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HomeMy WebLinkAbout0089 PINE RIDGE ROAD - Health vcotu Pine Ridge Road it A= 170 223 0zI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r1'"I 89 Pine Ridge Road Property Address P, Matthew Long Owner Owner's Na a W� information is required for every Cotuit Ma. 02635 08/25/2017 r' page. City/Town State Zip Code Date of Inspection Eti 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. General Information �'�# a 5q( on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Cityrrown State Zip Code a 508-280-3356 Si3938 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 08 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa/gee11 of 17 D V, S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. Cityrrown 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: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with.Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f G Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) I { 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)'and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and-the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes". or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): < 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: l Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail d/6 6, ajo �-�� -jf Sump pump? ❑ Yes ®. No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6116 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. Cityrrown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 10-18-1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2411 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): • Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon septic tank Sludge depth: 1" l5ins.doc•rev.6116 Title 5 Official Inspection Form: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 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 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 36" Scum thickness 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 12" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 89 Pine(Ridge Road Property Address Matthew Long Owner Owner's Name information is Cotuit Ma. 02635 08/25/2017 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No'` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins.doc•rev.6/16 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 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 flows ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuratiori 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 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: ® hand-sketch in the area below 0 drawing attached separately PC t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 ' TOWN!OF BARNSTAUE Lt1CATI�N��11�/� Rt�� � SEWAGE VILLAG 4I -fix � � _ ASSESSOR'S MAP G LOT INSTALLER'S NAME G PHONE NO. � ti) ��(.u!(� � 4L��_► IV 77-(.7X- SEFIIC TANK CAPACITY I UDU CAL, 1-4`10 !.EACIUNG NACILITY:(type)_I. FtW t 1 � (0(*W) .3 NO.OF BEDROOMS,, _^PIRIVATE W&I.L ORS BLIC W TA E�r BWMMROROWNER ✓deft(�. .3�9 �G�s��xr> L 4TE PERMIT ISSUED: - DATE COMPLIANCE ISSUED: VAR1E NCE GRANTED: Yes No f ���-r A) Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is required for every Cotuit Ma. 02635 08/25/2017 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: - 9 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed.- Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole to 9 feet to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M W 89 Pine Ridge Road Property Address Matthew Long Owner Owner's Name information is Cotuit Ma. 02635 08/25/2017 required for 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 r � Q v►ern �F S. �-.S, � � ZJ t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -\ COMMONWEALTH OF MASSACHUSE`ITS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEEAFTI4:1•ENT OF':ENVIRONMENTAL PROTECTION TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM, PART A CERTIFICATION � Property Address. V • r Owner's Name.. P /7 0 Owner's:Addres di Date of Inspection Name of Inspec jl� Please print) _ Company Names Mailin-.Address: TelephoneNumber. .1.: l ' ' CERTIFICATION STATEMENT , I certify that.I have personally=inspected the sewaQe'disposal systerii at this address.and that'the information reported below is true,accurate and.complete as of the time of the inspection. The inspection was'perfo,rmed based on my training and experience-in the.:nroper function and maintenance of on site sewage.disposal systems. I am a DEP . 'approved systerm inspector pni'suant to Section 1'5:340 of Title 5(310 CMR 15.000). ;The system: y Passes ' Conditionaliy.Passes '' Needs Further'Evaluation by the Local Approving Authority 4-; Fails Inspectors Signature ✓ :_ - Date:. cT}. The system inspector shall subnit a copy oft his inspection report,to,the Approving Authority(Board of Health or DEP);within'DO 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 systen owner shall submit the report to the appropriate regional office of the DEP The original should be sent to the system owner and copies sent to the buyer,if applicabl d, and the approving authority "Notes and Comments•. ' ****This report only describes conditions at the time of inspection.and under.tlie conditions of use at that time.;This inspection does not address how the system will perform in the futurd'under the same or different conditions of use. Title,5 Inspecti,on Form . 