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HomeMy WebLinkAbout0268 POPONESSETT ROAD - Health 268 Poponessett Road Cotu it P 019 063 --- - -- ----- ----- - - - - - - - _ - - i r I� �i � .. _ 70 C" Town of Barnstable Heat nspector �kIME roy, Regulatory Services office xours .�, 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 STABLE, % Public Health Division 1639• `fig �pTFc 6��A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 50M62-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date:March 29,2010 1. General Information: Size of Property: 0.44 acre lot Address: 268 Poponessett Road in Cotuit Map 019 Parcel 063 Name: LORI T.MARTIN' Phone#: 508-737-7522 .2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? N 0 If yes,how many? ID 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?'X 2d.Please include a copy of'the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in".the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Js the dwelling connected to public sewer? N 0 If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public suppl~}�wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? F 7. Is a disposal works construction permit on file? YES or 'NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits''obtained for construction of additional bedrooms? YES or �NOrn n 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified'inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at thisproperty. J Special Conditions: Signed: Date: 6 -7'20 L2 Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyappl.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road -Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: v� only the tab key to move your Darren M. Meyer cursor-do not Name of Inspector use the return key. n/a , Company Name r� P.O. Box 981 Company Address i East Sandwich �� MA 02537 City(rown State Zip Code 508-362-2922 S 1 3920 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 - t Inspector's Signature Date The system inspector shall submit a cop of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of comp a Ing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. �1 VU I 4 f 1 268 Popponessett Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every 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: ® 1 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. Answer yes, no or not determined (Y, N, ND) in the❑ 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. ND Explain: ❑ 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 ❑ obstruction is removed 268 Popponessett Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name i otu formation is Cit required for MA 02635 January 3, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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. 268 Popponessett Road,Cotuil-Front House-TITLE V INSP-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is COtUIt required for MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 ® 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 268 Popponessett Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owner's Name information is required for Cotuit MA 02635 January 3, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes 'No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a publicwell. ❑ ® 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. El ® 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 El ❑ ,the system is within 400 feet of a surface drinking water supply El ❑ 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. 268 Popponessett Road,Cotuit-Front House-TITLE V INSP-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road -,Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Cityrrown 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)] 268 Popponessett Road,Cotuit-Front House-TITLE V INSP-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): unavailable Sump pump? ❑ Yes ® No Last date of occupancy: July 2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): 268 Pop ponessett Road,Cotuit-Front House-TITLE V INSP-08l06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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 El 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, date installed (if known)and source of information: system installed in 02/24/95 Were sewage odors detected when arriving at the site? ❑ Yes ® No 268 Popponessett Road.Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 12 inches 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.): No issues, no signs of leakage Septic Tank(locate on site plan): Depth below grade: 9 inches feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene y El 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: typical 1,000 gallon tank 8.5'x4.82' Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 32' Scum thickness 011 Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? tapes/rods 268 Popponessett Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 c � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown 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.): Tank appears in good condition, Tees are intact, liquid levels are even with outlet pipe, no signs of leakage, structural integrity appears sound. Recommend pumping-every 2 years Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 268 Popponessett Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is Cotuit MA 02635. required for January 3, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert n/a 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.): D-box was level,flow equal, no signs of solids carryover, no signs of leakage, everything functioning normally, D-box was 30" below grade. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ❑ Yes ❑ No 268 Popponessetl Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address' Timothy Scales Owner Owners Name information is Cotuit MA 02635 January 3; 2009 required for y every page. City[rown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,-excavation not required): If SAS notlocated, explain why: Type: ❑ leaching pits, number: ® leaching chambers number: 4-Tx 29' ❑ 4 leaching galleries number: ❑„ Teaching trenches -number, length: ❑� leachingfields 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.): f 4 1nfiltrator Units(Tx 29' configuration) hand auger to stone showed no signs of hydraulic failure, no ponding, soil conditions normal, vegetation normal. 