. Septic Tank(locate on site plan): 6„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H2O 2000 gal tank If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gals 201 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness less then 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place. tank at working level in new condtion. tank does nt require pumping at time of inspection 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityrrown 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 �d Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityrrown 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.): Dbox in good cond. H2O. no carry overs present no decay t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Citylrown 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: 8 flow defusers ❑ 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 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.): Dry and clean 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityfrown 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Cityrrown 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 1 gf 0 � - 30 1 e'' 3 A f2� 3�- U c 2,5� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 page. Citylrown 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: 10'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: 2017Date ❑ 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: plan design water 10' below grade. system 5' above water table per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form.-Not for.Voluntary Assessments 114 Peppercorn Lane Property Address David Mugar Owner Owner's Name information is required for every Cotuit Ma 9/22/2020 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I 10/5/2020 Town of Mashpee Town of Mashpee (508)539-1419 Billing Information Transaction Detail Chad Hathaway Mastercard P.O.Box 151 XXXXXXXXXXXX7302 Forestdale MA 02644 10/5/2020 7:54:30 AM hps1oncape@yahoo.com Approved 261377 Invoices Health Dept 26827247407075067 $25.00 SUBTOTAL $25.00 SERVICE FEE $1.00 GRAND TOTAL $26.00 https://www.invoicecloud.com/portal/(S(tb3a 1 daxg4fbt01 kOyhbep5y))/2/CloudPaymentConfirmation.aspx?pg=3ae2d424-5f4d-480b-a777-dal e3a9a4b... 1/1 10/5/2020 Town of Mashpee Town of Mashpee (508)539-1419 Billing Information Transaction Detail Chad Hathaway Mastercard RO.Box 151 XXXXXXXXXXXX7302 Forestdale MA 02644 10/5/2020 7:52:02 AM hps1oncape@yahoo.com Approved 425876 Invoices Health Dept 26827247407075066 $25.00 SUBTOTAL $25.00 SERVICE FEE $1.00 GRAND TOTAL $26.00 https://www.invoicecloud.com/portaV(S(hxnf5lgzvptzpOwrhylvvgis))/2/CloudPaymentConfirmabon.aspx?pg=13921 a73-0ffd-4a2d-9eeb-36f863el24b8&r... 1/1 10/5/2020 Town of Mashpee Town of Mashpee (508)539-1419 Billing Information Transaction Detail Chad Hathaway Mastercard P.O.Box151 XXXXXXXXXXXX7302 Forestdale MA 02644 10/5/2020 7:50:12 AM hps1oncape@yahoo.com Approved 618324 Invoices Health Dept 26827247407075063 $25.00 SUBTOTAL $25.00 SERVICE FEE $1.00 GRAND TOTAL $26.00 r https:/Avww.invoicecioud.com/portaV(S(ixtgc2zwt5oxs3yjmzfhctfb))/2/CloudPaymentConfirmation.aspx?pg=eadOb42e-b44a-4cf0-966b-1387253be620... 1/1 Town of Barnstable P# 15 5� Department of Regulatory Services _ At ,�nxsnlst Public Health Division Date . �5 17 MARS, � 039.a� 200 Main Street,Hyannis MA 02601 A1Ep MA't 6 — Date Scheduled Time Fe P e d. y - Soil Suitability Assessment for Sie Dispo al Performed Byltt "6 G"'% D Y1� Witne sed By: LOCATION&:GENERAL INFORMATION Location Address �?