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HomeMy WebLinkAbout0010 PUTNAM AVENUE - Health - -`_ _ 71 - 1 0 Putn,aniAvenue cotuit _- -- ---- - �__ -�-- - A= 036-033 � , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Putnam Ave " GSA' IMS�1 Property Address Peter Hallemeier i� Owner Owner's Name / Ila information is V 'rl required for every Cotuit Ma 02632 6-11-18 , page. City/Town State Zip Code Date of Inspection r,.ewl Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I y1 ! use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation kCompany Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13747 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and,complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-11-18 Inspector'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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 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 was in working order at the time of inspection. 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•3/13 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 M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 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 to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 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 ❑ 0 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 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A ° 10 Putnam Ave M Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of.a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Putnam Ave M • Property Address Peter Hallemeier Owner Owner's Name information is Cotuit Ma 02632 6-11-18 required for every , page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® 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): 7 Number of bedrooms(Actual) 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 829/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage See below 9 ( Y 9 (gPd))� Detail 2016- 199,OOOgallons (520GPD) 2017-63 000 allons (172 OOOGPD) Sump pump? ❑ Yes ® No Last date of occupancy: Weekends onlyDate Commercial/Industrial Flow Co nditions: onditlons: Type of Establishment: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: n Date Other(describe below): General Information Pumping Records: Source of information: Owner-last pumped 2016 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information"(cont.) Approximate age of all components, date installed (if known)and source of information: 2007 per plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 3, . 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 Dimensions: 2000gallons Sludge depth: 6 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. CitylTown 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 34" Scum thickness 1 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 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 11 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA * 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17 F L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (5) 500 gallon ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Leaching was dry when viewed with no high staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 tins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Putnam Ave M Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 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: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C/011 I 1 Driveway A Cl 2 Garage Al-11.6' A2.20' A3.59.6' A4.52.2' 1 to C01 =16.3' A5.74.6' 2 to C01 =27' 3 . $1.35' 1 toC42=42.9' O o $2.33' 2toCO2=11.6' 4 i33.60.4' $4.58' $5.76' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is Cotuit Ma 02632 6-11-18 required for 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 high ground water: GW @ 144" feeee t 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: Aug-15-2007 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 10 Putnam Ave Property Address Peter Hallemeier Owner Owner's Name information is required for every Cotuit Ma 02632 6-11-18 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a TOWN OF BARNSTABLE p LOCATION /® ?4 &4fA SEWAGE #02 — �O VILLAG ASSESSOR'S MAP & LOT � � INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ���'���> H 1� (size) V�'3, d'AC NO.OF BEDROOMS , BUILDER OR OWNER P p PERMITDATEZ&2 9." COMPLIANCE DA : 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 �f 1 � c \� 6-7 i No. Y' 36 1� . Fee A9 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ppricattou for �hgpo!6a[ *pgtem Cottgtructtou Permit Application for a Permit to Construct( ) Repair( ) Upgrade(°"Abandon( ) ❑Complete System ❑Individual Components Loca-tiio�n Address �oor�Lot No. ! tA.@/1L.r3-�"'l �iw Owner's Name, ddress, d Tel.No. Assessor's Ma0arcel (y3 C Apr -3 CC✓✓ 0`0/Q Installer's Name,Address,and Tel.14o. Designer's Name,,Address and Tel.No.,A S©8- 4 _9�'®0 - 77/- Type of Building: �J Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building ., No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 7 0 gpd Design flow provided gpd Plan Date VI C ®7 Number of sheets Revision Date CZA A 10 7 Title /O Size of Septic Tank D Type of S.A.S. �'mo Description of Soil e- -0-36 Nature of Repairs or Alterations(Answer when applicable) �c.� 6 s d�a�a— �—� /2-- v T 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 Environmen 1 Code and not to place the system in.operation until a Certificate of - Compliance has been issued by this koardjoHeh. Signed Date �/�4 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. �' j� l Date Issued 7-7 i t No. V Fee ZOO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes 'PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applicat ion u for �DizpoaY *p.5tent_CoAtr- i4,n Permit - Application for a Permit to Construct O Repair O Upgrade(Abandon O ❑.Complete System ❑Individual Components Location Address �oorr�Lot No. ,IW ` Owner's Name,,,Address,and Tel No. R Assessor's Map/Parcel CB`IT 3 J L 444- Installer's Name,Address,and Tel.No. &4X6" _ Designer's Name Addressand Tel.No., Sol'- - 300 Type of Building: s Dwelling No.of Bedrooms 7 Lot Size sq. ft. Garbage Grinder ( ) i Other Type of Building 9,"X No.of Persons Showers( ) Cafeteria( ) fi Other Fixtures Design Flow(min.required) 770 gpd Design flow provided gpd Plan Date* jl p7 Number of sheets / Revision Date g/2 A 10 7 Title �.t.�de�.+c. � /0 N0 Size of Septic Tank 0.9 cR"a, Type of S.A.S. Description of Soil r - • —A. ,� � �C 9 Nature of Repairs or Alterations(Answer when applicable) l_— - v z i Date last inspected: r Agreement: The undersigned agree'sto 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 the system in operation until a Certificate of Compliance has been issued by this, oard of Heaith. Signed DateIV E� Application Approved by Date Application Disapproved by: Date for the.following.reasons Permit No. (�� !210 pate:Issued 5 _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( &e< Upgraded ( �)� Abandoned( )by at /0 AXL^ e� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q04 3 LQ& dated Installer �.,.� , ��( — Designer #bedrooms Approved design flow gpd The issuance of this Vs 11 of be onstrued as a guarantee that the system w' I f,n aion as designed. Date Inspector —————————————————————--- No. Fee - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lw,i!5po!5a[ *p5tem CougtructionYermit Permission is hereby granted to Construct Repair Upgrade � ) Abandon ( ) System located at 1 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: Con tructio must be completed within three years of the date of t p i Date Approved by i 4 Town of Barnstable .