6/1512000 page .I Page 2 of l l 4 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner:. Date of I pection: , 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 crite.ria.not evaluated are indicated below. Comments: ` B. - System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or,repair;as approved by the Board of Health; will.pass. Answer yes, no or not determined(Y,N;ND)in the. for the following statements. If"not determined"please explain. The septietank is metal:and over 2.0_years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltratiori or.tank failure is 'imminent:System will pass inspection if the existing tank is replaced with a.complying septic tank-.as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available: ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken on obstructed pipes)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are.replaced obstruction is removed distribution box is leveled or replaced . ND explain: The system required pumping more than*4 times a year due to broken or obstructed pipe(s).The system will pass.inspection if,(with,approval.of the.Board of Health): broken pipe(s);are replaced obstruction is.removed . ND explain: Z. Paee 3 of I 1 OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: rfi ✓'. Owne'ri Date of I ection: C. Furtber.Evaluation is Required by the Board.of Health. Conditions exist which require further evaluation bythe:Board of Health'in order to determine if the system is failing to protect public health, safety or the environment. - 3. 1. System will pass unless Board of wealth determines in accordance with 310 CMR 15 303(l)(b) that the system is not functioning in.a manner which will protect public Health;safety and the environment: Cesspool or privy is 4ithin,50,feet of a surface water' Cesspool.or privy is within 50 feet of a bordering vegetated wetland'or a salt marsh n 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.systemhas a septic tank an 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 aseptic tank and SAS and the SAS is Within Zone ]:of a public:water'supply. - - t The system`has a septic tank and SAS and the SAS is Within 50 feet of a private watersupply tive'll. _ The system.has a septic tank.and SAS and the'S'AS 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 laLoratory, for coliform bacteria and volatile organic compounds indicates that the well is.free from,polfution from that-facilitt,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: 1 3 J Paoe 4 of.l 1 OFFICIAL.:INSPECTION FORM,-..NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property.Address: /. LL Owner.Date ope�on �- D System Failure Criteria applicable to all systems: You must indicate"yes"or"no."to each-of the following for all_inspections: Yes . No _ �•i 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-le.vetin the distribution box above.outlet invert due to an over]oadedor.clogged SAS or / cesspool; V Liquid.depth in.cesspool is less than 6" below invert or available volume is less than %day flow �/. Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number4 ' 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 I00.feet of a surface:water supply or tributary.to.a.surface water supply a� Any portion of a cesspool'.or.privy.is within a Zone 1 of a.public well. �t 1 Any portion of a,cesspool.or privy is within 50 feet of a.private water supply well. ►� Any-portion of:a cesspool or.-privy isless than 1.00 feetbut greate.r.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 colifor.m bacteria and volatile,organic compounds indicates that*the.weli is free from pollution from'thaf:facility'and the presence.of ammonia nitrogen and!,nitrate nitrogen is equal:to or less than S ppm, provided that no other failure criteria are triggered.A co.py-of the analysis,must*be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The.system'owner should contact the Board of Health to determine what will be necessarvto correct'thefailure. ` E. Large:Systems: To be considered a larger system the system must serve a.facility with a design flow of 10,000.gpd to 1.5,000 gpd You must indicate either"ayes"or"no"to each of the following: (The following criteria apply to large systems in addition-to the criteria above) yes no the system is within 4.00 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-I WPA)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: es"i . "Yes". n Section D above the large system has failed e a g x . 