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HomeMy WebLinkAbout0070 PINQUICKSET COVE CIR - Health J _ O V it I )".. 70 Pinquickset Cove C.i t, �\ Cotuit l� Y �r i IIII r i �, 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '�. a>.•' 70 Pin uickset_Cove Road _ Property Address Jason Eldredge _ ------ - ------- _..._._..-------------- Owner Owner's Name ----- information is Cotuit MA 02635 Jul 9, 2013 required for ---- .-...-- ---------------- -- ----— ---- ----- -- -- Y 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 computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not --------------------------_____ use the return Name of Inspector key. Septic Inspection Services Co. _ - - ---------- Company Name PO Box 1487 Company Address Marstons Mills MA 02648 ----•----._....._.._._... ------- --... - — City/Town State Zip Code 508A28.1779 SI 12855 Telephone Number License Number B. Certification 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 July, ul 9, 2013 Job # 58 Inspector's lgnature 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 is�a.shared system ors< Y. has a design flow of 10,000 gpd or greater, the inspector and the system ownerPall submi0the 7 report to the appropriate regional office of the DEP. The original should be sent�to the system owner Fa; and copies sent to the buyer, if applicable, and the approving authority. v r \ b ""This report only describes conditions at the time of inspection and under the conditiona use at that time. This inspection does not address how the system will perform in the utuInder. the same or different conditions of use. -- 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 II F� L / . ` Commonwealth of Massachusetts ' ��~��M �� Official N Inspection �� Title �� ��V� NN��N��� Q�����������8���� 0—oN~m Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 70Pin ickse Cove Road Property AcGes� Jason E|dned Owner ownorxwame������_ ____ _ information is required for Cotuit ____ �____ �A 02635 JulyS 2013 u,r �e� City/Town�� te Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:� Check A.B.C.D orE/always complete all of Section D ` ' AJ System Passes: ihave' not found any information which indicates that any of the failure criteria described | in 310CK4R 15303orm 310CyWR 15304axist. Any failure criteria not evaluated are � indicated below. ` � . Comments� ' � Tank was not in need ufpumping at time of inspection, leaching systemshowed no evidence cf sa(uxshonorouroh ^ ` ' BU System Conditionally Passes: ' One or more system components as described irf the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, ao approved bv � the Board of Health, will pass. ` Check the box for^yes^. ^nn^ o/"not determined" (Y. N. ND) for the following ents. |f^not detennined.^ please explain. The septic tank is metal and over 2O years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration cxexh|tnahon 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 ofHealth. ' A metal septic tank will pass inspectiory if it is structurally sound, not leaking and if a Certificate of . Compliance indicating that the tank io less than 2U years old isavailable. D y N Fl ND (Explain below): . � | em 'su Title o Official inspection Form.Subsurface Sewage Disposal System'Page 2mn � � . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquickset Cove Road Property Address Jason Eldredge Owner Owner's Name — information is required for Cotuit __ MA 02635 July 9, 2013 every page. Citylrown 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): 1❑ 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 healt h, 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 15ins°3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System°Page 3 of 17 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquickset Cove Road _ Property Address Jason Eldredge Owner Owner's Name information is required for Cotuit MA _02635 July 9, 2013 ------- ---------..--------------- 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 wate, 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: f 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 15ins•3f13 Title 5 Official inspection Form:Subsurfac..Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pin uickset Cove Road Property Address Jason E ld red qe — ---- ------------- --- -- Owner Owner's Name information is required for Cotuit MA 02635 July 9, 2013 --------------------.,_.----- ------ 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 groundwater elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1-1 ® Any portion of a cesspool or privy is within a Zone 1 ull 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 CM 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 El ❑ 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. 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts > Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 70 Pinquickset Cove Road Property Address Jason Owner Owner's Name information is Cotuit MA 02635 Jul 9, 2013 required for ---------------.___.----------------------- ------ ------- Y every page. CitylTown 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? %j;� ❑ 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? 