�P�r� 1I�. "n ��� Owner's Name t I c6 ( h Address 1 '_:�CVSA--0,v YkAPC 021l Assessor's Map/Parcel: /j�l.r 6011 011 a . Engine s Name t NEW CONSTRUCTION V REPAIR Telephone# °C.O 4: Z — ' ' Land Use BSI Slopes(%) ®— Surface Stones Distances from: Open Water Body ft Possible Wet Area <01 ® ft Drinking Water Well ft Drainage Way ft Property Line "®� ft Other o ft f SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) k ,, f +2 +, Q'o'4 elf, t C Parent material(geologic) S Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face G Estimated Seasonal High Groundwater ?r 5 r ij DETERMINATION FO� �t SEASONAL HIG WATER TABLE se - Method Ud: _® /Va"i �,�o`l Fr// mot E<< Depth Observed standing in ob§.hole: - - -in. "Depth to soil mottles: '- - in Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date 2 Time Observation Hole# 2c� T Time at 9" Depth of Perc J ! rr �6�C Time at 6" Start Pre-soak Time @ Q O Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed �- Site Failed: Additional Testing Needed(Y/l) Original: Public Health Division Observation.Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. QASEPTIOPERUORM.DOC �o V S DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) to-2Y'` l3 S.�Ad D rg l� d6-o�" 2 Cotes S9 /a 3 g -l 32 C 3 So to R 7/� DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) to-l9`' I3 etlg 76 SL- (32" C 3 ,kj_ S,-e-1 to ! DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel)_ -? � S x Z2- t 20 C 3 .f',-n 7/7 DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) ly- 2 " ,� s �r�c�z 3l2 T3 Y6 76( c Z Cegrsc Sid `a �9 2�3 74/-lz® 'f C ate ( �U ��/�' 71) Flood Insurance Rate Mao: Above 500 year flood boundary No Yes Within 500 year boundary No_ Yes Within 100 year flood boundary No_ ' Yes X Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring fervious material? Certification ? �� l2 I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by,me consistent with the required trafiiia,.expertise and ex erience escribed in 310 CMR 15.017. Signature A4L,/ R IFI Date �/ �r✓l Q:\SEPTIC\PERCFORM.DOC 1 ..c TOWN OF BAIN;;TABLE LOCATION ��^^�`�{ Q ,� `-E. SEWAGE# �11 " X-17 C� `VILLAGE Ir ,,, ASSESSOR'S MAP&PARCEL -_LZq INSTALLER'S NAME&PHONE NO. �t.r SEPTIC TANK CAPACITY °- LEACHING FACILITY:(type)(JS '��e�✓ Val�� ��(size�Z� 3�i x�L.b 1'�y'` NO.OF BEDROOMS 7 OWNER bckV-& �e PERMIT DATE: 0111-) COMPLIANCE DATE: I 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 -�,nr%j at'i 6� I T �`ayez i etc, 6 ae r 1 r r J No. ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Disposal *pstrm Construttion Permit Application for a Permit to Construct(� Repair( ) Upgrjde( Abandon( ) [ Complete System ❑Individual Components Location Address or Lot No. 114 Owner's Name,!Address,and Tel.No. 1Dki%vfmPeak\ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel..Tel No. �1�6� ��u�,ewly,�coatsc.�io+5o 570'% o 7lc 502-4' g--Sg4V Type of Building: Dwelling No.of Bedroom n c+I! Lot Size tZ,(,7 ii sq.ft. Garbage Grinder(L Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .n 0 gpd Design flow provided gpd Plan Date Z.C+(71 Number of sheets Revision Date Title 5 O&— 1—�?(rho" Tj m�o�Pt o� Size of Septic Tank Type of S.A.S. T-w_D.S Description of Soil `� 0S ; 0"(3aL 0 (A-IeL ®.Z.-g a Ac(Agm 10` &3 f�t C��,v'��` N� 0 S-2 Q 13 t�jlo � .c&4en rpO 2 0-s4 C,,. [_i `iCf.- 2 `L(.1 k f ILA SNUD '4..7 0' Cr LMsA L 'L61r <a�u� 7 6-li ci . So rYle9 5 � Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore�described on-site sewage disposal.system in s accordance with the provisions of Title 5 f the Environmental Code et-to place the system in operation until a Certificate of Compliance has been issued by this o S med , f Date lU� Application Approved by Date Application Disapproved by V Date for the following reasons Permit No. Date Issued ol No: 41xl. Fee 1� a r' t T P THE COMIl IONWEAL•TH OF MASSACHUSE'T 'S Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN�OF, BARNSTABLE, MASSACHUSETTS 1 , I ) 2ppYicatiort for Disp sat 6 irm, wstructiDn Permit Application fora Permit to Construct Repair( ) Upgrade(,;j,`Abandon( ) .21 Complete System ❑Individual Components t. Location Address or Lot No. 114 Je0P4-(%1rn L"et ', Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 064_0a q-yw Installer's Name,Address,and Tel.No. F Designer's Name,Address and Tel. No. `;r1iX.