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'.10 CMR 15:304.The system owner:should contact.the appropriate regional office of the Department. Page 5 of 1.1 OFFICIAL INSPECTION FORM=NOT'FOR VOLUNTARY ASSESSMENTS SUBSUR:F'ACRSEWAOE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: - ' >, Date of Tns` ection Check if the following have been done.You must indicate"yes"or"no" as to each of the followi Yes. No . Pump'ing.info rmation was:provided by,the owner, occupant "o, Board.of Health ' _ --,—^ere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two 'week period ? ave large volumes`of water been introduced to the system recently or as.part of this inspection? We.e as built plans of the system obtained and examined? (If they were not available note as NIA) 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 _V Were the septic tanl: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 differenH` om owner)provided-with information on the proper maintenance of subsurface 'sewage disposal systems The size and location of the Soil Absorption System (SAS) on.the site"has been'determined`based on: Yes" o 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 As unacceptable) [310 CMR.15.302(3)(b)] y Pave 6 of 11. OFFICIAL INSPECTION.`FO.RM NOT FOR VOLUNTARY ASSESSMENTS SUBSUR-FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INF.ORiVIATIOlY Property Addressc /I, i Owner: Date,of.a pection: ( FLOW CONDITIONS RESIDENTIAIV. Number of bedrooms.(design): Number of bedrooms(actual).:. DESIGN flow based on:310 C P ..MR 15.203 (for example: 11.0.gP of bedrooms)d x n : . Number of current residents:. / Does residence,have a garbag grinder(yes or no):�l o Is laundry on a.separateaewage system(yes or,no): ).[if ves separate ins' ectioarequired] Laundry system inspected(y�.or no) 1 Seasonal use: (yes or no; Water meter readings. if available last Z year u aae:.o � C? � . ( y s d :� � V(Vs' Sump pump (yes or no): ) Last date of occupancy:,Lf.1 1' , COMMERCIALIINDUSTRIAL. V Type of establishment:: :; Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes'or.no)- Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or.no): Water meter readings; if available: Last date of occupancy/use: OTHER.(describe): GENERAL INFORMATION Pumping Records Source of information: / Was system pumped as part of the.in pecdon(yes or no): eW If yes, volume pumped: gallons--How was quantity.pumped determined? Reason for pumping: TYPDOF SYSTEM eptic flank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _ _Shared system (yes,or no)(if yes, attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the.current operation and maintenance.contract(to be obtained from system-owner) Tight tank _Attach a copy of the.DEP approval _Other(describe): Approximate age of all components, da installed(if known)and source of information: Were sewage odors:detected when arriving at the site(yes or no):. Page 7 of 17 OFFICIAL IN SPECTION CIION FORM —NOT FOR*`OR A SSESSMENT TSA ACESEWAGE(DISPOSUBSURF SAL,LSYSTEM INSPECTION FORM; :- PART:,C SYSTEM.INFORMATION(continued) Property Address: ' ' I` OwneN__ t Date.of - pection: _,PD BUILDING SEWER(locate on site plan) Depth below grade: Materials'ofconstruction: cast iron 40 PVC other(explain)- Distance-from private water,supply well or.suc$ion line:- Comments (On condition`of.joints venting, evidence.ofleakage, etc.): .:i SEPTIC TANK: (locate on siteJP plan) Depth-below grade:�_RLA Material'of construction: concrete_met4 fiberglass : ..polyethylene _other(explain) If tank is metal list age:_t .Is aae:confu-rried,b.y a Certificate of Compliance(yes-or no);!' (attacha copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet',tee or baffle. ` Scum thickness: / Distance from top of scum to top:of outlet tee or baffle.. 1 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions.determined: ih a 4 Comments(on.pumping recommeniations, iiu eat and outlet tee-'or baffle condition, structural integrity, liquid levels as related to outlet invert evi e ce of leakage, etc): zrw7 ,�. .� . �. GREASE TRAP: (locate-on site.plan) Depth below grade: Material of construction:_concrete metal fiberglass .".polyethylene_other (explain): _ — Dimensions: r Scum thickness: .. i Distance from top of scurn to.top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or' baffle: Date oflast.pumping: Comments on pumping n recommendations, t ons mle, and outlet tee e or baffle condifiori=structuralintegrity, P g ,. .h uidaeve p . 9 is as related to outlet invert, evidence of leakage; kc). 7 1 � I Page 8 of 1.1 OFFICIAL INSPECTION,FORM—NOT FOR:.VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP:ECTIO FORM PART C SYSTEM INFORMATION(continued) Property Address:,. J} ,fad Owner. Date of ection: f,ee ae,B Z TIGHT or HOLDING TANK: 1Q .tank must be pumped at time of ins ection)(locate.on.site plan) ( P .P P Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain);. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumpins: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan). a Depth of liquid level above outlet invert: ?' Comments(note;if box is:level and distribution to outlets Wual,.any evidence of solids carryover;any evidence of ,lea agg into or ut of ox, etc.): /w c 9 e PUMP CHAMBER:: (locate on site plan)744 . . Pumps in working order(yes or no); Alarms in working order(yes or no):. Comments(note condition of.pump chamber, condition of pumps and appurtenances, etc.): 3 Page 9 of 1 1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE-SEV/AGE'DISPOSAL`SYSTEM INSPE'CTTON FORtVI PART C SYSTEM INFORMATION(continued) Property Address: J. d' Owner.: Date of I• ection: SOIL ABSORPTION SYSTEM,(SAS): `.