0 ❑ 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? Z ❑ Was the site inspected for signs of break out? Z ❑ Were all system components, excluding the SAS, located on site? Z ❑ Were the septic tank manholes uncovered, opened, ar.d 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? Z ❑ 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. ® El `,the in„the field (if any of the failure criteria relai: d to Part C is at issue approximation of distance is unacceptable) [310 CMR 1 .302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 -- Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): 550 t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pin-uickset Cove Road Property Address Jason Eldredge Owner Owner's Name -------------------------- ------------- information is Cotuit MA .. 02635 July 9, 2013 requiredfor -- ----- --...------- - --- --- ---- ---------- - every page. City/Town State Zip Code Date of Inspection D. System Information Description: Unknown Number of current residents: 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: Sump pump? -------------- ❑ Yes ® No Unknown Last date of occupancy: 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? w ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 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 70 Pinquickset Cove Road Property Address Jason Eldredge Owner Owner's Name information is required for Cotuit MA 02635 July 9, 2013 - 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: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons . How was quantity pumped determined? Reason for pumping: — — 1. 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): 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquick_se_t Cove Road Property Address------------- --------- -------- Jason Eldredge Owner Owner's Name information is Cotuit MA 02635 Jul 9, 2013 required for _ y 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: Compliance date: 10/17/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth bealow grade: 2'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: 2'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: 10.5' lor,,x 5.8' long- 1500 gal. Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquickset Cove Road Property Address Jason Eldred_ae Owner Owner's Name ---- - --- — — -- information is Cotuit MA 02635 Jul 9, 2013 required for ------ -------------- ---- Y 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 30" Scum thickness Trace 6 Distance from top of scum to top of outlet tee or baffle 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.): Tank was not in need of pumping at time of inspection, liquid level was at bottom of outlet invert and tees were intact. 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•3113 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 a 70 Pinquickset Cove Road _ Property Address Jason Eldredge_ Owner Owner's Name ---- - ------- - information is required for Cott: y it MA _02635 Jul 9, 2013 ----- -----------......-.-------------------- -- every page. Cityfl own State Zip Code Date of Inspection D. System Information (cont.) Comments i;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 ❑ polyethy.:;ne ❑ 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 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 COr monvvealth of Massachusetts Title - Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 70 Pinquickset Cove Road Property Address Jason Eldredge__ _ Owner Owner's Name information is Cotflit MA 02635 Jul 9, 2013 required for Y every page. City/Ti own 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.): Plo solids-or nigh stains present. Liquid level was at bottom of outlet.pipes. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: F1 ,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 requires,): If SAS not located, explain why: 15ins•3/13 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 a 70 Pinquickset Cove Road Property Address — Jason Eldredge — Owner 0wr-rr's Name --_--- —information isis Cotuit _ MA 02635 Jul 9, 2013 required for -- ------._...--- -----_-.------ --- - - y every page. City/i"own State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Five 500 gal drywells. ❑ 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.): Leachiing chambers had no standing water or evidence of saturation. 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 Miaterials of construction — indication of groundwater inflow ❑ Yes ❑ No l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquickset Cove Road___ _ Property Address Jascn Eldredge Owner Own, s Name information is required for cot,. ` _ _ _ _ MA 02635 JL.y 9, 2013 every page. City/ .vn State Zip Code Date of Inspection De system Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of pondinn, condition of vegetation, k,ic.): ivy (locate on site plan): r, aterials of construction: Urnensions — i�epth of solids -- - Comments (note condition of soil, signs of:hydraulic failure, level of ponding, condition of vegetation, I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts r Tifle 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquickset Cove Road r Property Address - '.. - Jason Eldredge Ownerne! -......_ ic information is COtI!i'. required for MA 02635 July 9, 2013 every page City[r, •.vo -- -..._..-- ........ 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 be;3,w: hand-sketch in the area below (_ drawing attached separately 51 55 :\F r\•+ i\i i\i \ \ \ \ \ \ r\ ♦r\ \r\ . 69 81 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Pinquickset Cove Road___ Property Address Jason Eldredge Owner Owner's Hame information is required for Cotuit _ MA 02635 July 9, 2013 __—_--_— every page. Cityrro��,n State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope �I Surface water ® Check cellar :Shallow wells • 12+ Estimated depth to high ground water. 