268 Popponessett Road,Cotuit-Front House-TITLE V INSP-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 268 Popponessetl Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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. FIzoWr or- A- I I 3 , A - y Zit 268 Popponessett Road,Cotuit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 MOPTCAGE IVSPECTION P[,AIV APPLICANT.• SCALES TO WN. COTUiT 75.g2 GAR. LOT 176A LOT 176G cn � LOT 177E DECK STEFH=N `= c� J. ► A DOYLt aY5 . !v'r^3' y CCt ♦�v� 16 p0' POPPONESSETT ROAD FLOOD PANEL- 250001_0021 D FLOOD ZONE. "C DATED.- 07—02—92 I hereby certify that this mortgage inspection plan was prepared for: Plan is For SOVEREIGN BANK Bank Use Only The location of the building shown does _MZ:- fall within a special flood hazard zone. DEED REF = 15899_-1 Per taped inspection it appears the location of duelling does ------ conform to the local by-laws in effect at the time of construction with respect to horizontal dimensional setback requirements PLAN REF. 94=47 __ or is exempt from violation enforcement action under Ales General Laws Ch. 40A -sec z Scale 1" Referenced Deed subject to and with the benefit of all rights, rights of wa be y, easements, reservations — _ 0'_4 __ FT. and restrictions of record, if any there and insofar as the same are of legal force and effect Date: _01_—_0_9_—_05_______ PLEASE NOTE The structures on this Inspection were located by tape not instrument and are approximate only. An actual survey is necessary for a precise determination of the building location and encroachments, if any exis4 either way across property lines. This inspection must not be used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan purposes. This inspection must not be used to locate properly lines Verification of building locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. This inspection is not to be used for any purposes other than mortgage. Yankee Survey accepts no responsibility for damages resulting from said reliance. PHONE• 508-428-0055 YANKEE , 'UR VEY CONSULTANTS FAX 508-420-5553 UNIT 1, 40 INDUSTRY RD, MARSTONS MILLS; MA 0264E 3 738 0 JF Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'w. 268 Popponessett Road - Front House Property Address Timothy Scales Owner Owners Name information is Cotuit MA 02635 January 3 2009 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: > 25 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: i You must describe how you established the high ground water elevation: Research of perc test conducted shows no groundwater observed to 146", using Barnstable topographic and water contour maps, groundwater is approximately 25' below grade I 268 Popponessett Road,Coluit-Front House-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1a+4 Copy Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the I computer,use 1. Inspector: only the tab key to move your Darren M. Meyer cursor-do not Name of Inspector use the return key. n/a Company Name P.O. Box 981 Company Address East Sandwich MA 02537 City/Town State Zip Code 508-362-2922 S 1 3920 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 eeds\Further Evaluation by the Local Approving Authority /Vn Inspector's Signature Date The system inspector shall submit a copy of ihis 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 or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. [A. 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is Cotuit MA 02635 January 3, 2009 required for y every page. CitylTown 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: ® 1 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. Answer yes, no or not determined (Y, N, ND) in the❑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. ND Explain: ❑ 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 ❑ obstruction is removed 268 Popponessett Road,Coluit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection h B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: w ❑ 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: 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 ❑ F Cesspool or, privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if 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. 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 c Commonwealth of Massachusetts EKES W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments °�.. 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown State J Zip Code - Date of Inspection d: B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: -------------- y" This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes ;; No a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El Discharge or ponding of effluent to the surface of the ground or surface waters r- due to an overloaded or clogged SAS or cesspool r❑ 4 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less s than 1h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or i tributary to a surface water supply. 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is COtUIt required for MA 02635 January 3, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 ❑ 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. 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' '«M 268 Po onessett Road - Rear Garage e g Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown 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)] 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wk a,V 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? El Yes ® No Water meter readings, if available(last 2 years usage(gpd)): unavailable Sump pump? ❑ Yes ® No Last date of occupancy: July 2008 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: Last date of occupancy/use: Date Other(describe): 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP-08/06 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system installed in 03/17/2006 ' Were sewage odors detected when arriving at the site? ❑ Yes ® No 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is COtUIt required for MA 02635 January 3, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 14 inches 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.): No issues, no signs of leakage Septic Tank(locate on site plan): Depth below grade: 12 inches 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: s typical 1,500 gallon tank 10'6"x5'10" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? tapes/rods 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 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.): Tank appears in good condition, Tees are intact, liquid levels are even with outlet pipe, no signs of leakage, structural integrity appears sound. Recommend pumping every 2 years Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): r - Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information formation is COtUIt equired for MA 02635 January 3, 2009 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert n/a 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.): D-box was level,flow equal, no signs of solids carryover, no signs of leakage, everything functioning normally, D-box was 24" below grade. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ❑ Yes ❑ No 268 Popponessett Road,Cotuit-Rear Garage;TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e,•'"� 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is Cotuit MA 02635 January 3, 2009 required for 1. y every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 -2'x 2'x 24' ❑ 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.): 2 Trenches(2'x 2'x 24'configuration),hand auger to stone showed no signs of hydraulic failure, no ponding, soil conditions normal, vegetation normal. 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 d Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 268 Popponessett Road,Cotuit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 200.9 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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. r A - ( f--I A_ � 8 268 Popponessett Road,Cotuil-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 MO TGA GIT,' PF, C TJON P[,A /V APPLICANT.• SCALES TO WN. COTUIT 75.32 r GAR. N LOT 176A w LOT 176C LOT 177E DECK cc STE-HEN c J. ► OOYLE ► ♦ . ♦ ."fir'^ r^ ♦ ♦ ,0 SUR (♦ ♦V11 -ivy 82.11' 16,00' POPPONESSETT LOAD FLOOD PANEL- 250001_0021 _D FLOOD ZONE T_��__ DATED. 07-02-92 1 hereby certify that this mortgage inspection plan was prepared for.- Plan is For SOVEREIGN BANK Bank Use Only The location of the building shown does _1YQz_ fan within a special flood hazard zone. DEED REF. = 1_5_89_9_-I Per taped inspection it appears the location of dwelling does ------ conform to the local by-laws in effect at the time of construction with respect to horizontal dimensional setback requirements PLAN REF. = 94-47___ or is exempt from violation enforcement action under Mass. General Laws Ch. 40A -Sec. R Referenced Deed subject to and with the benefit of all rights, rights of way, easemen reservations Scale I�� _ � FT and restrictions of record, if any there be and Insofar as the same are of legs] force and effect Date: 01-_0_9_-_0_5_______ PLEASE NOTE The structures on this Inspection were located by tape not instrument and are approximate only. An actual survey is necessary for s precise determination of the building location and encroachments, if any exist either way across property lines. This inspection must not be used for recording purposes or for use In preparing deed descriptions and must not be used for variance or building plan purposes. This inspection must not be used to locate property lines Verification of building locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. This inspection is not to be used for any purposes other then mortgage. Yankee Survey accepts no responsibility for damages resulting from said reliance. PHONE' 508-428-0055 YANKEE SURVEY CONSULTANTS FAX 508-420-5553 UNIT 1, 40 INDUSTRY RD, AfARSTONS MILLS, MA 0264E 3 738 0 JF Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ° .0 268 Popponessett Road - Rear Garage Property Address Timothy Scales Owner Owners Name information is required for Cotuit MA 02635 January 3, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: > 25 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: Research of perc test conducted shows no groundwater observed to 146", using Barnstable topographic and water contour maps, groundwater is approximately 25' below grade 268 Popponessett Road,Coluit-Rear Garage-TITLE V INSP•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE� I i y LOC n ' ON �o, I�"VC-S]%--'7- Urc S AGE VILLAGE L10 7-4' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.1Q1EA1 6 w V E S d 9', SEPTIC TANK CAPACITY S 0 Z> LEACHING FACII.ITY: (type) /y��� � (size)a2 X NO.OF BEDROOMS BUILDER OR OWNER .� PER ITDATE: COMPLIANCE DATE: 3 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) f - Feet Furnished by ` pis \rn No. Fee ® THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Z.PPYication for Mizponl epztem C0115truction permit Application for a Permit to Construct-/)" Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No.J�(Us_ _ ���`�%{} Owner's Name,Address,and Tel.No. Assessor's Map/parcel 4 CD /L�� 3 Installer's Nam Ad 5s,and Tel.No. Designer's Name,Address and Tel.No. ,4AG� a--., ,s Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder (�) Other Type of Building e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.-required) gpd Design flow provided �' gpd Plan Date G 5�aif�d-5 Number of sheets a Revision Date Title !S Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not-to place t s e in operation until a Certificate of Compliance has been issued by this Healt i Date Application Approved Date I 5 lb Application Disapproved by: Date for the following reasons Permit No. �i ^��� Date Issued i� �O ,X No.- .O�-/ "� ti-* .+.+`; Fee �O THE COMMOEALTH OF MASSACHUSETTS Entered in NW PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ,Yes } �l hpplication for �Bigaal �& !te�ril Construction permit ' p Application for a Permit to Construct(�Repair O Upgrade( )` Abandon O ( Complete System Individual Components ti, > ' Location Address or Lot No.0(1p G }1/�SSe Owner's Name,Address,and Tel.No. S _ Co+.,, - rY1,41 Assessor's Map/Parcel O c3-b �d �t�J 5Ar---4'iL^foZ 3 Installer's Name 4Address,and Tel.No. Designer's Name,Address and Tel.No. i3602 Type of Building: Dwelling No.of Bedrooms Lot Size lal �Q sq.ft. Garbage Grinder'(V,� Other \ Type of Building 646 e (.Se=Yv� No.of Persons Showers( ,)"'Cafeteria( ) Other Fixtures AA" Design Flow(min. equired) � gpd Design flow provided >� gpd )an Date Date 65 d-5 Number of sheets a Revision Date Title S ' Size of Septic Tanker Type of S.A.S. Description of Soil IK,r t br �• Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Kam. — Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and no;)>to place the-system in operation until a Certificate of ` Compliance has been issued by this B ar f Health._ ! t eJ. Date Application Approved Date 5 1 Application Disapproved by: Date i for the following reasons Permit No. r_ (� —GAO Date Issued 5 to ————————————————-- THE COMMONWEALTH OF MASSACHUSETTS y BARNSTABLE, MASSACHUSETTS Certificate of Compliance THISJS TO CERTIFY thaf'the On-site Sewage Disposal System Constructed ( - Repaired ( ) Upgraded ( ) Abandoned( )by ('lh at c3l­&'R" �`�'�C�>rosmS Pt (70 v i has been constructed in accordance l with the provisions of Tile 5 and the for Disposal System Construction Permit No. aC0(D CGc9. dated I , / nstaller '�-r'��� Designer �7' c-0'K- p#bedrooms Approved design flow gpd ` The issuance of thi pe it shall not be construed as a guarantee that the system willl fit ct�on�,7asdes gned. 1. Date ( U Inspector No. ? _(Q 0(3 Fee._ ) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwi5po5af �&pgtem Construction Permit Permission is hereby granted to Construq ( ) Repair ( ) .