�Ify4+J C..Ax,+:v��CV+Ftr's'-�.i�S3YsVt�J�+L j �, U` CK1 er+ie� n t SC 1509-47 1' -! w ' Type of Building: Dwelling No.of Bedroom 3 Lot Size sq.ft. Garbage Grinder(i t� Other Type of Building ✓/ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1 gpd Design flow provided '7-7 5 gpd Plan Date 1'3E Z at Y Number of sheets - Revision Date Title i ,c,n 7[,,ga" R%V1*V tn1 C - Size of Septic Tank 00 Type of S.A.S. $" 1gufl+ ,.Sur S +r. Z."'i�.k3c CiwL * Description of Soil7 0-04.' 0 i_A 0,Z-e,e AC LOc*Ck It1 M31► l ea�rn�t`,P�//•ea? r 5 Ltntkf, It\11L 5,1(0 C , I.k\Ke -2,a'1 Q i« C=1kA Seo-0 S.a''70 Q (Mt& 7_11 (rs�f��Wt��f ��yl� ic'7.0^�1,13 �ot9�`iG� ?-�3�i �o�tu 1YICL�.S�►� Nature of Repairs or Alterations(Answer when applicable) Date last inspected:' Agreement: ;r 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 gind,not to place the system in`'operation until a Certificate of ' Compliance has been issued by this Board of'L,ea.th. / 4 - Signedg �i a r � eM)< //i'1 t"` DateIV �{ �(✓ i --• Application Approved b /(ll ,f�,f / f _ , .�? Date Application Disapproved by V / �V Date /r rr ., for the following reasons .q Permit No.t � Zf/ r> / r Date Issued 1 / Y I , - - ------------------_------- ----,---`-- - ._ _ . _ _-=----- _ = __ = ! ------1 1-- ------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage_D.isposal system Constructed Repaired( ) Upgraded ' Abandoned( )by at ��� C4�PQ^C� r^� �,ct has been con cte in ac/c�or�dIV a, co with the provisi o ns ofTanc�the for Disposal System Construction Permit No. ,+ ldafed Installer Designer r #bedrooms M _.M Approved design flow —7?0 gpd The issuance of this permit shall notabe construed as a guarantee that the system will function as designed. ~ p Date Inspector( --------- ---h--------—----`-- ---------------------------------------------------------------------------------------------- No. �� ~1G Fee tS� i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstern Construction Permit Permission is heFdby'granted'to construct Repair( 'Uppgrade( ) Abandon( ) System located at (N ?rf e r(e,!'r\ �t� / Gam`/ lJ i e 'r: and as described in the above Application for Disposal System Construct-ion Permit./The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. �s Provided:Construction mu t be co pll� within three years of the date of this permit. P91/ Date / Approved by Town of Barnstable Regulatory Services Richard V. Scali,Interim Director ► mmsrmm MASS. Public Health Division i6gq. � Thomas McKean,Director. 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 11- 17 Sewage Permit# _blj' 221 Assessor's Map\ParceloUl C61 061 s"I�lihi taller:Designer: S Ivk� (Ok � I G Lam L0.1�II�l f `— Address: 1� Address: r S l- � s Cl�t..lLQ. � f�-L� [�1 , On Lyiut5 c o,,,_ was issued a permit to install a ' t ( te) (installer)' septic stem at ( �� based on a design drawn b Y � Y (address) Iti�S CSC-t� datedt441M / ( signer) rm IAIVX I certify that the septic system reined above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced•above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory.. I certify that the system referenced above was•constructed in compliance with the terms f the IAA ap 'roval letters(if applicable) (Instal er s Signature) d i No.+,4itia j (Designer's Signature) (Affix De Ng eamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE / � �' OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- 0 s BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. f Q:\Septic\Designer Certification Form Rev 8-14-13.doc i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection 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. Important:When filling out A. General Information forms on the 314 computer,use 1. Inspector: /J only the tab key to move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC. Company Name raa P.O.Box 763 Company Address • Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - L s f _ 5/27/2009 s Inspector's Signature