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: l.1SGS topo map- You must describe how you established the high ground water elevation: Topo map shows property above el. 15. - Before filing this Inspection Report, please see Report Completeness Gnecklist on next page. t5ins•3/13 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 w 70 Pinquickset Cove Road Property Address Jason �Id redg e---------- --- --- ------ ----- — Owner Owner's !ante information is Cotuit MA 02635 July 9, 2013 required for ------------ — —----------- — every page. City(To,:.n State Zip Code Doi,of Inspection E. Report Completeness Checklist �?J Inspection Summary: A, B, C, D, or E checked [' Inspec!ion Summary D (System Failure Criteria Applicable to All Systems) completed I System Information - Estimated depth to high groundwater t Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 COMMON�Aj EAL;TI OF 1VIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. EPAP�TII E?ITT -F% PROTECTION TITLE 5 -OFFICL•4:n._:INSPEC'T'ION FORM=NOT FOR VOI U-NTA:RY ASSES'S-A4** TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM, . PART A CERTIFICATION Property A ddress: -70 . wth-4 e_6A&?_e_ :4 Owner's?'tame: ✓ Owner's Addre .Date df In'spee'tio 7 . Name�o.f Inspect please'print) Company Name. " 'Ylailing Address:. -.170 f ' Telephone Number: CERTIFIiCATION 8TA.TEMENT 1.certify that l 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 m)., training and experience.in the proper function arid'maintenance of on:site sewage.disposal systems;.I am a D.EP approved system inspector pursuant to Section 15:340 of Tifle 5(3.10 CMR 15 000). he system: Passes Conditionally Passes. ^ Needs Further Evaluation by the.Local-Ap, ,ing Authority s l AD Sp e ct o r9 J.S i a)i%i Ura., Dat P: •• .0.'' 61�.9 ^ The system inspector shall submit a copy of this inspection report to the Approving Autho�ty(Boardrof Heakth or DEP)within 30 days of completing thiOnspection. Ifthe.system:is.a shared system or has d esign flou'i of 1'Q`,000 gpd or greater,the inspector acid the system owner shall submit the.report to the appropriat8lgional c- ce o f: ie DEP.;The original shouldbe sent to the system owner and copies sent to the buwer, itapp:lic le, and t approo g authority. Co. rn Notes and-Comments This report only describes conditions at the time of.rnspection•and under.tb.e conditions:of use at that time.,This:inspection does not address how the system`wilI perform in the future under the same or different conditions of use. Title.5 Inspection Form 6115%2600 page 1 Page 2 of 11 t. OFFICIAL INSPECTION F ORM:-N:QT FOR VOLUNTARY ASSESS.NIENTS. SUBSURFACE E '�1GKI)ISPOSAL SYSTEM INSPECTION FORM .:-.. PART A. CERTIFICATION (continue �. Property Address:�� A Own:er•. Date of li ectibn:. — lrispection;Summary: . eck-A,B',C,D or);./ALWAYS eomplete:all of Section➢ A. System Passes: JI have not found any information Which,indicates that any of the failure criteria described in 3 15.3 03 or in 310 CMR 15304 exist.Any failure criteria.nbt evaluated are indicated be]ow. 10 CIv(R 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 {ill pass. Answer yes,no or not determined(Y,Nj 1D)in the for the following statements. if"not determined"please explain. The septic;tank is metal and over 2.0,years,ol& or the septic tank(whether metal or not)is structurally unsound, exhibits substantial:infiltration or exfiltration or.iarik 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 I;ess than 20.years old is available;' . v ND explain: Observation of sewage.backup or break out or high statid.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 T obstruction isremoved 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-systern will pass inspection if(with.•approval:-of the.Board of Health): broken pipe(s),are replaced obstMct Ion mremoved ` ND explain: 5 , Pave 3,Of I 1 OFF.ICIAL INSPECTION FORM-.NO'T FOR.VOLUNTARYASSESSMENTS SU]3SI1:P.FCE SE AGE pISPOSAL SYSTElYf INSPECTION FORtvT PART, CERTIFICATION,(continued)' . Trope, Address � •Owner. Date of spection: �- --C�� �% C. Fiirther.BvaluatioazIs Required by the Board.of Health: Conditions exist which require fiu-ther evaluation by the:_Board of Health in order:to determine if the system is failing to protect public health; safeby or the environment. 1. System will pass unless Board of wealth determines in accordance,with 310 GMR 15.'303(1)(b) that the system is not=functionzngin a marne'rwhich wilI.protect;p�blic health;"safet} ard;the.environment'. Cesspool or privy is within 5.0,feet of a surface water Cesspool or priv}w.is within 50 filet of a borderina vebeiated wetland.or'a salt marsh Z. _ System will fail unless the Board:of Health;(and_"Public.;Water Sup.plier,,: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 SAS1is.within feet of a. surface water supply,or.tributaryto a surface water:supply: _ The system has a septic tank and SAS and the�SAS -s.wiihima-Zone ]-sof a public water supply.' The system has a septic tank and.SAS and the SAS is within 50 feet ofa 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 j. "This system.passes if the well water analysis;performed at a DEP certified,latloratory,"for coliform bacteria and volatile-organic compounds indicates that the well is.freeTrom pollution-from that.facility and the presence of ammonia niL ot_en and nitrate nit open is'toual tb or less:than 5 ppm;provided that.no other failure criteria are triggered. A copy of the analysis:must be attached to this.form. 3. . -Other: 3 Page 4 of.11 OEFIC.1A:L:IN,,S.PECTfON FOP Nv1-..NOT•FOR VOLUNTARY:ASSESSMENTS ' SUBSURI+A:CE,SEWAGE DISPOSAL.SYSTEM-INSPECTION.FORM PART A CERTIFICATION(continued) Property.Address. 