� grade ( ) Abandon ( ) System located at c�h a1 'PS50 �G4- t- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction mu t be completed within three years of the d e of this pe t . Date Approved b I i TOWN OF BARNSTABLE LOCATION !A1 ?s"'r�/�'�S 'T ✓C SEWAGE ## VU LAGE• 'C0 r4- ASSESSOR'S MAP & LOT 9----3 _ INSTALLER'S NAME&PHONE NO. S SEPTIC TANK CAPACITY LEACHING FACILITY: (size) NO.OF BEDROOMS BUILDER OR OWNER a s� PERMIT DATE: OMPLIANCE DATE: 3 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r `-3 1 C/ cX 3e93f ' Ma r, 27. 2006 10:46AM No, 0964 P. 2 Town of Barnstable Regulatory Services Thomas F. Geiler,Director • SARMABM � 1=619, �� Public Health Division � Thomas McKean;Director 2.00 Main Street,Hyannis,MA.02601 Office:.508-862-4644 Fax: 508-790-6304 installer &Designer Certification Form Date: 6 Sewage Permit# Assessor's Map\Parcel__j 9,16 3 Designer: 7V"M6 M11L f,,499/L i1171 Installer: Cd&S7"G 'd� GD Address: b pep Address: P D • f D X v On Al Cf, CM S7 pew was issued a permit to install a (date) (installer) septic system at 21.8 E n PaE CS Frr 4F based on a design drawn by (address) S . dated s (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and-the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if requirpe'd�was.,inspected and the soils were found satisfactory. :.,"�u. (Inst I s Signatu " . e er S azure) (Affix Designer's Stamp Here) PLE E 0 BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF MPLIAN -WILL-NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARN STABLE PUBLIC HEALTA DIVISION THANK YOU. Q\SepticMesigner Certification Form Rev 03-09-06.doe Town of Barnstable Health Inspector �tHE RegulatoryServices Office Hours 8:30—9:30 Thomas F.Geiler,Director 3:30-4:30 9&MMnB Public Health Division �Ar16 so. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 _- r Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE '" / ( a Date: May 25` 010 1. General Information: Size of Property: 0.44 acre lot Address: 268 Poponessett Road in Cotuit Map 019 Parcel 063 Name: LORI T.MARTIN Phone#: 508-737-7522 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms?NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Shosil existing rooms the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room' clearly. ." 3. Is the dwelling connected to public sewer? NO ""' o`' } }:a If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? co rn 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribu ' ublic supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Sig Date: z v Q:\GIv1D-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnest a 1.DOC f\Y PP McKean, Thomas Y From: McKean, Thomas Sent: Wednesday, May 26, 2010 11:33 AM To: Dabkowski, Cindy Subject: RE: 268 Poponessett Road- Septic Questionnaire Received The submitted floor plan is a sketch (no straight edge used) showing two bedrooms plus a third bedroom shown on a separate page in the amnesty apartment. This adds up to three bedrooms, not two. However, the original application was for two bedrooms, The septic system was designed for two bedrooms, not three. It may be undersized. Please ask the applicant to submit a 16 page septic system inspection report , please include an assessment of whether the existing system can handle three bedrooms. '7 ,v 1 1._--' i C.r''t:.�'.�� �,. �• "`fir..-'"s**m.d.-�^''' � `,:,�.> --�'"" y 1 '1 � t i -�•�v�� _. � a ..a... _._ ,..m. }. r �. w, If 1.7 _.. F J W Ila I II It-3 2 6 3 2 i f l II II IF � 11 II 2 2 iki 2 I I El �- - � N{�. U� ,?D I- i I ' � I . i 1 • c 38 _ e-< D Tell j ---- .� OZ-rs g Cyr IV t F t e� 7 ,• 31S f*is`' I I `` 32" 2 f W I w II II II00000023 II II II NEI . II II � II II ' II II I I —MN Y. 2 6. 2 O 1 O«11 : 5 O WGPM RARNSTRBLE BO NO„41692 P. 2 OF HEALTH Town of DaY'nstal-Ae 1�1� � BcalY6,inspector Regulatory Services office Hours 8:30—9:30 Thomas F.Geiler,Director 1:00—2:00 Public Health Division Thomas McKean,,Director 200 Main Street Hya=is,MA 02601 Office; 508.862-4644 , ' Fay: 508490"6304 ,A1� STY "APPLICANT-SEPTIC OVESTIoNNAME 1. General Information: Size of P ��y. Address- aU 8 MarQ1 I 'Parcel 00 w Name; Phone#: 7 - 2a, How many bedrooms exist at your property now? 2b. Are you p121131ing to add any bedrooms? If yes,hoc)many? J 2e, iow many bedrooms total are proposed at this property(including the amnesty 4 S' 2d.Please include a copy of the floor plans for the entire property-she_ the tin rooms in the home plus the proposed amnesty apartment and/or additio'ii". Pleasbet each room clearly on the plans. 3. Is the dwelling co= sad to public sewer? Ell S or NO �thcdw.e]3�id� is ccarrieoF�,tdpub7i¢suer;: u,�sEiou�' t$ian b , ,. .. ,�°•`;,.•`•.• a. LecBtion of dwelling is INSIDE or 0tPi D a Zone of Con �S��p bohc supply wells? 5. h the dwelling connected to an ONS278 -" or PUBLIC yYATER? 1 6, Is a disposal wofks consttttctwn permit oa file? YES nr NO 64. If ycs,how many bedrooms were approved according to this permit? Bedrooms. 