DateI The system inspector shall submit a copy of this inspection report to the App owing Authority,(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared-system or has a design flow of 10,000 gpd or greater, the inspector and the system own r shall submit the report to the appropriate re ional office of the DEP. The original should be sen to the W'pg �;y�temrowner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found-any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma: 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a.private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs'of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consist of a 1000 gallon septic tank,distribution box and two flowdiffusors. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No 6,000 :3 Water meter readings, if available (last 2 years usage (gpd)): 2002007: ,000 Detail: 2007:98 gpd 2008:58 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 5/27/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 4.5' p g 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 gallon Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments I I 'GSM 114 Peppercorn Lane Property Address Ben Heckscher F Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 Flowdiffusors ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: i i ❑ innovative/alternative system ! Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): y . t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: II ❑ hand-sketch in the area below ❑ drawing attached separately f I ti � 175 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M s 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 6.2' 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of ground water elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 114 Peppercorn Lane Property Address Ben Heckscher Owner Owner's Name information is required for Cotuit Ma. 02635 5/27/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BA:RNST.ABLE _. LOCATION � y .. rd 7— _ -4EWAGE # Fa VILLAGE_- __.e..e�,c..3t = ASSESSOR'S MAP LOT o Ly:-4191` INSTALLER'S NAME & PHONE NO.,, SEPTIC TANK CAPACITY 1046 C L LEACHING FACILITY:(type) /f�1G!✓ t��fi.3"C�z� (size) NO. OF.BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE-PERMIT ISSUED: 9— /— Cc' DATE COMPLIANCE ISSUED:— VARIANCE GRANTED: Yes_ �—No— �/ tr q6) \ / 75 J - - o ( 20 .o0 (� U kHE COMMONWEALTH OF MASSACHUSETTS c� n BOARD OF HEALTH vTown---------- ------OF......Bar.?? b.l. .. m11trFation fur Daupuual Works Toniiuurtion rrrmit Application is hereby made for a Permit to Construct ( ) or Repair kXj an Individual Sewage Disposal System at: Peppercorn Lane Cotuit ................................................................................................. ..------------------------------------------...._..........----------------....------------------. Location-Address or Lot No. ztl.�xp i.n._He�kscliez.............................................. .................................................................................................. Owner Address ............................................................... .................................................................................................. M Installer Address Type of Building _ Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............ ...............................Expansion Attic ( ) Garbage Grinder ( ) PLIOther—T e of Building ............... No. of persons........................_... Showers — Cafeteria a' Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow............................................galloa..w WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-___-_-_______-.-_--_ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ...-.....................................-................................................................................................................... 