�"'E' ,.o Regulatory Services Thomas F. Geiler,Director 9 MAM �0� Public Health Division 1659-F Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Lct Sewage Permit# Assessor's Map\Parcel NO 33 Designer: fir—`J�L,I�kV&nstaHer: Address: Address: of Mk- 026-73 On //Az as issued a permit to install a (date) (installer) septic system at 1 O Pu N*w\ A-y�`'�." based on a design drawn by A vA (address) dated / (designe ) V I 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. l ater than 1 teral relocation of the SAS or any vertical relocation of any component he se syste ) butinaccordance with State & Local Regulations. Plan revision or if as-built designer to follow. Stripout (if required) was inspected and the soils found satisf cto i afore) i toret (Affix Mtw Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc E a Town of Barnstable P# .//9C Department of Regulatory Services ,-' ,. Public Health Division Date MAS& an Street,Hyannis MA 02601 t414• ��� 200 Main Stt H y k' A", /Date Scheduled I�, , TimeFee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: LOCATION& GENERAL INFORMATION L Location Address 'Owner's Name �t Fi eI SoIJ Address Cv¢vr'f , A 2��yewvo� of j o7�So Assessor's Map/Parcel: ?>(o P A 33 - Engineer's Name s Sue- ,r,L NEW CONSTRUCTION REPAIR Telephone# 5013- 5?- 1 j(o/0o � ��., c!ti` Land Use" '�'� �•`�J Slopes(g'o) � Surface Stones�_ Distances from: Open Water Body /y ft Possible Wet Area ft Drinking Water Well 'J<A- ft �` ��a !l t� ft Other Drainage Way ft Property Line KETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands(n pro)6mity to holes) a r N ' y Y- O cm C 4-U 'A r N� Ql tit � tC) I � Parent material(geologic) �l7f/�/d_ /t` Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face /VU �� Estimated Seasonal High Groundwater ���2' 6(l 1-66uzj DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed stobs.hole: _ Depth to soli mottles:. in, a m Depth to wee m side of obs.hole: U. Groundwater Adjustment Index Well# Reading Date: Index Well 1 .n .r Adl•factor )raundwater Level PERCOLATION TEST nuts l(�Thne Observation Hole# / - Time at 4" Depth of Percj Time at 6" 0 Start Pre-soak Time @ !� Time(9"-V) End Pre-soak. Rate Min./Inch `— U---S ° Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original• Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\S EPTICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole,# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones;Boulders. on isten 4'a ravel �A � Z. l DEEP OBSERVATION HOLEDepth LOG Hole# 2 P , Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones,Boulders. a Consisten % ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. Consi to c Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sol] Surface(in) Other (USDA) (Munsell MO:tling (Structure,Stones;Boulders. Consi t n I Fl ood Insurance Rate Maa• - Above 500 year flood boundary No_ Yes Within 500 year boundary No_ Yes C Within 100 year flood boundary No Yes Depth of Naturally Occurrine Pervious Material ; .. Does at least_four feet of naturally occurring pervious material exist in all areas observed throug hout the p area proposed for the sotl.absorption system? �S If not,what 0is the depth,of naturally occurring per ious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of iron ental Protection a that the above analysis was performed by me consistent with . the required traini x ise d e ce described in 310 CMR 15.017. a, Signatur Date Q:1S.EPTICIPERCFORM.DOC 3�PD 1. ff Q r. gyp' IL i! ,n CQN . 3 PINDIG L t !{ � 41y b a zi �•'q i a9YL! 3V. pGY7fiiu2'td:. E •l g a�� .� F I '4 r. [k 1 � i ID ' t . _4: ............. ..........:.........- ....:. - .. _ ,_. ------......- ----------- ------- ... ._....- .. -------- ....... 'Cr � . ..,,,..:. .., ,^"..v'rsc+s'w't.. --._ r.^....u.lm.eu-tv.:wna.,.n., .ua•-... t�Lam,-r,r„..,:,A+h - _..,,.,.,..,.... .. .xa,-,.T ...c,..- _n,--__...«_....._..._.