-�—. locate on site plan,excavation not required). If SAS not located explain why:. Type 6 leaching:pits,number.:_ _. caching chambers;number:. " eaching.galleries, number: , leaching trenches,number, length: leaching'fields,number, dimensions' ` overflow cesspool;number: inn ovatvefalternative system :Type/name`of technology: . Comments (note condition°of soil, signs'of hydraulic.failure'level of ponding, damp soil,'condition of vegetation, M1 etc..t 17 l a . ) b'A r CESSPOOLS:.(cesspool must.be pumped as part-of.ins pection)(locate`on site plan) Number andconfiauration: . Depth:-top of liquid.to inlet invert: Depth of solids-laver: Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of-roundwater inflow(yes or no): :' ` Comments (note condition of soil, signs of hydraulic faiiure,aeve] of pondin„ condition of vegetation, etc:): 1, 'PRIVY: (locate' site plan) f d Ivtaterials.of constn,ktion Dimensions: - -f De th of solids: • - _ Comments. note condition of soil .sa i( bns of hydraulic failure, level of pondin , condition of vegetation etc.): 9 Page 10 of 1.1 OFFICIALI INSPECTION';FORM—.NOT FORVOLUINTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM ..PART S-STEM:INFORMATION(continued) Property Address;. Sad 61 Own r.: AA Date of,I pection:. 7 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the;sewage disposal system including ties to at least two permanent reference landmarks.or benchmarks. Locate all wells within 100.feet.Locate where public water supply enters the building. - _ ✓` 00 �� 5e��► �e' Cl a� ��i Page 1 l of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS_ SUBSURFACE�SEWACE DISPOSAL SYSTEM.INSPECTION FORM • . PART C - SYSTEM INFORMATION(continued) ' Property Address: 60 A Owner: Date.of I ction: . SITE EXAM - Slope Surface water - Check cellar Shallow wells Estimated'.depth to ground water feet Please indicate (check)all methods used to determine the high -round water elevation: Obtained from.system deli 'n plans on record--If checked,date of design plan reviewed: 't Observed site (abutting property/observation hole within I50.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':'" z3 `f 11 I - Permit Number: Da te: Completed by: t °�' HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �L� rn � . or d/°�/L , .' ot No , Owner: Address: Contractor: Address �Y . lv(df V 1/'1 :Notes-- STEP, 1 Measure depth to.water table to nearest 1/10 ft Date month/day/Year . STEP g . 2 Using Water Level=Ran a Zorie' and..:Index.Well.Map locate site and deterrnme O A Appro.priate index well....:....r ,. ...,. T1 cry y OB Water level range zone ......... STEP 3 - Using monthly report."Current;" Water Resources Conditions" . .L •. . - - determine current depth to 7 water level for.index.weII: a ._ ,-month/Year STEP1 4 Using Table of 1Nater-level Adjustments for index well (STER 2A), current depth to water level for'.index well,(STEP 3),.," level zone (STEP 213) determine water-level adjustment ......... t STEP -5,' Estimate°depth to high:water,' _ _ by subtracting the water level`adju'stment (STEP 4) f from measured depth to water level af'siTe (STEP 1) ... .:. Z,J a ............. Y . r. . Figure 13.--Reproducible computation form. 15 . I .:.. .. .. .. .. .. .. 16 1 .100 _ w...�,�n�,wr..'�"^^'�•`••^�w�wM f a.wwww^1.n. i nCr.�..,..�..,w+ n �.. N..�� lea f Iv 77 1;2 . 1 •. _�M E a e TOWN OF BARNSTABLE 4C6PPiAS,ATI "66- At�. SEWAGE OI$-©1 VILLAG ),T ASSESSOR'S MAP & LOT INST?A LLER'S NAME & F HONE NO. SEFnC TANK CAPACITY 1000 LEACHING L?ACILITY:(type)-'- _�R60 ( ) .r . NO. OF`BEDROOMS PRIVATE WELL OR PUBLIC WAT � B ER OR OWNER FATE PERMIT: ISSUED: 4DA'PE COMPLIANCE ISSUIED: VARli.NC'E ,RANTED-. Yes No__�� _ QP ED C;: t Y� 93= S A61 k0l, e 14- No.... Fzc$ ........ THE COMMONWEALTH OF MASSACHUS'ETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuu for Uiupuial Workri C ontitrur#inn lirrutit Application is hereby made for a Permit to Construct l/l or Repair ( ) an Individual Sewage Disposal Syst a - a .---�►� ....�l--i lk. ---•----••---•--•- .........�5_:s......"f .. --------•----------. ..--- Location-Address o. ......................_.... -•----- -•••-__•. -••----......... - caner Address � Installer Address --------- Type of Building Size Lot_____�. .Sq. feet Dwelling— No. of Bedrooms.•........_ ___________________________Expansion Attic K)b Garbage Grinder ( j Other—Type of Building _ _ .A '__.______ No. of persons............................ Showers ( ) — Cafeteria ( ) p-' Other fixtures ._._.....___ W Design Flow.............1.1.C>.....................gallons per person pfr dly. Total doily flow........._...... -_-----___--__-_ los. WSeptic Tank—Liquid cap�i vl _galluns Length_�1"_�_ Idth . Diameter_. ___ D ptl _ .....Disposal Trench—No. _.__.__.. .�_._._. Width.................... Total Leng . Total leaching rea- .....sq. ft. --.-_ iameter--_--A A_----. De th below in13.3...... Total leaching area....... � epage Pit No............... p __ g .sq. ft. z Other Distribution box ( ) Dosing tank ( ) q Percolation Test Results Performed b ... p ......... ....�Lep-t Date........ .Z ~1- s--.