0 Description of Soil....................................................................................................................................................................... W Sand U --------------------------------------•--------------------------------------•---•---------------------------------•---------------------------- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... 1-10-0 Q Q allo.n---pit..----------------------•-----....------1• 140-0--ga 1-1-e-n---.a r-l£-------------------------------- Agreement: The undersigned agrees to install the .aforedescribed Individual Sewage Disposal System in accordance with the provisions of 7iT 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issue y t b of health Signed. .:' .c.. . -- . . . ••---------- ------•--9�118. ..... Date Application Approved By-------- - ....... 4 Date Application Disapproved for the following reasons:............................................................................................................. ---------------------------------------•-------------•••------------------------------•------------•-----------------------------••-•-----------•••.................................................... Dave PermitNo...... U ------•-------•------------ Issued....................................................... Dnze FA: ...2 0..00.._...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............T.o:vin..................O F......B.amns t.a.b.le..-----------------------......................... ApplirFa#iou for Disposal Works Tonstrortion Frrmtit Application is hereby made for a Permit to Construct ( ) or RepairX an Individual Sewage Disposal System at: Pnpercr .................................. ...•------•--•------•-•--•-•••-•--••------_...'-'---._.....-•----•-•-••......--"................. Location-Address or Lot No. ._ Owner Address Y---------------------- --•---__--------------- ---------------------------•--- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............3.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G I Other fixtures -----------------------•-------- . -------------------------------- -------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-__-__---___-_----sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.--__---_--_-_-___._-.. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... a -----•--•---------------------------------------------------------------'-'-----•-'-..........--•-•-......................................................... 0 Description of Soil...........----------------•----........---.................--••-------•-----------------------------------------------•---••-------------------------------•----•----- Sant c.� ••--•----------•---------•---------•---•-----•-----'-----------------------------------------------------------------•---------•--------------. W UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------•-------•Z-1 "C J 11_on...;it.......-----.........------------------.1..,1-OLQ-0----�;a-LLz) .-- ------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT . . y g g p y 5 of the State Sanitary Code— The undersigned furtl era agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health./' I �a Signed; -' '•?> ;�. a ° (11 14/1/44,/f A o 1 l Date Application Approved By...... �� _, .-. r--.. ------•..................•---•--•---V ••--•----•-c ate j Application Disapproved for the following reasons:-----•---------•----•---------------------------------------'-• --------------•------------------.....--•-•-••. _........-•-•••-----••-••••••-----'-'----'--'-----'---------------•---•-•-"-------'-••-•-•------'-•--'----•---•....---•--•------•----................................................................ Date PermitNo._�-C =...5_r'-7------------------------------ Issued_....................................................... Lit.