°z _ -_.._ ,. *""i''� - #700 Main Street { _ N 88050'10" E R3-5 1 [ J PROPOSED. SAS * 0 52 I Five 500 Gal Concrete i ' a Chambers w/4' stone or.. > sides and 2' stone on e.ids o Total Dim's = 63'-6" x 12'-10" m i I Exist. Cesspool to ( �► be pumped and crushed 63'-6" os 1 Proposed and d sand filled it I . . . . . . . .. . . . . . . -. . .. . . .. .. 2,000 Gal per Title V wt —Tank 00 00.0.. . 0 O 0001...00 r �., ..... ... . . . .: Install Co. to grade I DTH — 0 a J Barn nTFI ._ H � I Pec A r I J Proposed J # - D-Box ' DB—B x. C. t ` Gas Line o grade G G _ G �— TBM J I: Top. Fnd 52.0 .. I E Underground Elec - E E rr I `r l t Bldg 10 L --I- i 7 Bdr s Top Fnd = 52.0 k { (50.8) X - I oK . f % I II 2? I I+ M � I y I ,. 1 oily, I I � f I , F < - 193.5' I M A VENUE PUTIVA r Y f TOP OF - Raise covers to within 6" of Raise covers to within 6" of FOUNDATION EL 52.0 finish grade install risers as needed finish grade install risers as needed Ex Gra de 51. 7 FG 51.6 Cp `1 GROUND SURFACE EL_ 51_5___ ��' r' 4 Band Stainless �^r�7► T 7� D 7� T �r Steel Connector Top 49.0 D�p g X �.-- ►J .L A 1 V 1J A 11,D 1 V O TES DB-6 HIM (Typical) 3. 7 =49. " 2'WIN--3"MA X 47.8TOP EL 1) THIS PLAN IS FOR THE INSTALLATION / REPAIR OF A SEPTIC SYSTEM. MIN 2' LAYER DOUBLE WASHED INVERT EL 48.0 / 1-1 - N va•- v2' STONE 2) ALL INSTALLATION PROCEDURES AND MATERIALS SHALL CONFORM TO 310 CMR 15.000, THE STATE ENVIRONMENTAL CODE, LOCUS Existing INVERT EL 10 47. 78 _ _ _ _ _ _ _ - - _ - - - - _ Barnstable 14" 2'1 TITLE 5, AND THE TOWN OF _-_-_-__________ SUBSURFACE DISPOSAL REGULATIONS. INV EL - - _ - - - EFFECTIVE ~ INSTALL - - - - - - - - SIDEWALL 3) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE OF AVAILABLE PROPERTY INFORMATION WITH RECORDED DEEDS BAFFLE 47.27 47.1 OR ZONING REGULATIONS. Bot 43.4 INV EL 46.8 4 5 8-�4.25'� 3i4'- 1 1i2' DOUBLE 4) THIS PROPERTY IS SERVICED BY TOWN WATER � __....-___...._...._... INV EL INV EL Five 500 Gal Conc (H-20) (TyP1 o b WASHED STONE , SCI2001 chambers He stone on sides '� 44.8 5) THERE ARE NO KNOWN WELLS WITHIN 100 OF THE PROPOSED SOIL ABSORPTION SYSTEM CO t LII t 6" STONE BASE and 2, stone on the ends S BOTTOM EL Street Proposed ( '-10 4 " x 8'-6" x 3'-0') 6) ALL COVERS OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 6 OF FINISHED GRADE a� ti Bay 2,000 Gal Septic Tank s = 0.05 o i 7) ALL SYSTEM COMPONENTS SHALL REMAIN ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY � s - 0.02 I S =�. S = 0(st L� - 0.015 SAS (12'-10" x 63-6) (Typical) s - s o.or I UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTERFERE WITH THE PERFORMANCE, ACCESS, INSPECTION 1 ® 6' 5 50 34 z ® 16' BOTTOM OF TEST HOLD PUMPING OR REPAIR. LOCUS MAP ,. r �4,x tag q 2 30 EL 39.5 NTS �KX,a ., , 4 'i�,.-- 8) NO DRIVEWAY, PARKING OR TURNING AREA, GR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION 63 5' SYSTEM, EXCEPT WHEN VENTING HAS BEEN PROVIDED. 9) SEPTIC TANKS, GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE PLACED ON A 6" STONE BASE TO ENSURE STABILITY AND PREVENT SETTLINr 70) OUTLET DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST TWO FEET OF THEIR LENGTH. Bath 11) ALL SYSTEM COMPONENTS SHALL BE CAPABLF OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' OF DRIVEWAYS OR PARKING OR TURNING AREAS, IN WHICH CASE H-20 COMPONENTS SHALL BE USED. Laundry 10) ALL BUILDING SEWER LINES SHALL HAVE AN INNER DIAMETER OF 4» AND SHALL BE CAST-IRON OR SCHEDULE 40 PVC. 13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS SHALL NOT EXCEED 36" UNLESS VENTING HAS BEEN PROVIDED. 