'G(� 9 &ol �. Owner. ' Date of pection:. D.. System Failure.Cri ria applicable to alfsystemss 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 clog cod SAS or.cesspool Discharge-or ponding of effluent to the•surfaee'of the ground or surface waters due to an overloaded or clogged.SAS,or cesspool Static liquid-fevel;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. ' v of times puiriped y _ Any portion of the:SAS,cesspool or privy is..below high ground water elevation. Any:portion,o*cesspoofdr privy is.within 100,.feet of a.surface.water supply or tributary to.a.surface J water.supply.; Any portion of a cesspool.or.privy.is withi.ma Zone 1 of a:public well. Any portion of a cesspool or privy is withih.50 feet of.'a.private water supply well. Any portion of a cesspool or-privyis.less than 1.00 feet but greater than 50 feet.from a private water supply well with ith 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.well is free from pollution from that,facility and the:presencd.of ammonia nitrogen and!;riitrate 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.] ` 0 (Yes/No.)The system fails.I have determined that one or more of the above failure criteria exist as described in 3,10 CMR 15.303,thereforethe 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 serye:a facilitywith a design flow of 10,000 gpd to 1.5,000 apd- You must indicate either".yes" or"no"to each of the following: (The following criteria apply to large systems.in addition to the criteria above) yes no the system,is within 400 feet of a.surface drinking water supply the system is within 100.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 11 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 tfie 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 3.10 CMR 15.304.The system owner;should contact.the appropriate'regional office of the Department. P•ageS of 1.1 OFFICIAL INSPECTION FO'M NOT O.R'VODUN'TAkY.' SS SSiVTEN.TS -SUDS'URFA-CE'SEW-AGE DISPOSAL,SYS'FEA%I INSPECTION FORiYT . CHECKLIST .. , • _ Property Address: Owner: Date of T pection: � � Check if the following_have been done..You.must-indicate"yes"or"no"as.to each of the following:: Yes./No v ' Pumping.information was.provided by the owner,•occupant,or Board of iealth; _ Z e any of the system components pumped out in the previous two-weeks `'the'system stem received normal flows in the previous two wee e _ Y P h 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? (1f 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? y Were all system components, excludin-the SAS,:located'on site Were the septic taril:manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles ortees, material of construction, dimensions, depth of I quid,.depth of sludaela.nd depth ofscum lz_. Was the facility owner(and occupants if different from owner):'provided with information.on the proper maintenance of subsurface sewatre disposal systems'? The size and location of the Soil Absorption..Svstem'(SAS) on thhestte has'been'determinbd'based on: Yes no _ j/"'Existing information. For example, a plan at the.Board of Health, f Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 C R 15.302(3)(b)J Page 6of11 OFFICIAIr;INSPECTION FO.W NOtFOR:VOLU1�iT'A.RY:ASSESSMENTS. SIJBSIJRFAGE SEWAGE,DZSP,OSA *SYSTEM-INSPECTION FORM PART:C SXSTEK . FORMATION Property Address* Owner: Date,of I pection: / FIOW CONDITIONS RESIDENTIAL,,-' l Number of bedrooms(design): Number of bedrooms(actual)..: DESIGN flow.based on`3 I0;C ' 15.203(for example: 110 ZIP x#of bedrooms): Number of current residents:. Does residence have a-,arbage grinder(yes or no): Il(J Is laundry on.a separate sewage system (ye or no): 0 fif yes separate inspection required] Laundry system inspected(ye .or no): D Seasonal.use: (yes ornc): Water meter readings,,if av ble(last 2 years usage:(gpd)): 0(v" Z�D00 06— Sump.pump(yes or no). 0 �' nn Last date of occupancy: COMMERCIAL/IND USTRIAL,WO Type of.establishment:, Design flow(based on' 110 CM.R. 15.203): Qpd Basis of-design flow(seats/persons/sgtt,etc.): - Grease trap present(yes:orno):— 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: 111a7te ' Was system pumped as part of the.inspection yes or no):•J/ If yes, volume pumped: gallons--How was quantity pumped determined? Reason.for pumping: I TYP F SYSTEM —Septic Tank,distribution box,soil absorption system _Single cesspool —Overflow cesspool _Privy _ Shared system(yes.or no)(if yes, attach previous inspection records,.if any) Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system'owner) Tight tank: _Attach.a copyof the DER approval _.Other.(describe): proximate age of�11 corrmpo ents date installed(if known)and source of information: Were sewage odors:detected when.arriving at tRe site (.yes or no):. (J Page 1 of l 7 OrF7C7AL INSPECTION 1 FORT~r1—NOT FORVOLUNTARY ASSESSNIEItiTTS SUBSURF ACE SF' AGE DSPOSAL'SYSTEM INSPLCTT!bN FORM: PART.0 . SYST:E+1MINI FO:RMATTON.