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................Town.............OF...........Barnstable . .. ...................................................... �prtif iratr of �omt fi mrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired i XJ. by........ r-amb.e.r-----------------•----------------•----------------------•----------------•--.------------_--------•-•------•-------------._.----------_-----•---------•-- Installer at_________Pl'np.ercern Lane Cotuit .. ..................... been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__57'_:.---5"v_-�.............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................•••. ..-. .�-. K-------•-------..... Inspector.............. .....---4­4._D-----..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ Town Barnstable 6 .SC ........................OF................ -----------...---................---------......------............. $ 20.00 ._5 N . ..... �... FEE........................ Disposal Works Tomo#rioat rrmtit J P Macomber Permission is hereby granted........................................................................................................................................ to Construct ( ) or Repair KX� an Individual Sewage Disposal System at No...._Pep e corn La e Cotuit- ... •--- -- ------------ Street as shown on the application for Disposal Works Construction Permit ..... Dated.......................................... �f ..................'---_ ............................................................ / _ L O Board of Health DATE--------------------•--- r..-----••---•----•--•-------------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 'S O pAp D h • � rf o n a o n a II II II I I n nn n0y rn_> n AQA lO <r � 00 ------o-------- n 00 II II II II II II 9�n m� II mA 6 A� I II a� i II <p -TI y - II „o � Ib II II II II I—I- 11 q-P 70 C) z ---� IA z Flo I I n II II II II n ' If I I 11 iL II II { o o A o 6 FO �� m> I L�---- — n li u r; JOB NO:1618 � . 46 WAhh—Street.Suite 3A J. MUGAR RESIDENCE SCE: 6°Z;;°" GRASSI DESIGN GROUP Boston,MA 02118 FIRST FLOOR PLAN COTUIT,MA % C Ph6ne617-956-9992 R.PMl .:a a '-ftr 54:IN1€RIO S F..617-956-9993 m ��O i ' L 71 IIII� I I R� I I I I ❑ III �� I � I l f , III H p z o� I II I I I I II I I mm N I 0 rn I A O I I rn l —� _ sz A� O I �— I g JL O D I I m$ = Z II � - - - ❑I °° I I i > o II I u I A 3 I m� I A �b IIII�II'' IIII' I III — I -� �o JOB NO:1618 46 WAN—Street.Suite 3A J. MUGAR RESIDENCE DATE: 06.2317' ffGRASSI DESIGN GROUP Bo on MA 02118 N SECOND FLOOR PLAN Phone617956-9992 COTUIT,MA r F.617 956-9993 O 1w;.,.<a,i a BUFFER ZONE CALCULATIONS: ASSESSORS REF.: LOT CALCULATIONS. FLOOD ZONE: Ma 004, Parcel 009-001 ; Existing Hardscape Proposed Hardscape P 0-50': 1,380 SF (Bld) 0-50': 0 SF (Bld) Upland Lot Area: 82,200 SFt Based on Map # 147 SF (Deck&Patio) 0 SF (Deck&Patio) 25001CO752J ZONE. x 5, 0 SF (Misc.) 0 SF (Misc.) Floor Area: July 16, 2014 RF 1,527 SF (TOTAL) 0 SF (TOTAL) First Floor = 1,727 SF Area (min.) 87,120 SF (RPOD) Second Floor = 1,138 SF t Frontage (min) 150' Garage Second Floor = 675 SF ' 50-100': 173 SF (Bld) 50-100': 873 SF (Bld) Setbacks: Pooh Cabana = 352 SF OVERLAY DISTRICT: A= �v 0 SF (Deck&Patio) 1,451 SF (Deck&Patio) Front 30' Total = 3,892 SF (4.7%) 173 SF (Misc.) 0 SF (Misc.) AP - Aquifer protection District Side 15' 346 SF (TOTAL) 2,324 SF (TOTAL) Lot Coverage: Rear 15' i" Mitigation Required: Dwelling = 1,727 SF � + �k ° 4 x (0 SF -� 1,527 SF) + 3 x (2,324 SF - 346 SF) _ -174 SF Deck/ Porch 1,056 SF4 Garage = 896 SF � , 1 ff Mitigation Provided:N/A Pool Cabana = 352 SF - ' Poo/ = 8003�FS IRECrION . D Total = 4,8 (5.9%) From Hyannis - Follow Ro ate 28 West to vT , v - Co qH C+ ��� � ��, c,,A �� Cotuit; To'<e a left onto utnom Road, and Fn 4 1s `� c _ , I' F 5e follow to the end; T;eice a left onto Main rD. �^ N MA r f o`� Street; At Rushy Marsh take a right onto T' �j LOCH o � , / S e Lowell Rood, and continue straight onto Scale: 1 = 2000 f f / ) ,y r tt PP 9 ,,�� � �, � Pe ercorn Lane; Site is on the right, 114. i . II PERC TEST: 15,372 ,� '',l\ `•ti, � �v' � ', .