14) IN THE AREAS OF EXCAVATION, EXISTING GRADES SHALL BE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS. Kit + Bedroom 15) IF SOILS ARE ENCOUNTERED DURING THE EXCAVATION OF THE SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM #3 NIF Pantry Den THE DEEP OBSERVATIOM HOLE LOG, CONTACT A & M LAND SERVICES AND TOWN BOH BEFORE PROCEEDING James A. Killalea . Bib 16) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTILITIES. PRIOR TO CONSTRUCTION Bedroom Bedroom Dining #1 Bedroom #3 17) CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION Map 36 Parcel 49 #2 Bedroom TO A & M LAND SERVICES AND TOWN BOH FOR REVIEW AND APPROVAL. Bth Bib - .:j #e 18) CONTRACTOR SHALL NOTIFY TOWN AND DESIGN ENGINEER AT LEAST Family Bedroom 24 - 48 HOURS PRIOR TO INSPECTION(S). Living Bedroom Bedroom 15 ! I Po -roh I Porch 'l4. #700 Main Street L-- ! ! 1st Floor 2nd Floor I N 88050'10" E Vi 3.51-b DESIGN IAA TA ! I PROPOSED. SAS \�' ` DEEP OBSERVAjY O 1�T I Five 500 Gal Concrete52 7 M Chambers w/4' stone or.. Number of Bedrooms: ! ! sides and 2' stone on e.2ds HOLE Total Dim's = 63'-6» x 12'-10» LOG Garbage Grinder: N� ! Exist. Cesspool to \ Test Hole 1 Design Flow: 770 ! ! be pumped and crushed ! M.0' 63'-6" Proposed and sand,filled (EL = 51.5 f) ( / Y ) ! '' . ..'..'.'..'.. . .... . ... . . .. .... . 4-00 - In 000 Gal Per Title V \ 110 Gal/BR Da x Number of BR p ..... ... . .. . .... . .. . . ... .'... . . . p -Tank D P h lev Soil Soil Soil P 2, 000 ! ! - - - �In ft Horizon Texture Color Septic Tank: I. . . ) (USDA) (Munsell) (Minimum = Design Flow x 200%) Gal � 00 000 .O 0������000 ��OOO��, �� . .. . . 120' ....... ..... .. C.0. , I I LeachingArea: DTx o f to grade ! I 0 - 10" 50.6 A Loamy Sand 10YR413 Sidewall: z A 1 • ._ - #1 _n.-- nTH J Barn I _ 63.5' 2 _ 2 - s f I » (2 -Sidewalls x ------Ft x ---Ft� ! 1 Proposed # � 1 10 - 32 49 8 n Loamy Sand 5YR516 Perc IA D-Box � , 'O' ( I I � ._ . . (2 Endwalls .x 12.83 � x --.?--Ft) DR-6 ��J 1 „ 305.3 SF ---! 32 - 144 39.5 C Coarse Sand R.5Y7/4 Bottom: 814.7 SF 63.5__Ft x _12.83 _Ft) O Dee Obs Hole Date: August 10.. 2007 1,120 SF tall ! t� t� p g Gas Line I I I rade ;� Soil Evaluator: Ed Stone Long Term Acceptance Rate (LTAR): x 0.74 ! I-. G G - G g I d '� Witnessed By: Donna Miorandi Leaching Area Design Capacity: 829 GPD Pere Rate: < 2 MIN/IN ® 54" r� l I TBM J - - ! Soil Survey Description; CARVER (Sidewall Area + Bottom Area) x LTAR �^y\ Top Fnd 52.0 ( `- I ►� I I Under round Elec / -�- \ ! /F Geologic Material: GLACIAL OUTWASH MORRAINE III E - E E !� ( I� , N Depth to Standing Water: NA ' ! I ! - L - -� I I{ Mary� o Depth to Weeping Water: NA 829 GPD Provided 770 GPD Required red _59 GPD Reserve Land Conse Conservation T,,ust ---- �\ Depth to Mottling(Color): NA Lt I ! I Est Seasonal High GW: NA .Bldg ;/10 L_ J. I I b i Map 36 Parcel 36USGS' Observation Well: NA ���► of I ! 7 Bdr S Date of Last. Measurement: NA o� Top Fnd 52.0 I 'I Comments: VANsla w m FI 0 8/ ` I A 9POORa1 +NO.23040 110 1lD ! ox DEEP OBSERVATION e Septic Upgra d Repair Pl a n i HALE LOG . . In Test Hole #2 C® t Z,ZI t, MA Dgp�h lev Soil Soil Soil ! 1 ! In a Horizon Texture Color Located #58 Putnam Avenue (USDA) (Munsell) Loca ted At ! I 0111 � 0 - 10" 50. 7 A Loamy Sand 10YR413 10 Putnam A Tien ue z ! ! COtuit, MA ! I 193.5' ! ! „ 10" - 28" 47.2 B Loamy Sand 7.5YR516 I I I 28" - 144 39.5 C Coarse Sand 2.5Y714 Appllcantlowner Jill Edelson Ma rho t Ha rl e y Deep Obs Hole Date: August 10. 2007 Soil Evaluator: Ed Stone Witnessed By Donna Miorandi � Lane II PUT�V1�1V1 A V E_ V' U� Pere Rate: < 2 MIN/IN ® 54 Paddock " _ - Soil Survey Description: CARVER , I - -JrQ - - - - - -._- - - - - - -- - - - -- - - - - - - - -- -- - - - Geologic Material: GLACIAL oUTWASH MORRAINE AnC,L 0 Ver MA 01�1® Depth to Standing Water: NA. Depth to Weeping Water: NA - DATE' August t 15 2007 ! / Depth to Mottling(Color): NA SCALE 1 - 20 , ! Est Seasonal High GW: NA USGS Observation Well: NA Prepared By I ! Date of Last Measurement: NA A & M LG`�nU ServicesI Comments: ! ! 618 Main Street Suite 3 i I West Yarmouth, MA 02673 ! ! Ph. 508 771-5263 anmland@comeast. net I I ASSESSORS MAP 36 LOT 33 I i I Deed Reference I Bk 9541 Pg 21i� �- .......... - - -- - ------ -- _ - - -