(continued) Property Address: C C Owne Date bf spection: 0J Bun I)ING SEWER(locate on site plan) Depth below grade:. Materials of construction:_cast-iron 40 PVC_other(explain): Distance-from private water'supply well or suction line:... Comments (on-conditionbf_joints,venting, evidence of Cr etc.): SEPTIC TANK:Zlocate'on site plan) I1 ; Depth below trrade: Material of construction:. ncrete metal_fiberglass Polyethylene —other(explain) If tank is metal list aae:_ .Is agexonfirmed by a Certificate of Compliance(yes or no)';_(attach..a copy of certificate) y Dimensions:/0 X (a )< Sludbe depth: =1 Distance from top o sludcle to bottomm-o outlet tee or baffle:., J,. Scum thickness: Distance from top of scum.to top:of outlet tee or baffle'.. Z J/ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions deterrn.ine.d � ' Comments (on pumping recomme atlons inlet and outlet tee or baffle condition, structural integrity, liquid-levels related to ou#let invert, evjdence of leakage, etc.): � GREASE TRAP:Ablocate on site-plan). Depth below grade: Material of construction:._concrete..: metal._fiberglass_polyethylene_other ' (explain)`: — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ofscam to bottom'of outlet tee oi•baffle: Date oflast-pumping: Comments (on.pumping recommendations, inlet and outlet'tee orbaffle condition, structural integrity, liquid levels as related to outlet invert,-evidence of leakage,`etc.): i Page 8 of 1.1 `OFFICIAL-INSPECTION FORM—NOT:FOR:;'YOLUNTA �SSEASSESSMENTSE- SUBSURPACSE'WA It�' GE DISPOSAL SYSTEM INSPECTION YOR.M PART C. SYSTEM-•IN:FOR.MATION(continued) Property Address: Owner: Date of Peet ion: TIGHT or HOLDING TANK: ///O(tank must-be pumped at time of inspection)(locate ca.site plan)• Depth;below grade: Material of construction: concrete metal fiberglass_�olyetliylene other(explain);. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present.(yes.or no):. Alarm level: Alarm in working order(yes or no): Date of last pumping: Commentsi(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Yof-present must.be'opened)(locate on site.plan) ��� Depth of liquid level above outlet invert:����outletsComments (note if box is:level and distributioal;.any evidence of solids carryover,any evidence of lea ge i. to.o out f box;e i� 7 J PUMP CHAMBER:.. z(locate on site plan): Pumps in working.order(yes or no): Alarms in working.order(yes or no):. Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of l l OFFICIAL INSPECTION FORMM.—NOT FOR VOLUNTARY ASSESSMENTS S-UBSIJ-FACE`SEV/-AGE IDZSPOSAL SYSTEIYI INSPECTION.FOR?1r1 PART`C SYSTEM 1INFORWTION continued) r /4 Property Address: ire AV Af� i Owner. Date of, spection: _ SOIL ABSORPTION S3'S FM (SAS): V (locate on site-plan,_excavatio'b not required) If SAS"not located explain why: Type eaching pits,-number:. le.aching chambers,number: leachino.galleries;number: leaching trenches, number, length: leaching fields,:number, dimensions: overflow cesspool; number: innovative/alternati.ve system- Type/name of technology:. Comments (note condition of soil, signs of hydraulic failure, level of pondina 'damp soil;condition of vegetation, CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)., Number and conflauration: Depth*—top of liquid to inlet invert: et Depth of solids layer: r Depth of scum layer: Dimensions'of cesspool: Materials of construction: Indication ofgroundwater inflow.(yes or no): Comments (note c'ondition-of soil, signs of hydraulic failure,.level of ponding, condition of vegetation, etc'): PRIVY:Awl ocare,oil site plan) Materials of construction: - Dimensions:. Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition bf vegetation, etc,):. 9 Paae 10 of 1.1: OFFICIAL INSPECTION-YORNI:= NOT FOR.-OLUNTAI ASSESSNIENT.S . SUBSUR FACE SEWAGE:DISPOSAL SYST EM INSPECTION FORM. FART-C' SYSTEMJNFORMATION(continued). Property Address: Owner: Date of I ection:. 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.Y00 feet.Locate where public water supply enters'the building. )0O r 5'ha� I� 0 LewA, . m Page.11 of 1 1 OFFIdAL INSFFCTION FORM --NOT FOR VOLUNTARY ASSESSMENTS SIJ3 SURFAC�F,SFI,WAOF,DISPOSAI,SYSTEI M.'-INSPECT bN FORiY1 .PART C SYSTEM-INFORMATION(continued) Property Address: ­70 Owner J � Date of Id pection: . � CJG SITE EXAM Slope Surface water Check cellar Shallow wells - Estimated.depth to ground water.. feet Please-indicate(check):all methods used to determine the high ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site(abuttin-,•property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USES'database-e�alain: You must describe how you established the high ground water elevation: 10 &i,/ r®ule 7 S Permit Number Dater Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 719 �faalah rj�/,�. if b � Lot No. Owner: / /'�9//�� Address: Contractor:_ �G Address: . Zl ,Z& A--�5�✓?/ Notes: /'�/� c>� S ✓'%/�lS f i STEP 1 Measure depth to water table ��� tonearest 1/10 ft. ........................................................:..................... .Date 0 J� month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well..........:........:..:............ �. .. Z OB Water-level range zone .......... ........ ........................... STEP 3 Using monthly report "Current Water Resources Conditions" / + determine current depth to L,�7[[[/�7 7 water level for index well ........................... , month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone(STEP 2B) determine water-level adjustment ................. STEP 5 Estimate depth to high water . by subtracting the water level adjustment (STEP 4) from measured depth to water l level at site (STEP. 1) ...... .... Figure 13.--Reproducible computation form. TO. 50 tic 7 a�`ale?lei b. ' 4 No.