-" f,,r t`j�•\.� PERFORMED B SO IL EVALUATOR NOJOHN O' I 2911 ENGINEERING / WITNESSED BY:DONALD DESMARAIS,R.S.-TOWN OF BARNSTABLE _ 7 'r. x / l SITE PASSED 1 _ 77 7 , �>/, 51/0, / PROPOSED TEST HOLE 1 TEST j lawn Shed'. TILITY PLATFORM r - 15 - 15 J' C. Ati6��.. .� r Possible \ � ST HOLE 2 EL.i Mean High Water \ UST Slane ParkingArea Emeter 1 i ty_ �L 11.3 s per Land Court Plan / .,_ ;_ E I t 2' 11.3 0.2' Lawn a . 1, `, c� Emeter r. i C; i \ AELAYERIOYR3/1 AELAYER10YR3/1 x ? w { i / VERY DARK GRAY VERY DARK GRAY \ / w PROPOSED n 0Trans 2' X 28. T ��\ ,l.. �,,...`.t,, }jlI �� i > 0 / .s' LOAMY SAND 10.7 0.8' f � '� �' � I ;' s. s;.._ � � �, LOAMY SAND 10.7 3 -. l r/ i B LAYER 1 OYR 516 B LAYER I OYR 5/6 �� GARAGE / n '' _...f. t c. '\ti YELLOWISFBROWNYELLOWISH BROWN Top Of Coastal Bank •, _ SLAB EL. l t i f ' , - ' LOAMY SAND 9.9 t < 11 } . �_.. y f 0 LOAMY SAND. 9.5 1.6' r. e.....w ., 3 ` . s Cl LAYER 2.5Y 6/6 Cl LAYER 2.5Y 6/6 i Lawn 511, } 1 j } , Fnd ,.., o j OLIVE YELLOW OLIVE YELLOW / f 1 { � �`� `�\..,> N 6 •OO' � < # � � 1 S6.55 � FINE SAND FINE SAND PERC TEST 8• x fats= 7' \� !' ' ,. 2 8' 7 t� ` � , s33g�'' n� 1 �� 25 GALLONS GONE IN 7 MIN. " - 1: /fY 3 ,35n W \tt<`A 5.0' 6.5 5.0' 4 6.5 MN RATE<2 MIN/IN LTAR 0.7 1 } .f VQ I j c m \ i' 1 Gara E \ �...... _._N S 81,° 9 C2 LAYER 2.SY 6/6 C2 LAYER 2.5Y 6/6 PERC 13. <. 9 r ✓ r { _.... t/ TO BE OLIVE OLIVE 17 COARSE SAND 4.5 DEMOLISHE ( / Lot � ...- r x. 7.0' COARSE SAND 4.5 7.0'_... s; i r \ C3 LAYER 2.5Y 6/6 C3 LAYER 2.5Y 6/6 if CB DH \ OLIVE YELLOW OLIVE YELLOW 0 G.W.EL.0.61 1 P v / r _ r Ua W-[peter ` r 1 S+ f, o 2 tv\ \ Fnd , v" _ MED.SAND MED.SAND 0.5, y -" y - /, � 1j� \ \7� O PRO OSE' v i ,' ; ;� 'f 11.0' 0.5' 11.0' O �Y' tling ., 0 PROPOSED ^, GROUNDWATER ENCOUNTERED GROUNDWATER ENCO TERED Q 7 5' 0" i f ✓ \ =i �z '4' ° TO BE I p p 5 t X A VED `�'' � D MOLISHED LLIN D - / �m DWE 3 r.m. TH 1 P F DRIVE \ E r _ F.F. ``, _ TEST HOLE-4 o EQ. 36� /�+�■ ' �. ' I ROPOSED S.A.S. TEST HOLE 3 EL tos EL.1o.2s Lawn; Q N RESERVE. EXISTING: S TIC Vc \ ' 01 TO BE "REMWED tv v � s\\ \ \\E � I�r l(j' .3, 10.2 0.3' 9.95 / O / � JO��O ���. � �-� -` � \ \\ �ti. .• �� 1V,. � /� �, �!/ AE LAYER lOYR 3/1 AE LAYER lOYR 3/1 ' � // �' -VERY DARK GRAY VERY DARK GRAY Q __� l v v� -1 : �/ 1.0' LOAIvfYSAND. 9.5 1.0' LOAMY SAND 9.25 PROPOSED CATCH BASIN k ._.:. ._._. v t � � • l ; �A \\ Tel :, .....,,., � O B LAYER70YR�/6 B LAYER t0YR5/6 _ "� �V A�'P .... Trans " � '' � v i � ����� - YELLOWISH BROWN YELLOWISH BROWN ., r „.,b \ T ., CTV i.5' LOAMY SAND 9:0 1.5' LOAM SAND 8.75 .... t;>..:,.x { 7 / �``� ' ' `� �' � "� '�. i C1 LAYER 2.5Y 6/6 Ci LAYER 2.5Y 6/6 _. \ ROPOSED r \\ ��M \ OLIVE YELLOW OLIVE YELLOW o 36' o. 7 Lawn PROP SED D- X _ FINE _., �-�C23' / \\ \�� e jr__. \ A P RCTEST 8.05 - -1 * A TI O 100 25 GALLONS GONE IN 7 MIN: FINES ND t p O N RESERVE. 3. / 2 e_ _ / l _.. _._ r l \ 7, 6.8 3.7' PERC RATE<2 MIN/IN LTAR=0.74 6.55 zC*) A E{. 11.2 Q > ` i. t. e � �.._ �`�•, .� C2 LAYER 2.5Y 6/6 „ a C2 LAYER 2.5Y 6/6 0 ��5r � ; 1 �Ep FEMA to PRO OSED S.A.S. \� ,TOLIVE OLIVE �`Q �� t o PROPQ 36 "�" ��� ✓t // I 6.0' COARSE SAND 4.5 6.0' COARSE SAND 4.25 5��'l,`�Cp� SEPTA TANK Zone Lm,e `I \ \ _ �� , C3 LAYER 2.5Y 6/6 C3 LAYER 2.5Y 6/6 o r - ' OLIVE YELLOW OLIVE YELLOW 0 G.W.EL.0.61 1. � �_ --_ -- ti . 10.0' MED.SAND 0.5' 10.0' MED.SAND 0. 5' of 32 r •-? �� GROUNDWATER ENCOUNTERED GROUNDWATER ENCOUNTERED 82,620,±SF to ML W :.,. _ _, PROPOSED 1 - 12' PATIO ; ' I 1 / �� 10 p DRYWELLS _ PRO F`O ROOF TFI 3 1 \ -K = ' - _ F�'UNOFF � \� ' & DRIVE AY 4 � I PROPOSED To of Coastal Bank o n 40' ;' PROPOSED P p 20' X 22' X 16 i _' /r / z r POOL Grade CABANA OZONE DISINFECTION 'l kr / E / �� Finish G d c OR APPROVED EQUAL Lawn n \ ' i /' 1 ` N €�. 11 3- -I{..,> 3Fabric � Filter Lown �.....�� r` �� CB/DH S 85. ' „ / M�j AND OR _ Fnd 24 OQ E J / Com ac od Fill / :. .. -:. i o I V - � 194.36 �O x Pea Stone 2 r 43 ` \ ® � ® 1 .,. " LP Gas �,_.