--_.. Test Pit No. I---.-. __.. minutes per inch Depth of Test Pit.....jz_ . to ground water. _ jAcne..�..-..`_.-.- ' Lz. Test Pit No. 2...... ----------nllnutes per inch Depth of Test Pit------- ...... Depth to ground water. _.CA a+ •-•••------------------•-------•---••••-•-•---••-•--•••_------•--••---------•-•••---•-_•-•_......-•--•......_• }.........._....---..........---•-...... 0 scription of Soil........P-®• 3= t���?1� Q1 L...- l�..l ?ll.°_. .�.`� c7.--°["s P V ...-- •-••--------••---------•••-•--_._.__•--•-_•_••--•--•-•••-••_•..._.....---•..............•-•--••_•------••-•-----_--••-•---•-•--••_----•-----••-•--•------•-----••_•••_•••_•-••__-•------•....... W ••• •-•---•-----�-= (�� 1R ------------------------------------------------- ........................................................................... UNature of Repairs or Alterations—Answer when applicable................................................................................................ --_••------•--•---.....•--•----••__-•--•--•--•••----•----•-•---•--•--••--•---••-•--•...................•----•-----------......---------------------------------------••••-_•••_.._..-_--................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been -ss d by F bo ealth. ` 7C Signed _�- ..........4. �. ApplicationApproved By ----------- ..... ... ...... ---- ----------------.....: >........................:....__ ....../. ...r. -. Da[e Application Disapproved for the following reasons: ....................._.... . ..... -- ........... .. . ............`..-- ...............`..... . _........ ...................... . .. .. ..... .......... .. ..... ............... .. .............. .. . ........................ .................................................._........... ...--- / Dace II PermitNo. _ ---------------------- Issued ........ .. ....................... .-- Dve No.... . =-(( Fxs......../. 2. ........ THE COMMONWEALTHiOF'MASSACHUSETTS _ BOARD OF`' HEALTH 3 TOWN OF BARNSTABLE Appliration for Di-nVu5ttl Wurk,i Towitrurtiurt ramit Application is hereby made for a Permit to Construct 1I4. or Repair ( ) an Individual Sewage Disposal Systv� .................. ......... ------ ................. . . ...... . .... ... Location t\ddress1 or•'Lot 1`io. _...'J.?�!:±•�_ .•-pia �_r�l '�= Pvt-t1 1. ................. 1 --_... caner Address W I IcistalIer - Address ff dType of Building Size Lot..__._!_.___; .Sq. feet U Dwelling—No. of Bedrooms-__-_-_-__-_�------------- -- .Expansion Attic ( Garbage Grinder ( � Other—Type of Building __-__-_o/ No. of persons---------------------------- Showers ( ) — Cafeteria ( )t_.. - 04 Other fixtures --....0.�.A------------------------------------- W Design Flow............. _.___._........._ ..gallons per person per day. Total daily flow................ Ions. R: Septic Tank—Ligdid,capaci.v --_.gallons Length_ _-'_ . Width . ___ Diameter_- .... Depth_._. _.... W Disposal Trench='No. ....1:-�.� ___. Width.................... Total Len th;Oc x Ze5 Total leaching area....�� s q. ft. 3 Seepage Pit No--------------------- 'Diameter-_-__? _ ;1------ Depth below inle`. : _ _._._. Total leaching area..................sq. ft. Z Other Distribution box ( ) Doing tank ) `a __... ..minutes per inch Depth 'oft Pit�.__� De t to DroundCwat�_.. ����• � Percolation PiTe�oRisult Performed b p � a ___ g �-- �•-�•-.----- fs+ Test Pit No. 2..._.. .._._minutes per inch Depth of Test Pit._.....t.t_�___..._. Depth to ground water.`P?KcAt a -------••-------•-----------••-----•'-----'---------•--••---•••-••-•--•...........................................i-------t................................. D D scription of Soil.------ -3 -- ` kc, i_L,_ L za rt.1.`.. �'1 .D �"� tJtt�.tr►_-Crab . U ---------------------------------------------------••- ................... - c��_ - . ,------------------------------------------- ----------------------- --=---------------------------------------------------- U Nature of Repairs or Alterations Answer when applicable-----------------------------___---.__-_---.____--._-____------.-.-------_-----•-•--•-_.._-.---. ..------•--'---------------------•-•----------------•------------ ................................................ -----------•-----------'--------•--------•---------•'-'-'-•--•-•-••--•--.....-•-- Agreement: The undersigned agrees to install the aforedescribed Individual-Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance xas been issued by the board-4-health. -�, Signed Dare - Application Approved By ....... _.....c.-,.�a ------------------------------.........----------------------------- ...... �`` Dace F Application Disapproved for the following reasons: --- ------------------------------------------------------------------------------------------------------------ ............................ ....... ---------------------.........-------------....---------------.........--------------........---- ---------..-... ........................................ Dare Permit No. t../ _ �.. �2 Issued ........................Dace...... ..... . i ...... --------.---—'-----.-----------,— _,--,—.— --- -- - — — ,. •r—•—_--`.—, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Ertiftrate of Compliance THIS IS TO CESWY, ghat th�Idividual wage Disposal System constructed ( ) or Repaired ( ) by ------------------- 6---- .----------.. ----- '-------------------- at ..........ri ' .. c f........ .A�t.4.... 4....�� ---------------------( _•_c ----------- --------------------- --- -- -- has been installed in accordance with the prom as s of TITLE 5 of The State Environmental Code described to the application for Disposal Works Construction Permit No. .y-------- ....... dated _�. ------ ..-. .---- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE HAT THE SYSTEM WILL FUNCTION SATISFACTORY. ' DATE......��---"..fie.-,_.. ..^....! L..... - Inspector - �� - -------- ---------------------_--------- ----`'----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE....�.��.r ?..... �i��ru��t1_ �rk� �u�t���rtiun �rrmit Permission is hereby granted........ -=t_.)nstruct,,,(>4 or Repair ( ) an Pdividual Sewage Disposal Sys em atNo`. ..._.lam-t'" �'f - F �."` ---' - c ---------0 --------------------------------------------- Ustreet as show n on the application for Disposal Works Construction Permit No.-�.....L Dated........... -'7.------------- �. i • _ DATE. � ,� `�/� �' � '-••Board of"rHealth � A.............^..r..... FORM 36508 Hr-�)BBS h WARREN,INC..PUBLISHERS , P- r No...?7::.y f f Fss.....7s...1. ... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -._.l..,o..w.`r ...............OF........ Ar" J: ......�5.................................. ApplirFation for Disposal Workii Tomitrnrtion ramit Application is hereby made for a Permit to Construct (a ) or Repair ( ) an Individual Sewage Disposal System at: Z 2 04/<4,.o 0 a/ f s� ��, ................__----------------------------..---------..----. .....-•---......_....._.----- .........---------• ---•------------------------•--•-•--------•-------......._.......---.------. Locatio ddress or Lot No. —_•-•••-"-G-J ftGH.Q............... ......---•-----------•---•---..................-•-•-•------•--..........._........................ Owner / Art /,/Address �6Y ..........�s --------. . ..---•--------------. .liilt.l ....................... a Installer Address _ \ Type of Building Size Lot.._.z /s �� S feet y U YP g r----------------•- q• Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures .......................................... Design Flow..........................SS_--.--__gallons per person per day. Total daily flow............... -3.�.._...........gal W Ions. WSeptic Tank—Liquid capacityea�5?__gallons Length��6.".. Width_`'Zi v Diameter................ Depthf��_.7.y- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/---------- Diameter:/o.".A."... Depth below inlet.6._._�r�'� Total leaching area..Z�_T-..sq. ft. Z Other Distribution box Dosing tank ( /V 6 6'39 '-' Percolation Test Results Performed b .:... �'l�=__.__.._.. __��^�f,,Yl ...C!' Date.-_...�_.�F' �p . Y � + 1 .. _. v - ... Test Pit No. 1____.Z......minutes per inch Depth of Test Pit--- Depth to ground water... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .................... ..... ��s� se.t-- ------........................................................ p ,3 r �� S ........................................................ Description of Soil.......... ----_-�-��----••----------�4�w-'-�------------------'� �.- x U --•------------- •------------ -------- •---------------•--------------------- •---------•----------------- --------------------------------------------------------------- Ws ----------------------------------------------------- ••---•----•------ ...... `•./..,v-l�------ ........................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------------•--------------------------------------------•------•--------•----------------•-•-•-•-•--•••-••----•--••••--•-•••-----.••---•-----------------.••-•-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL 1TL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b;�.zw soard of health. q- $� Signed ..--•---•------------•..... .......D... ............ A D Application Approved By..--------- ------ -------•----•--------•------- Date--2�i`S. Application Disapproved for the following reasons------------------•---•---------------------------------•------•-------------•--...•-•-------•--•--............-- •----••-•-----------------•-•--------••-...-•-•-------••-----•-•----•-------•----._.........-----••-•-•-.---•-------•--••---••-----------•----------•-•-----------------------••----•---•--•--•---....._ Date PermitNo......... _ Y g --------------- Issued_....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M A�C(, I DATA No....v..�... .� FEs...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z _ "7 OF. t : . :.s... ... f�P Appl ration for Uiipooal Works Tontratrtion Frrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: uw f.,, 7` ................__.. _.. •------ ._.............................:............. -••-••••••--...-•---••-•••-----•-........--••----.....-••••-...._..------••-•-••................-- J Location-Address or Lot No. c lr. _ t ec r r jar'^ , 7�/r`z W .......•---- .-..... •.................. ........................v - �a - ...... --- ...- O��er--- ..... SV f Address ��; In Address d ype of uilding Size Lot..... '._...