------ -� 1 Fee---- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-for Veil CootructionVermit Application is hereby made for a permit to Construct (''I, Alter ( ),'or Repair ( )an individual Well at: --- 1 •Location — Address Assessors Map and Parcel r rti TO t.0 _- _ `-- ____ -- — _------_--Address — — - bwne _Qg /hex F60 .A49kg A,er oAe ---------------------------�--�-----_ _______-_------------- Installer — DrillerV-- �_-- Address Type of Building Dwelling _—--- -- —- —- Other - Type of Building--- ------ No. of Persons-------------_------------_-- Type of Well Y �`� --_—_ Capacity— --------_____-- Purpose of Well Agreement: The undersigned agrees to install the aforedescribed 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 Certifica a of ompliance has been issued by the Board of Health. Signed ----- -�o Q o !date Application Approved By ! ` -- date Application Disapproved for the following reasons: -------- ------------------- --- - ------ ------------------------- date Permit No. l kJ_7 -- Issued--------5� ------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (►I, Altered ( ), or Repaired ( ) by--_ ---_---------- ------------- ---------- ---- Installer at---fL, Pc� Q u iG`fir G>� ctrT ----------------- — - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot'e5tion Regulation as described in the application for Well Construction Permit No. s =�7-Dated L THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- Inspector-------- -----------—-- I 5 - No. �2ul�- Fee-------------- ----- t. BOARD OF HEALTH TOWN OF BARNSTABLE M r Applicat ion Ar]Dell Conotruct ion Permit tA�pplication is hereby made for a perm' C t ( Alter,( �or Repair ( )an individual Well,at: 1® l°�U_�ai cl� >eT CDuc C� _ �� rv1�rt ---/� —dS — -- Location — Address Assessors Map and Parcel Mf . jU y'� San. e. /n� p / Owner / C Address -- --- 0 A SCu�lJtirl( L.,r ''f) /( I �6, /'or F4a A'1 � 1te AA --- — --_-- -------------------------�--- _—__--_----------- Installer Driller/ Address Type of Building Dwelling ------ -- ------------- Other - Type of Building------- =_-_ No. of Type of Well �� .�`' - - Capacity_ ___-- Purpose of Well t'o Agreement: The undersigned agrees to install the afi r'g4scribt4 Ln�ivi&alzw.lt in accords,e with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation `—�` e�u`rid rsigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the oard of Health. �7 Signed �-�^^� -- — cA- date " Application Approved By ` " V —__ ____—_ — /� /0? date Application Disapproved for the following reasons: - ---------------- -------------- date Permit No. � �- 1 -- Issued ----- 5— -- ---------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (tom), Altered ( ), or Repaired ( ) r l D A S", ' Installer --- ------------ --------_ ---- r has been installed in accordance with the provisions of the Town of Barnstable Boa,�d of Health Private Well Proteftion gapplication _ 5 /�� Regulation as described in the for Well Construction Permit No. --=--------- —Dated---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - Inspector----- - - —_ ------ -- BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Congtruct ion Permit No. Fee------------ Permission is hereby granted to Construct ( ✓), Alter ( ),, or Repair ( ) an Individual Well at: NO. . /��.��'A t c��S t 7' Co u r C f Street as shown on the application for a Well Construction Permit � No.- — Dated -— -------------- DATE - Board of Health � � ��- r x . V e C i P�� NO.— =�� Fee ---- BOARD OF HEALTH TOWN OF BARNSTABLE v� Zippiicat ion for Vell Cootruct ion Permit Application is hereby made for a permit to Construct (4, Alter ( )), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel _ Pioo,\�QU;CA- eooe, cr'l' O!w/ner Address SCu u Installer — Dri.ler Address Type of Building Dwelling --- —--—--—- Other - Type of Building—= - ------ No. of Persons------ ----------------------• fr Type of Well Y iN t`Ga 'row m w Capacity— Purpose of Well — Agreement: The undersigned agrees to install the aforedescribed 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 Certificate of C mpliance has been issued by the Board of Health. Signed D� _— te Application Approved By ------- ------ date Application Disapproved for the following reasons: ----------- -- ---— ----- - --- __---------- date�—_--- Permit No. W,2002 3 — Issued 6 ffi e- ---- -- - ---- date BOARD OF HEALTH TOWN OF BARNSTABLE Certifirate ®f ComPliance THIS IS TO CERTIFY, That the Individual Well Constructed (r/j, Altered ( ), or Repaired ( ) oOA by-- -, GO Installer-_---- •_---------- I / at �/ �!� t u t�ICS'.i V P G t t � �--___------- -----has been installed in 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. W�0923Z Dated � �^---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- Inspector------------- ----------- Fee--- BOARD OF HEALTH TOWN OF BARNSTABLE Ipplicat ion-for Vell Con5tructioupermit Ap lication is {hereby made for a permit to Construct (wf, Alter ( , or Repair ( )an individual Well at: — Location — Address A' Assessssors Map and Parcel 3 Owner Address — D A SCE r ,,. ff 0/ / , _ ?. eOX 9GO_ rU - Installer — Driller — -- Address Type of Building Dwelling Other - Type of Building-=--- ------ No. of Persons---------------—_—_—___ Type of Well ':-- Capacity-------------------- Purpose of Well- t rir Agreement: The undersigned agrees to inst 11 the aforedescribed individual well in accordance with the provisions of The g gI' ,� Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed __-- -te Application Approved By--,, ------ ----- t date Application Disapproved for the following reasons: ----- ----- ------ -- date— Permit No. W,)oo�-37 — Issued al --�— -- �- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (evl, Altered ( ), or Repaired ( ) D/a S Ca wA,, // Installe�at /L A U,< /K o✓r G - / has.been installed in 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. W� -37 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- -- Inspector-------------- —----- BOARD OF HEALTH TOWN OF BARNSTABLE 19ell Construct ion Permit No. -W o�Oday-3-7 Fee Permission is hereby granted 10 SIf G ^" /4wI/k I - to Construct ( �, Alter ( ), or Repair ( ) an Individual.Well at: No. I COUP C r Street as shown on the application for a Well Construction Permit 6 / — No._ (� UOa - 3 � 0 — _ Dated-- "� --- --------------------- ---�7` ---------_---.._..