7, Were any building permits obtained for eotutruction of additional bedrooms? YES or NO g• Is thcrc an engineered septic system pl=oa file at the Hcalth Division? YES or NO 9. Has the soptla sgstem bear inspected by a DEP certified iaspector within the last two years? YES or NO r • FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this r perty, Special Conditions . Q;/heada/r/rypJles/onbeesryapp �� 1 MAY, 26, 2010-11 : 51AM N0, 416 P, 3 -__ Page 6 of l 1 OFFICIAL INSPECTION FORM_NOT FOR VOILVNTA.RY AS8E:9SMjgTS SU8SURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM INFORM.A 17ON Prmpelt'ty Address: P o s R Cal ' Owner; berr ra Date of InsptctiQn: a ernher 7 200 RESTDENTIAL FLOW CONDITIONS Numbt:r of bedrooms(design); 3 Number of bedrooms(aotval): 3 DESIGN flow based on 310 CM[L 15.203(for example: 110 gpd x iP of bedrooms): 30 Number of current residents: _ Does residence have a garbage grinder(yes or no): No Ts laundry on a separate swage system(yes vrno):�—a iif Yes separate inspection required]Laura�Ysystem inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available Out z years usage(gpd)): Mgg & Sump lump(ycs or no): _Nw Last date of occupant)- _Unkr ,� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15,243): ----..gPd Basis of design flow(seatslpersons/sgtete.): , Grease trap present(yes or no): Industrial waste holding tank present(yet or no) Nan-sanitary waste discharged to the Title 5 system(ycs or no Water meter readings.if available: Last date of ocaapancy/use: OTHER(describe): GENERAL INFORMATION Pumpaug Records Source of information: N qwpler Was system pumped as part of the inspection(yeq or no): No if yes,volume pumped: ._--Zallons--How was quantity pumped determined? Ramon for pu nping, TYPE OF SYSTEM J Septia tank,distribution box,soil absorption system 5inglc cesspool Overflow cesspool Privy Shared system(yes or no) (ifyes,attach previous inspection records,if arty) lnnovative/Alternative ioChn41ogy. Attach a copy ofthe current operation and maintenance contact(to be obtained from System owner) Tight Tank . Attach a copy ofthe Dep approval Other(descnbe)i Approximate Age of all components,date installed(if known)and source of information: In 1 ed a/Z4 - er bydg and Were sewage odors detected when arriving at the site(yes or no): _lam 6 • A .MAY. 26. 2010 11 : 5]AM NO. 416 P, 4 3. � . .MA,V. 26. 2010_11 :S1AM / N0. 416—P. 5 r S�l�v pvlzkn:�-� 4x4Ll;� TDrnn-� W U \/ T clooF;� Town of Barnstable Health Inspector vpF1NE 1p Office Hours �. Regulatory Services 8:30-9:30 „ Thomas F.Geiler,Director 1:00—2:00 ,.r * BARN&rABLE �a Public Health Division '°lFn Mpl,p Thomas McKean,Director P 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: Address: C2-6 Z Mapo Parcel © b-3 LI Name: (�'yli(�— S Phone#: l 2a. How many bedrooms exist at your property now? 2b. Are you planning to add an bedrooms? If es how'man Y p g Y Y � Y } 2c. How many bedrooms total are proposed at this property (including the amnesty unit)? OvN Co 2d. Please include a copy of the floor plans for the entire property - sho g the existing rooms in the home plus the proposed amnesty apartment and/or addition'.' Please labels' each room clearly on the plans. 3. Is the dwelling connected to public sewer? �; S or NO "' If the dwellul rs connectedyto ublc sewer�skr uestrons#4�throu 9 below''= k� 'R 4. Location of dwelling is INSIDE or �OUTSIDE a Zone of Contri to_public supply wells? 5. Is the dwelling connected to an ONSITE� or t PUBLIC WATER? i 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. were-any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this r perty. Special Conditions ] ._ - 7 Q;/h ea l th/wpfi l es/a m nestyapp r r«� yt� s :r W C� FIRST FLOOR PLAN SCALE: Tim Scales Residence 268 Pompoue sc[Road Cxui[,MA tiOTES. ,01 r.�vNW� L � KITCHEIYET ��p�� 9� Bn�_ 92' V -- — --- -----A GNG DESIGN Inc. -- — — --- ----- UMHEATED "�} vouS 14 un BREAKF ST n HOBO 13'W1• � 2 �� 5 g2. 1 0 UIiHEATED BED RM. BATH 5cauo Rao 24-0• I65 mR N4Ra SY�CF 26•q' MAST& SECOND FLOOR AS BUILDS l FIRST FLOOR PLAN SCALE:1/4'-T-0• ( SECOND FLOOR PLAN SCALE:1/4•-1-0^ 2 .R. Tim Scales Residence 268 Pomponesset Road. Cotuit,MA NOTES: w:n.. Eca T.0 ' GIYG DE91GM,We a ' GH6 DPSIGI4 6c•cn.w.v. c1N t•1 w. M ❑ O L 32 8 —31 GNG DESIGN Inc., -- ------ ----- ---- 247 ONSET AVENUE nN P.O.Box 1200 ONSETVD.LAGE,MA 02558 •/�� TEL.� 508.743-0904 FAX 508-743.0903 gngdesign@comcast.net GNG CM1.CYW GNG Fol O AS NOTED c'IN e) A V 132. 1 1 13'-82' 2'_ •2 MN Sheet THie FIRST& SECOND FLOOR AS BLUDS .�rM1 Nnme.. oe. JUNE 6.2005 SM1rrl N-e. AMI SECOND FLOOR PLAN SCALE: 1/4' = 2 Page 6 of 1 I • O FFICUL INSPECTION FORM-NOT FOR VOLUNTARY ASS]ESS1V[EI"dTS yr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAMN Property Addreas: 20 Poponessert Road Cniuit MA Owner; .Ro ert Iranee Date of Inspection: September 7. 2004 FLOW CONDITIONS RES)DF,NTiAL Number of bedrooms(design); 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x V ofbedrooms); �3 00 Number of current residents: 0 Does residence have a garbage,grinder(yes or no): No is laundry on a separate sewage system(yes or no): ►'la [if yes separate inspection required] Laundry system inspected(yes or no): No_ Seasonal use(yam or no): No Water.meter readings,if available(last 2 years usage(gpd)): Unanallq& Sump Pump(ycs or no): .No_ Last date of occupancy: Unknown COMMERCIAVINi USTRiAL Type of establishment: Design flow(based on 310 CMR 15,203): >;nd Basis of design flow(seats/persons/sgif,etc:):_ Grease trap present(yes or no): Industri,l 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): CENERAL INFORMATION Pumping Records Source of information: Never pumped -Der owner Was,T,✓stem pumped as part of the inspection(yes or no): No if yes,volume pumped: �aa.11ons--How was quantity pumped determined?_ Reason for pumping: TYPI� 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 tecnnolOgy_ 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,date installed(if known)and source of information: Installed 2124195-per as built card Were sewage odors detected when arriving at the site(yes or no); No 6 o - ti a :�P gg Y b 1 t T oc . ""� a .in..s v - R�•� .C�� � �T z .......... .. — k +a - fyy If 0 W II 4 V-71' N� I II 3 II IT II II If 4 N 11 � II - - - - - . W I it N� II II N" � II II 2 � II II II I I • II. I - - , ° O r - � T� bq,� 7 .; j p 9 1 [� t. 1 h 9 J 'r3 9 li it it z 3 �.m ._ ° The Town of Barnstable BU � 16 39. Office of Community and Economic Development ,• ° a 230 South Street Hyannis,MA 02601 Office: 508-8624678 Fax: 508-8624782 � C-11 August 2, 2005 � :' +:r^i Mr.John C. Khmm,Town Manager CD ,ate Gary R. Brown,Town Council President X�, TM Barnstable Town Hall 367 Main Street Hyannis,MA 02601 co rn Re: Timothy Scales—268 Poponessett Road, Cotuit-a single-family accessory unit Gentlemen: This letter is to inform you that the Accessory Affordable Housing (Amnesty) Program has received a request for a project eligibility letter under the Community Development Block Grant (CDBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the criteria for the Local Chapter 40B Program. This office is reviewing the request. If the Town has any comments on the project,please forward them to me so that they can be addressed in the site approval letter. This letter gives you official notice of our receipt of the above application(s). We will issue a decision as to the acceptability of the sites and the consistency of this development within the guidelines of CDBG. Sincerel , ilizabeth Dillen rogram Coordinator Community&Economic Development cc: Town Attorney's Office Building Department cr Public Health Department j cn r� i I i i i i z(�l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 LOT y ' 117 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 268 Poponessett Road Cotuit, MA 02635 Owner's Name: Robert FraneyZiHi t... Owner's Address: a t .