__:_�__� .._Sq. feet Dwelling—No. of Bedrooms....................._...........__..__.Expansion Attic ( ) Garbage Grinder ( ) p I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P� Other fixtures -----------------------------------•---------- W Design Flow........................... _.gallons per person per day. Total daily flow..................... ....................gallons. WSeptic Tank—Liquid capacity'�- :.gallons Length.'.'�__::.. Width.`�::� ." Diameter________________ Depths _... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._....._�.____-__-. Diameter. �:_�..�:_':... Depth below inlet_-�__ "_U_":_. Total leaching area---':.G.l...sq. ft. z Other Distribution box ( -1) Dosing`tank /^ y . / f r.(rP. r1S r /( Percolation Test Results Performed by..._ro _�_.` -�--��'"y•� � �r Date.L,�4.^:�'___: as Test Pit No. 1......Z__._-_-minutes per inch Depth of Test Pit.../,. Y..Aepth to ground water_._.�'�_ _�--____. fi Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ ........ E. O Description of Soil..........% -f tr/.................................................... W [_./Po G�!_rJ v..,��� rr i.Ga. . r t•L r UNature of Repairs or Alterations—Answer when applicable...........................•_..____...___..............................._........_............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ' sued oard of health. Gy��j�-_ �- 7 Signed -- -----•-•---••-•...---•------••-•-.......--•-••........................••. Date Application Approved By...... ' -..,":_.'� Date Application Disapproved for the following reasons--------------------•-----•----••--------•-----------•--•---...-------------------------------••-----...--------- ------------------•------•----•---------------------------------------------------------------'-----•---------•----.._----------•-----•--------------•--------------•------------------------- Permit No-------- ... -g-----------•--. Issued............................ a . te Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................I........OF..................................................................................... Tnrtif irate of TontpliFatta THIS IS TO CERTIFY, That the Individua �„Sewage Disposal System constructed or Repaired ( ) by11A In stalle---.---- -.-`-----------------------------•--- ---•---------••--•--------••------•------.-..-----.------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit I...... .......... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM . L F CTION SATISFACTORY. DATE..., ---........ •...Z��.... ..7.... Inspector ......................................o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..OF...... .......................................................................... No................Y FEE.25 �io�ro��t� ork� �on�tritrtion rrnti# ��/� Perm' ion is hereby granted..•..... ...••........ ......... •-•-••-- •--•-•..... . to Cot�r ct or Repair ( ) a Indivi ual Sewage Disp System atNo..�.�1��-- •. -•-- .. . ...... lam c��...�------------------•-------•----•----------•-----------....-•---------••----........ Street as shown on the application for Disposal Works Construction Per of 7.7� _........ o D . a - Board of Health DATE------- --------•-•- `.� / FORM 12 5 HOBBS & WARRE INC.. PUBLISHERS �l TOWN OF BAG�tNSTABLE �. LOCATION .Jory l SEWAGE # 6 f - VILLAGEa _" ASSESSOR'S MAP & LOT 01 O � y INSTALLEWS_,NAME & PHONE NO. rl SEPTIC :ANK CAPACITY, �y ;; LEACHING FACILITY (type) 1- (size) pp (6�N0. OF BEDROOMS ^4 .� PRIVATE WELL OR UBLI WATER BUILDER OR OWNER c DATE PERMIT;ISSUED: "DATE COMPLIANCE ISSUED: - 9 ' 'VARIANCE GRANTcD: Yes a� �� 1 I l �i _ ,� � ,� � . r ,��. I �/ �/ �: � �`� ^ .�' �� - a ^�: � \� / '•!� j,p t/ � •{fir. Y 1� x.' is f,;� ��,9� i?�Y"vtisy-r ++1�' ,w���h�� � c), U.POLE _ #76217 PROJECT L OCA TION BENCHMARK n T�► T VM TOP OF CONCRETE .L--1.1 V.,�' ASSESSOR'S LOWS 4,2 & 43 BOUND RIDGE _ COTUI7 MA. .AA ELEV=52.10(ASSUMED) ROAD APPL/CAN T.- �� GRA LEL JONATHAN FLOREN . C.B. — ROAD _ 07 SOTH POINT DRIVE — SANDWICH. 1 �?0 00 3 FL IFFUS C.E. YANKEE SURVEY CONSUL TAN TS P. O. BOX 265 C UNIT 5, 40B INDUSTRY ROAD MARSTONS MILLS, MA. 02648 PH.(508)428-0055 FAX(508)420-5553 /DBOX I 5p 8• Q SCALE. 1"=20' TE, 10 11 94 � . � 12.0' 12.0' O 0 8, o sr REV. REV. �� 100' I \ \ o �8 yp ��5p °� \ \ \ JOB NO. 50573 SHEET 1 DF � PROPOSED I w \ . Ile.O 20 HO USE o o 1 L 0 31. 0' o PLAN.• 191143 ORCH C — _k f a� P DE o� RES. ZONE. "RF" l ua1i�, 1 .UA 10 I \ �77 LANDERS-CAULEY r CIVIL 40;2O"or I No. 35101 4c c.R 80. 00 f Ago fc \ � � � � C.B. W � �F� NA EENG��c, 44 ' I PORCH 45. o , HOUSE 4 48 N714O" " q f` 100. 00'49 v EL. _51.5_PROPOSED TOP OF FOUNDATION L 20' MIN. low 10 min CONCRETE CO VERS 4" SCH. 40 PVC PIPE VA MIN. PITC VARIES WITH LOCATION H 1/B- PER FOOT i 48.2 PROPOSED, 45. Ot EXT'G za LAYER of ' ' Tn CONCRETE COVERS. 46.0E EXISTING 1/8"-l/,2" / ' ' 48.5E PROPOSED JUS'HED SYVNE 11 4'" CAST IRON 4.5 t i / i , OR SCHEDULE 40 P. V.C. PIPE 4 SCHEDULE 40 P. V.C. DIST S=0.02, D=23.2' S=0. 01, D=37 6 BOX 12" y FLOW LINE CLEAN SAND INVERT 1 10" EL.=42.25 MIN. 19" ------ INVERT INVERT EL.=41. 53 2' ° Gl C7 G5 O t� O EL.=41. 