----- / Board of Health DATE t� — No.--'` 1 /W '' FEE CO COMMONWEALTH Of MASSACHUSTNt' 'l Board of Health, SAA4�1 /W C.A. , MA. 1 I/ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to ConstructK.RepairO Upgrade( Abandon( - ❑Complete System ❑Individual Components Location L j ( V I U& Owner's Name V/.3 9 EU7-A4 oV* •{ 1a&'t-(S Map/Parcel# G V7 Address CJV J�co Lot# t ( Telephone# i Installer's Name Designer's Name W jA_A ZA_ gA,34 dC_ _._.--- Address ,,IA k,,L Address Telephone# - Telephone# `7-77!S-- p-?3 Type of Building &-E.S iO %.-'J C-P- Lot Size A ft. 9• Dwelling-No.of Bedrooms Garbage grinder-.- N Other-Type of Building 1JLA- No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow (min.required) �� gpd' Calculated design flow 97 3, Design flow provided "73 E 7 gpd Plan: Date Number of sheets Revision Date Title �G bf►`l �.I.CZ,�•��mil-b� l` ��Ca c�-S Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation t, DESCRIPTION OF REPAIRS ORALTERATIONS C1 tSw/y X 5�D S'>< �. ' The undersigned agr s inst th ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to t plac em in operation until a Certificate of Compl an e has been issued by the Board of Health. Signed Date C�/ ���1 Ck(' /` C�a✓C,5 �,A �� l7, O.V i Inspections N �! A—W, yFEE4' - r u MMONWEALJH OF MASSACHIJ Board of Health, Z.4,M , 14 C-4-- APPLICATION FOP ➢ ISPOSAL SYSTEM[ (ONSTRUCTION PERMIT IT Application for a Permit to Construct..Repair( ) Upgrade( Abandon( - ❑Complete System ❑`Individual Components Location ( I ( Pl Pj V i G{LS V Owner's Name qhj 9 5-Cc 7_A4 E:rq Map/Parcel# 01-7 Address J M4 Lot# / ( _ Telephone# Installer's Nameliar Designer's Name W Z�_� e��4 dL Address y���-=- t �LJ Address P� yf-7 C 44,j-k—et1—JIk`A Telephone# - Telephone# -7 .— 7 3S— Type of Building 4� to V j Ls- Lot Size Dwelling-No.of Bedrooms Garbage grinder4-) N Q Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures esign Flow (min.required) gpd Calculated design flow 97 3 9 Design flow provided 6-73,7 gpd �Q,'an: Date Number of sheets c-1 Revision Date %DESC ®G F,Eta) 1Ek t"Z.,e.IZ ( 'n of Soil(s)ator Form No. Name of Soil Evaluator Date of Evaluation IONOFREPAIRSORALTERATIONS .,- C\,,c i '3-cl The undersigne agr s o ins thte—.m ove described Individutiiewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to of plat a in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 1 1 AvI V C-(1 /r, l ✓r.i { l U �r Inspections �� 16ZIN FEE /GO f Board of Health, MA. 5�r Description of Work:<0 Individual Components) �o' p13te System Y �i' J m The undersigned hereby certify that the Sewage Disposal System;°ConstructedCK),Repaired ( ),Upgraded ( ),Abandoned ( ) by: Cl;lL-�y uv 1 Gt��J�T/t.:rc�'� ✓rl at to UIC/LStT— f,O�I� ..�'- G.I/t_.C.L�. has been installed in accordance with the provisio s of.310 CMR 15.00 (Titlet55,and the proved design plans/as-built plans relating to fW j applicatio No �t` HLp, dated -1I f ICE) . Approved Design Flowk(4 (gpd) Installer ` ! r Designer ' Inspector0 .� l� 1��� Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. cw t /�� FEE /ao COMMONWEA1111 OF MASSACHUSETTS Board of Health, � �-�- MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at O t /( t j & j kC,cs t'F_, Go`—t U' as described in the application for Disposal System Construction Permit No.,) Od/ /4, dated Provided: Construction shall be completed Wt hin three years of the date o t is ermit. All al ad must be met Form 1255 Rev.5/96 A.M.Sulkin Co.Boston MA Dat Board of Health (,- /� v v : .. ix�� a w d . TO�VIFO)~BANS'I'ALEr ; s i 8. LOCATION LL-t .I I �h�:•V \C�Lt�,� . C�;v SEWAGE VILLAGE ASSESSOR'S MAP &LOT C>1 `� , ff�y INSTALLER'S NAME&PHONE N0. SEPTIC.TANK CAPACITY LEACH] G FACILITY: .(type) S(size) NO. OF BEDROOMS 5 t BUILDER OR OWNER l PERMIT DATE: =10i-C OMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Tableao the-Bo ttom;of Leaching Facility fleet' r. - Private Water Supply We11 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 -fa -`within'3UO�feet'of-Ieactungeihty}:_::� _:: -�.._ Feet - � Furnished by r 1 _ 2. I Id I R //5 IiV ` Town of Barnstable Department of Health,Safety,and Environmental Services OFIKE7 ,- ' Public Health Division Date 367 Main Street,I lyannis MA 02601 • BARNBTABM MASS. 039. rfnMn'tn Date Scheduled Time 10. CIO' Fee 1'd. Soil Suitability Assessment for Sewage Disposal Performed By:OcAAG1-. Witnessed By: d LOCATION & GENERAL INFORMATION Location Address G !� Owner's Name j Pl�JQ v icXS�J c n vF U.�, cv,,�.sLT o� Address o57clL vi��- Assessor's Map/Parcel: /�ri� .��j r%, ZS Engineer's Name NEW CONSTRUCTION ,� REPAIR Telephone# 2 SS d 5 S Land Use t 1 l - Slopes(%) /a Surface Stones Distances from: Open Water Body R Possible Wet Area R Drinking Water Well R Drainage Way It Property Line R Other R SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ti .. ,a� 3 o . c n; W 'A - J ^ b J � nH R ni y' Jtcr.cr.vc „i •'�' aV. Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face NN6 Estimated Seasonal High Groundwater DETERNINUION FOR SEASONA ,HIGH'UVATER TAI3L Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: _in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. Index Well# _ ,,.. Reading Date:.__,..__.- Index Well level. _ Adi.factor Adj.Groundwater Level PERCOLATION TEST >` ate ,iinc kO;OD Observation Hole# Time at 9" Depth of Pere tic Time at 6" Start Pre-soak Time @4 (C7; Time(9"-6") � - End Pre-soak Rate Min./inch Gb�trl If1 Site Suitability Assessment: Site Passed X Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant _ r DEEP OBSERVATION IIOLE LOG Mole #. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface IN (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. %Gray 1) DEEP;OBSERVATION'HOLE LOG Hole# �� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 0 o Gravel) k^SN n�' I� H n � t LOAK s�oo ioYi2 `;10 ?/ DEEP OBSERVATION HOLE LOG Hnt:e# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. rnncictenry ° Gravel) I DEEP;OBSERVATION>'HOLE LOG Ille# Depth from Soil Horizon soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories,Buulderes. Conskiency.° Gravel) Flood Insurance Rate Map- Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all,areas observed throughout the area proposed for the soil absorption system? If"not,what is the depth ofnaturally occurring pervious material? l Certification 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 ,,tr�aii�ning, expertise and experience described in 310 CMR 15.017. _.Y.!`._ LSf Date f oZ-' (�V Mas;sachilgetts Department of Environmental Management q q Office of Water Resources 11 4347 TYPE OR PRINT ONLY Well Completion Report 1.WELL LOCATION GPS.(OPTIONAL) LATITUDE • s LONGITUDE Address at Well Location: /Z "" `�+ �t s.� co c,t �a Property Owner:M e • Subdivision Name: ' y Mailing Address: `4 � City/Town: urn ws �'�y OZ) y /60 IA CitylTown: cortNTc e Assessors Map C!it Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no streett,addr s available Board of Health permit obtained: Yes [�3' Not Required ❑ Permit Number Date.lssued' 2. WORK PERFORMED; 3. PROPOSED USE y P 4.DRILLING METHOD Eff New Well ❑ Abandon ❑ Domestic 0 Irrigation ❑ Cable cQ,TAuger 0-Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer` Q Direct Push Re -fa' ❑ Other ❑ Industrial ❑ Other ❑ MudgRo`ta O ,❑ Other 5 �11VELL L'OG tr Unconsolidated Consolidated 6.°SITE'SKETCH(use permanent landmarks with distances} W Permeability Q > wa a From (ft) To (ft) High Low Q) g 0 Other Rock Type Sy f NS� 1 � ' \ . 7 inn T.'WELL CONSTRUCTION 8. CASING WF :-Total Depth Drilled yy From (ft) To (ft) Casing Type and Material . Size BAN OF BAFftllfSbbE pe Date nllin Complete 1� LPL I rl LA - _ _ u 9:-SCREEN From.(ft.) To (ft) Slot Size k Screen-T/jpe and Material Screen Diameter Ito 77 . t, 77. 73 Y 10 .FILTER PACK/GROUT/ABANDONMENT MATERIAL 11.ADDITIONAL WELL, INFORMATION From ft - Developed? ❑ Yes ❑ No O _To (ft) Material Description Purpose Fracture J Enhancement? ❑ Yes ❑ No . 1 Method Disinfected? ❑ Yes ❑ No 1 Z«WELL 1 EST;DATA(PRODUCTION WELLS) 13.,STATIC WATER LEVEL(ALL WELLS) Yield.NTime Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM) ` (hrs&min) (Ft. BGS) (hrs& min) (Ft. BGS) Date Measured Ground Surface (FT) 14:PERMANENT PUMP(IF AVAILABLE) Y e 15.NAME/ADDRESS OF PUMP INSTALLATION COMPANY Pump Description � Horsepower Pump Intake Depth X (ft) Nominal Pump Capacity �" (gpm) 16 COMMENTS' 17.,WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules gr and regulations, and this report is compete and correct to the best of my knowledge. Driller: '��/ FNrw .,,, Supervising Driller Signature: Registration #: Firm: �'�` r fl - Date: L�y/U� Rig Permit#: I I 19 NOTE.: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. �# .:f 4 ' `. 4 Y BOARD:OF'HEALTHtCOPYj _ _ , ;„. _ s. , f •. _ .. . ,r sr v o o e s r• ti f�i i cif, .,{s a. .a .♦s E s .. r w �. + . H - c _ e = a,. ?c< : i .',�L k ..� <a,-4 e • r c t•x t s.r E+ S+ Ye. II . 11 - 1 J £At , so,.000 t Ns. �J TEST HOLE LOG 1 DATE: 12-27-00 P-9905 \� SOIL EVALUATOR: M. O'LOUGHLIN, CSE WITNESS: E. BARRY, BOH PERC RATE: < 2 MIN./IN. 22.0 0" 22.0 0" ORGANIC ORGANIC 21.7 3" 21.6 5" A LOAMY SAND A LOAMY SAND 21.5 2.5Y4/3 61. 20.7 2.5Y4/3 15"• Bw = LOAMY SAND Ba LOAMY SAND 7 L�-Z- Ae[ 19.5 10YR5/8 30" 18.8 10YA5/e 38'f ' \\ ► Cl =COARSE SAND Cl =COARSE SAND gas\ 2.SY7/8 2.5Y7/8 \ 16.6 65" 16.5 66" J�\ C2 =FINE-MEDIUM C2 -FINE-MEDIUM / \ SAND SAND \ f 2.5Y8/3 2.5Y8/3 12.0 120" 10.5 138" �\\ NO WATER ENCOUNTERED C N Foe N, DESIGN DATA DAILY FLOW: (5) BDRMS. x 110 GPD = 550 GPD SEPTIC TANK: 550 GPD x 200% = 1100 GPD USE: 1OFA(GALLON PRECAST SEPTIC TANK LEACHING USE: (5) 500 GALLON PRECAST DRYWELLS LINED G W/4' OF DOUBLE WASHED STONE CAPACITY: 1NQ��C SIDEWALL: 127 x 2 x 0.74 = 188.0 Q BOTTOM: 13 x 50.5 x 0.74 = 485.8 TOTAL: 673.8 GPD M4 #r ice. DANIEL q� ��_� �dt l��2SC SI.O� �•O� BRAMAN yG� Laloc CIVILI V No.3262686 NOTES: 1. ALL PIPE TO BE 4" DZA. SCH 40 PVC. 2. PIPE TO BE LAID LEVEL FOR 2' OUT OF DISTRIBUTION BOX. I �. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN I0. 6" OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. \'st'/4 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6" LAYER OF STONE. 'Vb 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2" LAYER OF 3/8" PEASTONE OVER -- �ij DOUBLE MSHED STONE --------.---- ALL AROUND TOP OF FOUND. @ ELEV. 23.5a _____"_ I 'rope El. l8.7d -------------------- ?'°`°p 8•oc - ------------- , 5.5 SEPTIC SYSTEM PROFILE �1T T 0. SITE SEWAGE PLAN FOR GENERAL NOTES LOT 11 PINQUICKSET COVE CIRCLE COTUIT, MA 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION ASSESSORS MAP 17 PARCEL 25 OF ALL UTILITIES, ABOVE AND UNDER(WOUND, PRIOR TO ANY EXCAVATION OR CONSTRUCTION. J PREPARED FOR 2. SEPTIC SYSTEM TO BE-INSTALLED IN COMPLIANCE WITH • . 310 CMR 15. 00: TITLE V. T .A. NELSON CONSTRUCTION 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. DATE: MARCH 1 , 2001 SCALE : AS NOTED 4. ALL DISTUR88D AREAS TO LOANED AND SEEDED. 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY WELLER & ASSOCIATES REQUIRED INSPECTIONS. 1645 FALMOUTH RD. - SUITE 4C P.O. BOX 417 CENTERVILLE , MA 02632 TEL: (508) 775-0735 FAX: (508) 775-0754 APPROVED BY: