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HomeMy WebLinkAbout0009 PRUDENCE LANE - Health '7 9 Prudence Lane Cotuit A 040 059 -- - �.- ---- _ i i OL16 0C- j Commonwealth of Massachusetts l Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments } 9 Prudence Lane Property Address h�3 Keith Sexton Owner O I"1 wner's Name information is r• required for every Cotuit MA 02635 7-24-18 page. City/Town State Zip Code Date of Inspection h•� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 1311 a ��ut�ttl�lir�n use only he tab on the computer, �F 1. Inspector: oy> q key to move your . cursor-do not 3 �yG James D.Sears _�: JAMES N use the return key. Name of Inspector Ca ewide Enterprises Company NameTtF 153 Commercial Street 4,4L .....S Company Address Mashpee CltylTown MA 02649 State Zip Code 508-477-8877 S 1623 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �_e� jg� w- 7-25-18 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I�� c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 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: The system is a 1500 Gal. Tank D Box and four chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is Cotuit MA 02635 7-24-18 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due o broken or obstructedpipe(s) or due to a broken, settled or uneven distribution box. System will t pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced . ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6YI6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 c Commonwealth of Massachusetts ,/p Title 5 Official Inspection Form 1 <io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in UEEq=is less than 6" below invert or available volume is less than %day flow J,�14C#IvC t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 c Commonwealth of Massachusetts 69 Title 5 Official Inspection Form aI e Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Prudence Lane `r Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or El ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system'is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form t a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Prudence Lane `J Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health •❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ❑ ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is Cotuit MA 02635 7-24-18 required for every State Zip Code Date of Inspection page. CitylTown D. System Information Description: 1500 Gal. Tank D Box and four chamber's. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No NA Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form ' t1I; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is Cotuit MA 02635 7-24-18 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 Permit # 2001 -657. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 26" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): water supply well or suction line: Distance from private pp y feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pi ein is 4" PVC SCH - 40. Septic Tank(locate on site plan): 16" Depth below grade: 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 1500 Gal. Precast H-10 Dimensions: 1" Sludge depth: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" OilScum thickness Distance from top of scum to top of outlet tee or baffle 8° Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt- Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tankand covers at 16" below grade. In and outlet tee's. No sign of leakage or over loading Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc,): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every COtUIt MA 02635 7-24-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-3' below grade w/cover at 16". Box is clean and solid w/two line's out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form .� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is Cotuit MA 02635 7-24-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): Leaching is four 500 Gal. dry well chamber's w/3'stone. Chamber's are wet on Bottom. Clean like new. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Prudence Lane V Property Address Keith Sexton Owner Owner's Name information is COtUIt required for every MA 02635 7-24-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Y t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments mot;- 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE "�< ©P LOCATION 420,e 44 e,1 6: SEWAGE # cZCK)I <P S 7 VILLAGE (V,-)4 ' t ASSESSOR'S MAP & LOT 0 O 0 INSTALLER'S NAME&.PHONE NO. SEPTIC TANK CAPACITY IS-0 0 6d¢L LEACEN FACILITY: (type) Rio j)e y w c a! (size)(V) Too 6,41 NO. OF BE ROOMS BUILDER OR OWNER C-I# PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I B 4C I � S-1, � c 43 - bl Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Prudence Lane u Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 10, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9-18-01 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: T.H.on Design plan 10' no G.W.. Bottom of chamber's at 6' below grade. Bottom of chamber's at 4'+ above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Prudence Lane Property Address Keith Sexton Owner Owner's Name information is required for every Cotuit MA 02635 7-24-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION Olt 4-ah9 SEWAGE # 0100( —�57� VILLAGE (9oh., t ASSESSOR'S MAP & LOT QY0 94 1' INSTALLER'S NAME&PHONE NO. -Yea tY- S` �h;c!�f C J-o S) f 2-0 -< o SEPTIC TANK CAPACITY LEACHING FACIL=: (type) H/0 .tW c.Q cl t (size) S-06 6 Al NO.OF BEDROOMS BUILDER OR OWNER KC ik S&K VA PERMITDATE: COMPLIANCE DATE: _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i� No.�^ ��!.� } ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprfcation for Migogal *pgtem Congtruction Permit Application for a Permit to Construct�<Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. �t) �LYs C Xr, Ow er's Name,Address and Tel.No. Assessor's Map/Parcel C- t"` srn oo �► 6Q r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. "'bwV OA19e_ Type of Building: Dwelling No.of Bedrooms of Size (AC-sq.ft. Garbage Grinder( ) Other Type of Building E No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /,Y e-t o gallons per day. Calculated daily flow `'t 40 gallons. Plan Date .- ciet 000 Number of sheets Revision Date Title V&1 Q jr-e Size of Septic Tank / pe of S.A.S. Description of Soil A/ 1u Q, 4 YU� Nature of Repairs or Alterations(Answer when applicable) Va} COa �,tal n'��/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of T' 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y s Board f Signed Date Application Approved b Date Application Disapproved for the following reasons Permit No. l���- t�-.�^� Date Issued .,,,, ��.;. ._.v.''ice.. ,,v..wae.aw ;- f .`•,._' •,.. � 'y - No 0,0,04 4 1: w.. Fee _ ' LTH OF MASSACHUSETTS Entered in computer: THE COMMONWEA P, PLIC�HEALTH DIVISION,-TOWN OF BARNSTABLE., MASSACHUSETTS s r Ti 21pplication for Diopoof *potent ttCongtruction Permit - r Application for a Permit to Construct PQ Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ) � � Owner's Name,Address and Tel.No. . Assessor's Map/Parcel /�,��1 qq �/1 a i"' b "IsR c( jf Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. cy b 1 rj T Type of Building: Dwelling No.of Bedrooms of Size G ( -sq.ft. Garbage Grinder( ) 4 Other ape of Building No.of Persons ` Showers( ) Cafeteria Other Fixtures µ Design Flow• gallons per day. Calculated daily flow 440 gallons. Plan,-Date.r�QeP l d .'0091 Number o sheets , + iRevision Date Title v d� CIc E ?Ui�.� '" l - t , 7 Size opTank ye of . t Description of Soil; /V' � j t/yy ft) Nature of Repairs or Alterations(Answer when applicable) � � V. �, 119 M U f 'I� Y.'fir'a.7� :! 1 j 3 _ .. ) 1 �.w.r. --.� .. 'Y s .r_[• -G{ ;r.. L-+Litt - D,ate"%st inspected / Jf �4 Agreement: The utidersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the�px_.o.,visions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by/this Board Wqth. Signed `i4 f Date Application Approved b Date Application Disapproved for the following reasons Permit No. e,4,00,: " Date Issued_141 " - --==—==1—=--=---------------------------- ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,t thepn-site wage Disposal System Cons r cted( )Repaired( )Upgraded( ) Abandoned )by U at I 0 0 X_ eY' 2 i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permito Installer Designer The issuance of thi permit shall not be construed as a guarantee that the sy to Vwiljunctio esigned. Date Iu Inspector 4,v' ---_---- ------————————————---—— No.�l rl +s ��' q�r Fee� Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS , Migooar bpgtent Con!6tru' rtion Permit Permission is hereby ranted Cons ct( )Repair( )Upgrade( )Abandon( ) System located at t�l 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 must be completed within three years of the date of this permit. Date: Approved by TOWN OF BARNSTABLE e°C< ©P LOCATION `Z „4-eel t 4 An 9 SEWAGE # ,200l -(�S 7 VILLAGE &oil,,i t ASSESSOR'S MAP & LOT(9 ® 0 INSTALLER'S NAME&PHONE NO._�c b tf S` Yh;,IWJ SEPTIC TANK CAPACITY _ IS-0 0 66¢� ,/1 j LEACHIN FACILITY: (type) Cd!U 1W ci ell (size)(/e / FO6 6A1 NO. OF BE BUILDER OR OWNER C I t c-X 6 h q PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by j 2 A _2s ;,, ARSa iI The Sc6t& 2 7' 8" x 4' • 1120 Sq. Ft. W E S T C H E S T E R M ,0 D U L A R H 0 M E S 16' x 40' Unfinished Second Floor • 640 Sq. Ft. First Floor Second Floor (Suggested Layout) i ROOF DINING LIVING ROOM MASTER ROOM 14'0"X13'1" BEDROOM - - WALK-IN WALK-IN 10'5"X 13'1° 14'3"X 13'1 CLOSET CLOSET 27'8" BEDROOM 2 LINEN oN BEDROOM 3 160" 12'8"X.16'11" 13'11"X16'11" - w BATH D. I n 10 1 rL--KITCHENL d 0 j t 10'8°X 13'1 ENTRY O LIN: O t 77 I L i It0 3 0° BATH 0 ROOF OPTIONAL KITCHEN a 40'0" I 40'0" z • Luxurious First Floor Master Suite • 4-3046 Floor Windows • 1 1/2 Baths Interior Fireplace Andersen • Formal Entry Foyer Consult an Authorized Westchester u' Formal DiningRoom Builder for a Complete List of Options /""'~��, ® Feawring Andersen® Tilt-Wash Windows ESTCMESTER MODULAR ONIF� ES INC. • Formal Living Room • Artist's renderings and Floor Plan Dimensions are L approximate.All specifications must be Written in the 30 Rea aDS Mill Rd.'! WI❑ dale,New York 12594 • Spacious Eat-in Kitchen with Pant g g p �' Contract.No oral conditions. (800) 832-3888 • (914) 832-9400 www.westchester-modular.cotn - — s3.5' SYSTEM PROFILE TEST HOLE LOGS TOP FNDN AT E L. (NOT TO SCALE) ACCESS COVER TO WITHIN 6 Or FIN. GRADE ACCESS COVER (WATERT.IGHT) TO ENGINEER ARNE H. OJALA, PE MINIMUM .75, OF COVER OVER PRECAST /` WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 61 5' ED BARRY RTE 28 WITNESS: _ 2' DOUBLE WASHED PEASTON t 60.5' FOR PIPE_ IRSTLEVEL 3� MAX. DATE: SEPTEMBER 18 2001 RUN - PERC. RATE <. 2 MIN/INCH LOCUS PROPOSED 1500 59.0' GALLON SEPTIC 5 .7 CLASS I SOILS P# 10062 PRUDENCE LANE 00 60.0 TANK <H- 10 ) GAS O O C7 O O m BAFFLE 58.52' o0 58.35 0 58.17°'° © C7 O C] L7 C3 O t� C7 3' AT SIDES A 0 r_7 E] C1 0 2.5' ENDS P MIN 2_.% SLOPE) �6' CRUSHED STONE OR MECHANICAL 217r ©+� © 56.17' a��� m COMPACTION. (15.221 [23) 3/4 TO 1 1/2 DOUBLE WASHED STONE 4 ELEV. oo� DEPTH OF FLOW = 4 (-2-5/ SLdPb 0-- 61,5' - 61'7 TEE SIZES, 0 & A O & A INLET DEPTH = 10" LS L.S 3" 1OYR 2/2 3" 10YR 2/2 LOCATION MAP NTS OUTLET DEPTH = 14 . E FOUNDATION- 10' SEPTIC TANK 75' D' BOX 20' 4 17 LEACHING 26'f FS S ASSESSORS MAP 40 PARCEL 59 FACILITY 6op 10YR5/2 g" 10YR5/2 ZONING DISTRICT: B B LMS LMS YARD SETBACKS: ° „ 10YR 6/6 10YR 6/6 � FRONT = 30' 3 ' 6 36 _ 58 5 58.7 SIDE - 15 51.5 GROUNDWATER EXPECTED AT EL. 30t REAR = 15' C C PLAN REF. - LCP 22824 D 4.1 63.9 MS MS FLOOD ZONE: C + 10YR 6/6 10YR 6/6 �L �$ L=66.06' \ �, R=40.03' V4 63.1 rA �.+ + 62.4 6 \ 64 + 64.3 s + .5 \ 120" 51.5' 120" 1 1 51.7' - 63.6 � �61.7 BENCH MARK CTR. OF C.BASIN NO WATER ENCOUNTERED NOTES: EL. 60.7 SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED > 1. DATUM IS APPRQXIMATED FROM QUAD 2' '(+ 64.2 0 --`"' DESIGN FLOW: 4- BEDROOMS (110 GPD) = 440 GPD 2, MUNICIPAL WATER IS AVAILABLE .+ .1 s _ LOT 72 7 USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8' PER FOOT. 26,755t SQ. FT. �DEN DWELL, yo3 SEPTIC TANK: 440 GPD 1 = 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H_10 0.61t ACRES \ 5. PIPE JOINTS TO BE MADE WATERTIGHT. 60.6 USE A 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. .�� �'" '� 4 LEACHING: ENVIRONMENTAL CODE TITLE V. g�, 2(39 + 10.83) 2 (.74) = 147.5 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 63.3 62.8 GAR SIDES:p' 62 TO BE USED FOR ANY OTHER PURPOSE. +b`1<9 \ 60.4 BOTTOM: 39 x 10.83 (,74) = 312.5 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4# PVC. sqgyp, zk \ L=37.17'R=40.00' TOTAL: 621 S.F. 460 GPD b3.8 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT \� � �-" INSPECTION BY BOARD ❑F HEALTH AND PERMISSION OBTAINED + 1. i USE (4) 500 GAL. LEACHING CHAMBERS WITH 3' STONESTH2 / 60.2 AT SIDES AND 2.5' AT ENDS FROM BOARD OF HEALTH. / / ��9• o 63.5 � '/ 60.0 + 62. + 61. / 61 59.6 LEGEND TITLE 5 SITE PLAN 60 ,/ 100.0 PROPOSED SPOT ELEVATION OF TH 1 h / 2.1 �� 59.3 Q� 100x0 EXISTING SPOT ELEVATION LOT 72 PRUDENCE LANE �o y IN THE TOWN OF: + 61.6 �, /� 00 PROPOSED CONTOUR h �� (COTUIT) BARNSTABLE61 6 q S / `� 100 EXISTING CONTOUR o , / PREPARED FOR, ETH SEXTQN s 30 0 130 _ 90 59.3 BOARD OF HEALTH ' + APPROVED DATE MA SCALE: DATE: 1 At /04 off sob-36i*454 1` fax 508 362� f ��tr OF of � R do wn cape engineering, Inc. q�� c� �r A N ARNE H. GH. Z OJALA OJALA y t CIVIL ENGINEERS e CIVIL ti � Ncs.263413 ,o�r N 0792 En ����• LAND SURVEYORS r . EYOR � s 939 vain st. yarmouth, rya 02675 r`N 01-217 �� H. OJALA P.E., P.L.S. DATE