78 LEVEL INVERT ° e o o n o r� m ° 3' IN VER INVERT EL 40.8 34 0 0 ° o o° ° ° o o ° ° o 1000_-GALLONS EL = 41.15 EL.=_40. 98 ° ° ° ° ° _ ° °° ° EL=38.98 SEPTIC TANK -- — 52' x 8' WASHED STONE 3— FLOW DIFFUSERS PROFILE OF 3' STONE ON ALL SIDES S SEWAGE DISPOSAL SYSTEM TO J NOT SCALE BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL= 33. 0 i�- ALL ELEVATIONS ARE ASSIGNED SOIL LOG J. LANDERS-CAULEY,PE ti Of ,y WITNESSED BY: E11K.1 RaRR HEAL TH OFFICER JOHN rya •? I ANDERS-CAULEY ^i CIVIL y GENERAL NO TES PERCOLATION RATE �2_ MINI INCH � � No.35101 P# 8289 4 �x TEO-o 1. THIS PLAN IS FOR CONSTRUCTION OF A NEW SEWERAGE DISPOSAL SYSTEM. l DATE 9-27-94 2 THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM . TEST HOLE 1 AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. . = = 3. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. EL. 45 EL 43 5 DESIGN DA TA. TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE 4. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN rOP & SUB MP & Sue NUMBER OF BEDROOMS 3 12" OF FINISHED GRADE. ; solt sort 5. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE EL. -42 3' EL. =40 3.5' GARBAGE DISPOSAL NO SAME, UNLESS NOTED BY FINAL CONTOURS. 6• ALL COMPONF'NTS OF THE SANITARY SYSTEM SHALL BE CAPABLE j MEDIUM TOTAL ESTIMATED FLOW 330 GPD OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER MEDIUM OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SAND SAND ( 110--GAL./BR./DA Y x _3_- BR.) SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING. SEPTIC TANK CAPACITY 1000 UNLESS NOTED. NO MORE THAN 5' OF FILL IS PLACED UPON THE STRUCTURES. 7 ANY MASONRY UNITS USED TD BRING COVERS TO GRADE SHALL EL. =33 12' EL =33.5 10' LEACHING AREA REQUIREMENTS BE MORTARED IN PLACE. 8. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH SIDEWALL AREA RATE _ 5_ GAL IS.F. DEEDED OR ZONING REGULATIONS OWNER/APPLICANT IS TO BOTTOM AREA RATE _I. O_ GAL/S/F h J OBTAIN SUCH DETERMINATION FROM APPROPRIA TE AUTHORITY. No IVA ER No WATER LEACHING CAPACITY (BOTTOM & SIDEWALL) 64 7 GAL � 9. THE EXCA VA TOR�CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND (10-f-28)(2)(1. 93)(2.5) f 1Ox28)(L Sx UTILITIES PRIOR TO ANY EXCAVATION. THE WATERGATE WAS NOT FOUND, THE GENERAL 0�_647gpd CONTRACTOR SHALL VERIFY LOCATION WITH WATER DEPARTMENT. RESERVE LEACHING CAPACITY 647 - GAL SHEET 2 OF 2. JOB NO.: 50573 ' _ _ TEA( ' . a YS E NOT TO SCALE TOP FDN. , FINISH GRADE OVER EL.s9.,_ FINISH GRADE - :;.:,•,:.,_ FINISH GRADE OVER DIST. BOX ' FINISH ORA E OVER :;�.► • SEPTIC TANK .Le ° LEACHING PITS • VARIES .o:o:o �: "'' .o .:.... ..aa; •:d. : e.;. •••:' 3" OF 1/B" — 1/2" .12 MAX 1 0,:b :o:' A PRECAST CONC. OR i^o a 3„ e AShfED PEA STONE �,u:±� ;:�:;-: • OUTLET PIPE LEVEL BRICK"& MORTAR TO 12 BEL ON GRADE FOR 2 FT. MIN. :•;. :e.y°° •o:�s:: :;'o: ..o.o..;• . H6 r7% 77�t.- o. e• :p. - e::: • y.. s — �:b:•6•'o.:•o:v: ;o, :.e �.e,• Q: o'o C. I. OR PVC TEES o- 4 SST. FLR. a M GALLON DIS TRIBU TION BOX EL . INSTALL ON LEVEL BASE " A 6 ' e PRECAST CONCRETE p WASHED 1-1/2" o PRECAST :'o e'.•p'. p.•e:'p: I °:'a•.°•• H-10 REINFORCED s CRUSHED CONCRETE : e:o .• oq:o' o:a ..a.o;e o.e•o.'p.:a:o p'.e:. :.y : 6 p.: b o.:o: STONE b:.o: o.8;.0.0°.o:o•"a'.d.o.° . c;a:4•a :o a o:o °' ;°:.'0:•.4'b:0:: I: Q ' SEPTIC TANK a H— !0 REINF. ° :I INSTALL ON LEVEL BASE ;•''''�'D ' NOTE.• EXCA VA TE TO ELEV. • OR LOWER TO REMOVE ALL IMPERVIOUS MATERIAL BENEATH THE LEACHING AREA REPLACE EXCA VA TED MA TERIAL WI TH CL EAN. CL A Y FREE SAND EFFECTI VE IAMETER f GENERAL NOTES LEACHING PI T 1. ALL ELEVATIONS SHOWN ARE BASED 0N ,45SelyrD INSTALL ON LEVEL BASE 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON rl000 GALLON OR SCHEDULE 40 PVC. OBSERVA TION PIT ' PRECAST CONCRETE 3. THE BOARD OF HEAL TH MUST BE NOTIFIED SEPTIC TANK WHEN CONSTRUCTION IS COMPLETE PRIOR .w TO BA CKFIL L ING PERCOL A TION RA TE.• 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED "` MIN./IN. BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WI TNESSED BY.• SURVEYING CO., INC. 5. MATERIALS AND INSTALLATION SHALL BE IN ° COMPLIANCE WITH THE STATE SANITARY `` ` " "'" � BAD. OF HEAL TH DESIGN DA TA 49 �� '"' CODE — TITLE V — AND LOCAL APPLICABLE DATE.' RULES AND REGULATIONS o _ ________ - PREc sr coNcRErit ,•� u 1 NUMBER OF BEDROOMS LEAc ING PIT�! �h 6. NORTH ARROW IS FROM RECORD PLANS AND 7G IS NOT TO BE USED FOR SOLAR PURPOSES GARBAGE DISPOSAL 7. FLOOD HAZARD ZONE DA IL Y FL ON� � � � � � � ,��� ��a GAL . l \ B. WA TER SUPPLY REO 'D. c:� GA L SEPTIC TANK o • r1.. �.`~ SEPTIC TANK PROVIDED ca flc• GAL . L EA CHING REQUIRED GPD. L _wc SIDEWAL L AREA S. S. F. X G/S.F. = r. GPD BOTTOM AREA S. F. I� f —� LEGEND , tti ' S.F. X G/S.F. _ =' GPD LEACHING PROVIDED = "1'Y= GPD PROPOSED ELEVA TION EXIS TING CONTOUR —' OBSERVA TION PIT SINGLE FA MIL Y RESIDENCE 0 DISTRIBUTION BOX AGE PROPOSED W k . SE DISPOSAL SYSTEM G ,• -- G URTRAND LEACHING PIT PREPA RED FOR 0 o SEPTIC TANK MCSHA NE CONSTRUCTION �04 lRP RESERVEr A L O T 22 OAKWOOD S TREET CO TUI T — BARNS TABL E — MASS. PIPE INVERT EL EVA TION DA TE.• , PLOT PLAN { CAPE G ISLANDS SURVEYING, INC. SCALE: I "— SCALE AS NOTED P. 0. BOX 334 MAP 5'EG PCL LOT HSE - PLAN NO. TEA TICKET, MASS. b