~n Date of Inspection: September 7, 2004 € Name of Inspector: (Please Print) James M Ford r> Company Name: James M. Ford + > Mailing Address: P.O.Box 49 ` ou Osterville,MA 02655-0049 -_,j rrt Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date:, September 13, 2004 The system inspector shall sub 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 or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 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 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,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 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 268 Poponessett Road Cotuit, AM Owner: Robert Franey Date of Inspection: September 7, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (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 necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end 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: Never pumped -per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 2124195-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 BUILDING 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 condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (locate 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 of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 TIGHT or HOLDING TANK: None (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: P-allons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 D-box was level and clean. No solids were present. PUMP CHAMBER: None (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.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 4 infiltrators (7'x 29)-per as built card 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.): The infiltrators were dry and clean. There did not appear to be any signs of failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: " Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 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. n I Q 0 ► QL a ;L 313 aq 3 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Poponessett Road Cotuit, MA Owner: Robert Franey Date of Inspection: September 7, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours map Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 TOWN OF BARNST_ABLE LOCATION S PUPPOt�lE55 !l —+�to SEWAGE# _ .VILLAGE a ul r ASSESSOR'S MAP&PARCEL ! (Q &3 ff,+ � S NAME&PHONE NO. D!}-QJl m m e U.y sm HS P 6!�t-o2 SEPTIC TANK CAPACITY I-00 G'•9'w n t LEACHING FACILITY:(type) 10h CTgkl'7 6 (size) 2a �L X -7 �W NO.OF BEDROOMS ?J OWNER I l morT t PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to.the.Bottom of Leaching Facility T zs Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Z b� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 300 Feet FURNISHED BY Fip�oNT of T h-I 30 3 r A 4 33 , i G3.Li . 2� TOWN OF BARNSTABLE LOCATION 24pg POPPOOESSP'Tj IZD.-�e SEWAGE# VILLAGE 6M/T' A•SSESSOR'S MAP&PARCEL /� 1&3 nN�NAME&PHONE NO. ,Uf172Myi !1/! AIL!je l 9jK 362—ZJ22 NS Pt-r—Tv2 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 2 — VM 6&ES' (size) NO.OF BEDROOMS '2— T3CZ OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Z S Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) y 3° u Feet FURNISHED BY fv_ACR a� .............. 14 A r 3 �- 2� g� 3 •. 30�� A • h 23 �, • 5-3� 41 - � : 4$ ' I � 1 �GC 06 3 r i Fims........�.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for DioVoottl Wor1w Tonotrnr#inn f amit Application is hereby made for a Permit to Construct ( ) or Repair (K an Individual Sewage Disposal System at: .., 6.....,1�� Q�� ..... .............. ----C-�!.=u .. �...............---------..............---------------•------...------ - o - ddrrss r Lot N i .. 1 U...................................................... -------�--.............iVL�Gct, !/Y►./1�1?Lt.S ---------- Owner Address Gc-uu ... ........................ GJ�tf�f�6�9--- �7.p.... ..:----�!11- -5.............. Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--_-- !�7 _.-----Expansion Attic ( ) Garbage Grinder (—)-AJO aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------- -- W Design Flow..................` ..............gallons per person per day. Total daily flow............___-7-7o_______..........gallons. WSeptic Tank—Liquid capacity 496-_gallo ism Length................ Width--------- Diameter................ Depth................ x Disposal Trench—No. ......../......... Width.................... Total Length.... Total leaching area................:...sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet...... FTC-_- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 94 •--------------------------------------------- -............ •---------------- ._..------------ ---........... ---......... ----.................... ..... --........ 0 Description of Soil........................................................................................................................................................................ x w x ---..........................................-......................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable._-_INSz�/2� _.._A- %.&tlCL_, ...�5 .�.r.7`! ±11�a pLtiS.l_�....... isL t ......../N -14� '-T!! -•----.. ` 1-'`--- � ,'L...._.....-•--•--•......... ......... 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 G:)mpliance h been issue b e board of health. / Signed ............G/` ~ ... .//L ........................... 1... Dace Application Approved BY a ... ..(v�. ..�. ...'.................................................................... Dace a,ey- -.eg • Application Disapproved for the following reasons: . ............................................................................ . ........................ ............................. Date PermitNo. ---------- ° . ....[ ------------------- Issued .......................... .................................... Dare q ` y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Bi-tivu!3Ml Worku Tunutrnrtiun rumit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: f ..... ..... . ......... ocation-Address Lot No L(jr f,1J .................................................... . Owner ,7 b Address W �S�O G�'Uct 1 C f�Ns; J GJ�-/ �B`� l�1J ✓� t v'l4 / LA S ,-� . ............. E Installer Address Type of Building Size Lot................ Sq. feet Dwelling—No. of Bedrooms.....S.2.n-__%��_---tz§�-------Expansion Attic ( ) Garbage Grinder (----�,Q0 Other—Type Other fixtures it.............•---------•-----••-• No. of...persons ----- --------•......Showers-••-•-•-•-• ......-••••............... Ga yp g p ( ) Cafeteria W Design Flow..................... ..............gallons per person per day. Total daily flow...............�'3�._....__.........gallons. WSeptic Tank—Liquid capacity/�OY)----gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No. -------Z......... Width----:7_....___.___ Total Length.. .... Total Total leaching area....................sq. ft. Seepage Pit No------------- ------- Diameter.................... Depth below inlet-----_/•lff-_ ... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by..................•------------•---------------------------...---------••• Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........:-_-___---_-_--- a •--••-•-••-••••••.........•-••-••••----••-••--•---••••••-••••--•----•-••••......•-----••-••...---•-•......................................................... ODescription of Soil........................................................................................................................................................................ W U ........••-•-•-•--•••---...••••••--•---•-•--••--•••-•----•-----•-•-•-••----••-•--•-----•••....------• --•-••••-•--------•--•--------••••-------••••••••-•--•----•---•••--•••-•-••••--••-•-•-••••--•--••. W -------•-••-----------------------•----------------------------------------•- -------------•------------------•-----.....-----....-------••••-•---------•-••-•••••-• - U Nature of Repairs or Alterations—Answer when applicable._-.l��.�/^.��:..._A_...1.w a._C.J...,�.cl��•�,_-7/l±Jk� �b 1.l........•-•c 1c...t.....;. !L..........� U?`-1_�' .!1 -;Yr�l.S'• l f........__. 711!�1��......................................... 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 has been issue by . e board of health. Signed -----------/. h�d� ....... .................... ............................ - r� Application Approved By ------------- -� v-. - y.. ._.�, -.�(-- - . Date f r � Application Disapproved for the following reasons: ...................... ................................................... . ................ ..................... -- . ......... . . ................. ......... ................. ............................................................. ......... ........................................ Permit No. ..........C/._ ..-....� Issued --------------------------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 'ClErtifir 2te of Q-11omplianre THIS IS TO CERTIFY, ThatAe Individual Sewage Disposal System constructed ( ) or Repaired (c't) by......... ---- Ad o✓ ------ --------------------------- ------------------- -- --------------------------- -------------------------------------------------- Installer at ............... ........... ............._....... .� 77- .. ... /----o,a ....... L V.t T has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ........ .........[&_-)..... dated ........_......................._............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----...... -4 -4 �1 V �--------------------- ----- Inspector ...........................�,'............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.....,.:. �. .. FEE.... �.... Disposal Works Tunutrudiun "rrmit Permission is hereby granted....................... U<':G c.n-_!�••-___••..•C..,�1s C-'7 G'u to Construct ( ) or Repair an Individual -Sewage Disposal System atNo................................................... ......... w ass•--- -------- --.--- C G-7y / Street as shown on the application for Disposal Works Construction Permit No. Dated............ ...".......�............ C� --------- Board of Health DATE................ ......... -y-••' .................................. FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS TOWN OF BARNSTABLE LOCATIO v �G E' S' _ v� SEWAGE VILLAGE <C> Uiy� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.WI'rU�� SEPTIC TANK CAPACITY /6)DO OQ/ ��� - l LEACHING FACILITY:(type)--/") � ci/'S S�� (size) 7 �o�J NO. OF BEDROOMS PRIVATE WELL R PUBLIC WAT _ BUILDER O OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes �. ._. ...No_._. p B �,- 30,' Q1'a9 3 .. TOWN qF BARNSTABLI,E��- Z LO ,iT10N � �d O � 2�- S� SEWAG # (iiT,LAGE C On ASSESSOR'S MAP & LOT O 1°l' UV3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK f CAPACITY LEACHING FACILITY: (type) Y• /^r+ /A od (size) x a NO.OF BEDROOMS 3 n SUILDER OR OWNER `� • rA�1+�'1 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ,Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leaching facility) , Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi facility) Feet Furnished by i/1Sj2eojun ro/� roA A � i v1. L a ag a� 3 33 a9 s TOWN OF BARNSTABLE LOCATIO G Q ASS SEWAGE VILLAGE �[� c ASSESSOR'S MA 6 LOT INSTALLER'S NAME & PHONE NO 2 �414/ �/m rl 7�e jSEPTIC TANK CAPACITY 1606 aQ/ss?,6�C LEACHING FACILITY:(typeiz;r7//?/G/'S (�) (size) NO. OF BEDROOMS PRIVATE WELL R PUBLIC WAT BUILDER O =OWNE:��) d DATE PERMIT ISSUED: za_ DATE COMPLIANCE ISSUED: _ VARIANCE GRANTED: Yes No 30.' E:t I I 3 l VICINITY MAP N.T.S. solL LOG SOIL LOG DESIGN FORMULA: TEST FtOLE#1 - ELEV.=38.2± TEST HOLE 2 - ELEV.=38. 1 ± * OTHER STRUCTURE, EPTH FROM BOTTOM OTHER STRUCTURE,(NO GARBAGE GRINDER ALLOWED WITH THIS DESIGN) DEPTH FROM BOTTOM 3 „ ` 5 SOIL SOIL TEXTURE SOIL COLOR SOIL STONES, BOULDERS, SURFACE OF LAYER SOIL SOIL TEXTURE SOIL COLOR SOIL STONES, BOULDERS, Y s SURFACE OF LAYER HORIZON USDA MUNSELL MOTTLING CONSISTENCY % GRAVEL INCHES HORIZON (USDA) (MUNSELL) MOTTLING CONSISTENCY % GRAVEL SYSTEM REQUIRED PROVIDED (INCHES) ELEV. (USDA) ( ) ) (INCHES) ELEV O»-5" 37.8 0 LOAMY SAND 10 YR 2/2 NONE FRIABLE -0»-6" 37.6 0 LOAMY SAND 10 YR 2/2 NONE FRIABLE DAILY FLOW: 4 r TIM SCALES 2 BEDROOMS C�? 110 GPD/BEDROOM 220 GPD 5»_g" 37.5 E LOAMY SAND 10 YR 4/1 NONE FRIABLE 6"-g" 37.4 E LOAMY SAND 10 YR 4/1 NONE FRIABLE N SEPTIC TANKS: 8"-14" 37.0 A LOAMY SAND 7.5 YR 3/4 NONE FRIABLE 8"-15" 36.9 A LOAMY SAND 7.5 YR 3/3 NONE FRIABLE f� r 220 GPD x 200% 440 GAL. 1,500 GAL 10 YR 4 6 FRIABLE 10 YR 4 6 FRIABLE » » 14 -38 35.0 B LOAMY SAND / NONE 15 -36 35.1 B LOAMY SAND / NONE LEACHING AREAS: » 10 YR 5/4 LOOSE40 LOOSE t 38 -126 27.7 C MEDIUM SANDNONE 6 -138 26.6 C MEDIUM SAND 1 R 6/4 NONE 0 Y 2 TRENCHES @ 24' LONG x 2' WIDE ` fie t 2 EFFECTIVE DEPTH SOIL EVALUATION BY: DAVID D. COUGHANOWR, R.S. SOIL EVALUATION BY: DAVID D. COUGHANOWR, R.S. 24'+2')x2x2'x 2 TRENCHES 208.0 SF f� SIDEWALL:( WITNESSED BY: DON DESMARAIS, HEALTH AGENT, BARNSTABLE BOARD OF HEALTH WITNESSED BY: DON DESMARAIS, HEALTH AGENT, BARNSTABLE BOARD OF HEALTH 4 xTRENCHES11, 2005 M• (2 2 )x 2 304 0 SF 7 . 11, 2005 BOTTOM: DATE: OCTOBER DATE: OCTOBER TOTAL PERMIT: #1112 PERMIT: #11127 a PERCOLATION TEST: DAVID D. COUGHANOWR, R.S. PERCOLATION TEST: DAVID D. COUGHANOWR, R.S. SITE LEACHING CAPACITY. WITNESSED BY: DON DESMARAIS HEALTH AGENT BARNSTABLE BOARD OF HEALTH WITNESSED BY: DON DESMARAIS, HEALTH AGENT, BARNSTABLE BOARD OF HEALTH . 71.0 GAL DATE: OCTOBER 11, 2005 ' ' DATE: OCTOBER 11, 2 SIDEWALL• 208 SF x 0.74 GAL/SF 153 9 GAL BOTTOM: 96 SF x 0.74 GAL/SF 005 PERCOLATION RATE: LESS THAN 2 MIN/INCH IN C SOILS, NO GROUNDWATER ENCOUNTERED PERCOLATION RATE: LESS THAN 2 MIN/INCH IN C SOILS, NO GROUNDWATER ENCOUNTERED ��� TOTAL: 220 GAL 224.9 GAL POPPONESSETT MAP 19 � '� i � ROAD LOT 53 MAP 19 / / THREE MANHOLE COVERS LOT 54 SEE SEPTIC TANK DETAIL BRING MINIMUM OF ONE COVER TO WITHIN 6" OF FINISHED GRADE. BRING OTHER COVERS 4" PERFORATED PVC, SCH 40 i TO WITHIN 12" OF FINISH GRADE. @ 0.5% SLOPE WITH 3/8" MIN. / PROPOSED TRENCHES AND 5/8" MAX. PERFORATIONS 17.8' � 2' WIDE X 24' LONG SLAB EL. = 39.33 11.8' �{H2 2' EFFECTIVE:..DEPTH - 3/4" - 1-1/2- DOUBLE A&E FIRM 4 PLACES F.G.=39.0 FINISHED WASHED CRUSHED STONE 11.0' I-- RESERVE AR- i GRADE MIN. 2% -� F.G.=38.62 2" OF 1/8"-1/2" DOUBLE 6" SUMP SLOPE WASHED PEA GRAVEL TURNING MILL I RESERE AREA I PROPOSED / F.G.= 38.0 4 OUTLET 2' LEVEL TOP OF PEASTONE " - � DISTRIBUTION BOX 2% ELEVATION= 35.32 CQNSiTLTANTS, INC. 11.1 �w2� 1500 GALLON 2% 2% 4" PVC CAP DEVELOPERS, ENGINEERS / 10.0 QO; INV.OUT . AND CONSTRUCTION MANAGERS PROPOSED O <c, T INV. OUT INV. IN SEPTIC TANK 0 1,500 GALLON �" 35.75 35.24 INV. END 68 T[rPPER ROAD UNIT 3 o Q 35.49 INV. IN �+ 34.39 PO BOX 1159, SANDWICH, MA 02563 25.7' SEPTIC TANK INV. IN INV. OUT 34.63 2' PHONE: (508) 888-4383 - FA% (508) BM-42" A3 0, 35.04 34.87 BOTTOM OF � 12.9 10.1, TRENCH BOTTOM OF MAP 19 ELEV.=32.39 24' -I TRENCH SITE ADDRESS LOT 64 12.1' MAX BOTTOM OF TRENCH LEVEL FOR ENTIRE LENGTH ELEV.=32.39 LEVEL STABLE EXISTING R 6" STONE BASE 14.1 MAX GARAGE PROPOSED DISTRIBUTION BOX SHALL HAVE A MINIMUM NOTES: 268 P O P P O NE S S E TT FOUNDATION 1 BEDROOM Z SUMP OF SIX INCHES AS MEASURED BELOW APARTMENT � THE OUTLET. INVERT ELEVATION. 1. SEPTIC TANK SHALL BE EMBOSSED WITH SEAL ROAD STATING CONFORMANCE WITH ASTM C 1227-93. MAP 2 (OVER Q N COTUIT MA LOT 62 GARAGE) � � 2. ALL SEPTIC SYSTEM COMPONENTS SHALL BE x O -0 TYPICAL SEPTIC SYSTEM PROFILE 2 Lo DESIGNED TO WITHSTAND H-10 LOADINGS. 39.2 � SCALE: N.T.S. SEPT-1 3. SEPTIC TANKS SHALL BE PROVIDED WITH AT LEAST THREE 20" DIAMETER MANHOLES WITH READILY REMOVAPI IMPERMEABLE COVERS OF DURABLE MAP 19 LOT Z 63 r�. �.a-�__ - .MATERIAL. S U B M ITTALS 19,392 S.F. 3" MIN. 20 MIN. W F_ cn 6" MIN. 0 �2" MIN. O 1 O NO DECK 24„ I �- 1`0" MIN. MIN. CONTRACTOR TO INSTALL CORROSION RESISTANT GAS BAFFLES BY TUF-TITE, PATIO OR EQUIVALENT APPROVED BY THE R ENGINEER, ON OUTLET TEE EXISTING 3 BEDROOM U HOUSE EXISTING A 05/24/05 ISSUED FOR P RMIT cr oaa GAL TYPICAL SEPTIC TANK PROFILE 3 a- SEPTIC TANK SCALE: N.T.S. SEPT-1 PROFESSIONAL STAMP EXISTING EXISTING DISTRIBUTION BOX. INFILTRATORS (4) o 0 7'x 29' \�./\ III=III=4" LOAM AND SEED OR PAVING=III=1_ S - ---=--� !-1 I I 111-111-111-j 11-111 111-111-1 a-u i 111-1 CLEAN BACKFfLL 2" LAYER OF GENERAL NOTES: N . E 1 i _38 (9" MINIMUM 1. ALL DIMENSIONS ARE PERPENDICULAR TO THE PROPERTY LINES. ) DOUBLE WASHED S �__-------- " . . EA STONE WITH THE STATE P ONE 2. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN COMPLIANCE W 'E SANITARY EXISTING 000 CODE TITLE V AND THE BOARD OF HEALTH REQUIREMENTS. DRIVEWAY 6' C 3. ANY CHANGE TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND DESIGN ENGINEER. 82.1 N .$ INV IN 4. BEFORE BACKFILLING THE SYSTEM, THE CONTRACTOR SHALL NOTIFY THE DESIGN ENGINEER N 6d32' 0.00 E O > C7�C� » AND BOARD OF HEALTH TO INSPECT. 0 n " © }" 6 PERFORATED 5. HEAVY EQUIPMENT SHALL NOT TRAVEL OVER DISPOSAL SYSTEM DURING OR AFTER CONSTRUCTION. TT -L/ SCH 40 PVC 6. TIGHT JOINT T.J. PIPING SHALL CONSIST OF POLYVINYL CHLORIDE PVC PIPE SCHEDULE 40. PPQNESSE c> oo o ( > ( ) ' PO 2•0' ca © 3/4" TO 1-1/2" SHA ALL PIPES M�CHANICADLL� SOUND AND TAGHT.TO BE WATERTIGHT, ALL CONNECTIONS AND JOINTS DRAWN BY: SRS - MIN DOUBLE WASHED C, 7. PROPERTY LINES FOR LOT (MAP 19, PARCEL 63 ) ON DEED RECORDED 1N DEED BOOK 15899 PG.001, STONE AND COMPILED FROM DEEDS ON RECORD AND PLAN RECORDED IN THE BARNSTABLE COUNTY REGISTRY MAP PLAN 94-47 CHECKED BY: M.F.J. GRAPHIC SCALE COCCI 8. THE DESIGN ENGINEER SHALL CERTIFY INSTALLATION. 9. PARCEL SHOWN ON ASSESSORS MAP 19 LOT 63 AND IS ZONED RF (RESIDENTIAL DISTRICT) PER PROPOSED SITE PLAN 1 20 0 �o zo 40 - SHEET TITLE: TOWN OF BARNSTABLE ZONING MAP. SCALE: 1 » = 20' SEPT-1 2.0 . 10. LOT IS SERVED WITH TOWN WATER SERVICE. 11. SUBJECT PROPERTY LIES WITHIN A TOWN OF BARNSTABLE. AP DISTRICT (AQUIFER PROTECTION OVERLAY DISTRICT). 12. SUBJECT PROPERTY LIES WITHIN A TOWN OF BARNSTABLE RPOD DISTRICT (RESOURCE PROTECTION OVERLAY DISTRICT). PROPOSED SEPTIC BOTTOM OF TRENCH 5 MINIMUM IN M M SEPARATION 13. PROPERTY IS LOCATED IN FLOOD ZONE C, PER FIRM MAP 25001 0018 D, DATED JULY' 2, 1992. SEPTIC SETBACKS (MI_N.1 FROM DESIGN PLAN GROUNDWATER 14. GARAGE:. FOUNDATION IS EXISTING. LEACHING TRENCHES TH TEST HOLE LOCATION MAINTAIN 6.0 FEET 15. ALL DISTURBED AREAS WILL BE LOAMED AND SEEDED IMMEDIATELY ;UPON COMPLETION OF CONSTRUCTION. 10' PROPERTY LINES BETWEEN TRENCHES 16. CONTRACTOR TO OBTAIN REQUIRED PERMITS. 20' BUILDINGS EXISTING STOCKADE FENCE 17. IT IS THE CONTRACTOR'S RESPONSIBILITY TO NOTIFY DIG-SAFE AND ALL UTILITY COMPANIES PRIOR TO CONSTRUCTION 100' WETLANDS X 62.5 EXISTING SPOT ELEVATION - FOR LOCATION OF ALL UNDERGROUND UTILITIES AND UTILITY COMPANY APPROVALS. - - -10- - - - EXISTING CONTOUR 18. ALL EXISTING UTILITIES SHOWN ARE APPROXIMATE ONLY AND ARE .NOT WARRANTED BY THE OWNER AND ENGINEER SEPTIC TANKS 10 PROPOSED CONTOUR TYPICAL LEACHING TRENCH DETAIL 4 TO BE CORRECT, NOR DO THE OWNER OR ENGINEER WARRANT THAT ALL UNDERGROUND UTILITIES ARE SHOWN. SHEET NUMBER: 10' PROPERTY LINES 19. CONTRACTOR TO PROTECT ANY UNDERGROUND UTILITIES FROM BEING DAMAGED. SCALE: N.T.S. SEPT-1 20. PROPERTY LINE INFORMATION IS COMPILED FROM DEEDS AND PLANS OF RECORD AND IS NOT THE 10' BUILDINGS 100' WETLANDS SEPTml RESULT OF A FULL BOUNDARY SURVEY.