� 3/4" - 1 1/2» j Tank E '� , uble Washed - H meter //' CI9�D ( 4' E , N / Fnd 12' Stone Area ; John J & Kat hleen hleen46.3'Ea eme d 45.1 See Doc. #1,016,038 ------------------- Gorrally r F FLOW DIFFUSOR PROVIDE DRYWELL FOR POOL DRAWDOWN cRos SECTION way ^Sty Shed --------_ ____ _ NOT TO SCALE �' f 1 I � f' • INµ E '/ // FEMA Flood CB/DH Zone Line Fnd , i � � B.M. // �/ EL 14.2 F.F. EL. 13.0 I f i 1 Access Cover S86°28'16,W p.) 257'f ' F.G. EL 11.0 (See Note 6 I I j D 11 i F.G. EL. 11.00 N/F DESIGN DATA Single Family ' Christopher D 7 Bedroom @ I IQ GPD IIeCkSCher No Garbage Grinder _ �. PROPOSED As ' Flow }quilizers f Total Daily Flow=770 GPD EL. 9.50 equired SEPTIC NOTES p Installer To Use a 2000 Gal Septic Tank EL. 9.00 Confirm Prior 2000 Gallon8.75 1.Location of Utilities Shown on This Plan Are Approx.At Least 72 Hours To Any Work H-20 H-20 LEACHING AREA Septic Tank EL. 8.17 D-Box Y To El. 8.00 Prior to Any Excavation For This Project the Contractor Shall Make P EL. 8.0 P the Required Notifications to Dig Safe(1-888-344-7233)and contact 770 GPD/0.74(LTAR)=1,041 SF Required Bot. EL. 6.50 Sullivan Engineering&Consulting Inc.(508-428-3344). Sidewall=2 X 2(12'+36')x 0.96'=184 SF EL. 7.46 Flow Diffuser 2.The Contractor is Required to Secure Appropriate Permits From Town Bottom Area=2 X(12'x 36')=864 SF To Be Installed On / H-20 os �P�SH OF Mgss Agencies For Construction Defined by This Plan. Total Provided=1,048 SF °; Stable Compacted Base 00 3.Wherever Sewer Lines Must Cross Water Supply Lines Both Lines Shall Bedding,"T"s, & Baffels `6 / OH C O� Be Constructed of Class 150 Pressure Pipe and Shall be Water Tested to LEACHING CHAMBER DESIGN as Per :Thle 5 Remove & Replace EL. 0.61 ✓ - Assure Watertightness. In General,Water Lines Shall be Constructed in All Unsuitable Soils Within 5' of High Groundwdter„ U Cn All Pipes to be Schedule 40. Use 9 a �a Eit3 Coordination With Cotuit Water,and Shall be in AccordanceThe Outer Perimeter of The System MonitoringWell in Test Hole 3 P With 248 CMR 1.00-7.00&310 CMR,15.00. 8 Flow Diffusers in 2- i x 36' June 201 4.A Minimum of 9"of Cover is Required for All Components. Double Washed Stone Fields as Shown. PROFILE Qx, v �/� FFS /OVAL 5.All Structures Buried Three Feet or M9re or Subject DEVELOPED 1 / !OFI L E OF SEPTIC S I ST EI V I to Vehicular Traffic to be H-20 Loading.It is the Engineer's Recommendation that H-20 Always be Used. NOT TO SCALE 6.Install Watertight Risers and Covers to Within 6"of Finished Grade Over Septic Tank Inlet,Outlet,D-Box,and Two Leaching Chambers. REVISION: Adjust Footprints Landward 181211171 All covers are to be maximum 18"for,.oncrete or 24"Cast Iron. NOTES: PREPARED FOR: PREPARED BY. TITLE: Pl&n 7.Septic System to be Installed in Accordance With 310 CMR 15.00&248 CMR 1.00-7.00 Latest Revision and the Town ofBarnstable '"� Board of Health Regulations. S.A11Pipingtobesch.4oPvc. 1.) The property line information shown .was compiled from available record information. CPeSL'�V Proposed ' ' �" �� lent" 9.D-Box Shall Have a Minimum Inside Ilimension of 12 ,and a Minimum /� D V� n�Q�y & - Sump of 6". o - Ma✓ar Suffivan ,consuitift,the 23 West Bay Rd,t3u,te G 10.The Separation Distance Between the Septic Tank Inlets and 2.) The topographic information was obtained osterviue s 02655 At Outlets Shall be No Less than the Liquid Depth:Inlet Tees Shall Extend from an on the ground survey performed on ( ��ww w�„ �> MA02655 (508) 420-399�/ca 1995�om P a Minimum of 10"Below the Flow Line.Outlet Tees Shall Extend 19" t'Below the Flow Line,and Shall be Equipped With a Gas Baffle. or betureen 81JUL107 and 241JUN109. 114 IrCom Lane 3.) The datum used is based on NAVD 88 as --- Draft: JOD Field: RRL MML _ i Cotuit ■ as updated 27/JUN/17. 0 10 20 40 80 I 20 Review: Comp.: RRL DATE: SCALE: rr r Project: 20018 Project # C694 ---- July 7, 2 1 7 1 = 2