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Home My WebLink About0479 PUTNAM AVENUE - Health 479 Putnam Aven a 0— Cotuit ----- - - -- --- A= 038-010 1. t ,� -�- Town of Barnstable. r# Deptartmentof Regulatory Services l� Public Health Division Date 10 �i Mid a 200 Main Strect,Hyannis MA 02601 e-)Date Scheduled Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: '_`L %j Witnessed By: _ LOCATION&GENERAL INFORMATION Location Address .�Iq VwroAµ V Owner'sNameCkRf bt'L&_ tDoo" Co Address 4'4 q Qwr w 1%m ire C Aster's Map/Parcel: p3%10%0 EngmecesName e,�(1 uC ctma- NEW CONSTRUCTION REPAIR Telephone# 0;0;4 ?j Z 0464 Land Use Slopes(%) 3' Surface Srones Distaeces fioin: Open Water Body >100 ft Possible Wet Area Q17 ft Drinking Water Well -�100 ft Drainage Way >(U0 ft Property Line (0` It Other It SKETCH:(Street name,dimensions of lot,exact locations of test holes 8c perc tests,locate wedands in proximity to holes) �3, Zit M jo ` 4 y t, p s T(� 1 �$7- �y3.o2 CA 04 , a Parent material(geologic) C a/V&m16o.-.-.I .i .J Depth to Bedrock Depth to Groundwater: Standing Water in Hole- 1 -1 t' Weeping from Pit Face Z� , Estimated Seasonal High Groundwater 5•b v\ D GTEATION FOR SEASONAL HIGH WATER TABLE Method Used: Q_-.'►A P Depth Observed standing in obs.hole: in. Depth to soil mottles: b-1J C- in. Depth to weeping from side o hole o in Groundwater Adjustment • .7-1 ft y Index Wdl#kA c'^'' Date: t I I Index Well level Adi.factor 3,'Z Adj.Groundwater Level_G 3 PERCOLATION TEST Date 71IStit Time 1( 0 Observation Hole# Time at 9" Depth De P ofPerc Time at 6" Start Pre-soak Time® Time(9"4-) End Pie-soak 1 L ��gtrtoNs�ss�Mt„15 na�wte� Rate MinJinch . Site Suitability Assenment: Site Passed {� Site Failed: Additional Testmg 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:ISEPTIC\PERCFORM.DOC r i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) 34-s� A 1A0 A A �oYR 5J(y v.4.� "-' DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other t Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 0.19 M-rd0 C, M.sad aS 511- IW �5�g1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency %Gravel) ai I s p - ti DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven Flood Insurance Rate May: Above 500 year flood boundary No_, Yes Within 500 year boundary No ,'� Yes Within 100 year flood boundary No ✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? - I& If not,what is the depth of naturally occurring pervious material? Certification I certify that on 64 900'r) (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature Date '1 5 1) Q:\SEPTIC\PERCFORM.DOC Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 ' page. City/Town State Zip Code Date of Inspection .Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. . Important:When filling out forms A. General Information on the computer, I / use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State - Zip Code 508-477-0653 S 14595 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 4/21/11 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. Lkt( t5ins•09/6s 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 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is Cotuit Ma 02635 4/21/11 required for 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by, the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal arid over 20 years old' or the septic tank(whether metal or not) is structurally ' unsound, exhibits substantial infiltration or exfiltra.tion 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 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. Cityrrown 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections:. Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is Cotuit Ma 02635 .4/21/11 required for every 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 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. l5ins•09/08 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 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): reglulation Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r Commonwealth of Massachusetts ; W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: - 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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 resent? El Yes El No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 ' 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 F 'M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract - ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): .a ^ t5ins•09/08• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , nM 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is Cotuit Ma 02635 4/21/11 required for every page. Cityrrown State _ Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ®- No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): r Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): e At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): 4 Depth below grade: 1 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 5.2x5.2x8.6 Dimensions: _ Sludge depth: 6„ t5ins•09/08 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 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" 6" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? scour 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.): At time of inspection tank appeared to be in good shape tees present no sign of back up. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 479 Putnam Ave. Property Address Don Campbell ` Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 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 El'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•09/08 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 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is. required for every Cotuit Ma 02635 4/21/11 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.): At time of inspection d-box appeared to be in ok shape no sign of carryover or backup.Concrete starting to deteriorate but at time of inspection no sign of leakage. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: , ® leaching pits number: 1-600 gal.w/3' ofstone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good shape no sign of staining .Water level was 6" below invert .An increase in flow rate,may effect leaching conditions. 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•09108 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 G7M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I'.I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 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: ® hared-sketch in the area below ❑ drawing attached separately f 7D21\1F-WAy V 13 C (� o o r _B37- t C3� Z t c Y t5ins•09/08 ° Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 479 Putnam Ave. Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 page. City/Town State Zip Code Date of Inspection D. System Information .(cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells x >61511 ti v Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 ° 479 4, Putnam Ave.w - Property Address Don Campbell Owner Owner's Name information is required for every Cotuit Ma 02635 4/21/11 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 v t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Z/ I Q°. d W T � � r c � a S CB FND CB FND SAVERY PARK LOT LINE FROM \ PLAN BOOK 211 PAGE 87 S 88'12'30" E 73.28' CB FND CB FND LOT LINE FROM PLAN BOOK 100 PAGE 91 06 \ G SCREENED W PORCH 25a z w �y 1 W ,�. PROPOSED 12 x 24 25.6 N ; K ADD/710N Q Zc6 N LOT 1 A <Q 13,879 SF o � z C3 � \ CB FND n CB FND 143.03' N 88'12'30" W �LQT_:2A . STREET LINE FROM PLAN BOOK 100 PAGE 91" STREET LINE FROM PLAN BOOK 211 PAGE 87. \ NOTES: 1. HOUSE No. 479 PUTNAM AVE 2. ASSESSORS No. MAP 038 PARCEL 010 3. SITE IS WITHIN: FLOOD ZONE C EXISTING \ " PROPOSED ZONING DISTRICT: R7 ` STRUCTURES STRUCTURES (FRONT SETBACK: 30 - SIDE: 15 ) BUILDING CODE WIND EXPOSURE CATEGORY B . 4. SITE IS NOT WITHIN: ZONE Ii OF A PUBLIC WATER SUPPLY. I CERTIFY THAT THE HOUSE Is WIND BORNE DEBRIS ZONE �ZHOIs L�XONAL LOT 1A AS SHOWN. 5. BUILDING LOT COVERAGE: EXISTING: 10.9% PROPOSED: 12.61%- �� THOMAS a JACKSON17 BUNKER N a NO.32653 c® p AND SURVEYOR BSS 6 ANAL LAND S�� DESIGN DATE: ®®®' ENGINEERING & SURVEYING CERTIFIED PLOT PLAN PREPARED FOR www.bssdesign.com DONALD CAMPBELL BSS Design, incorporated 479 PUTNAM AVENUE 164 Katharine Lee Bates Rd Falmouth Massachusetts 02540 BARNS TABLE, M ASSA CH U SE TTS 508.540.8805 FAX 508.548.8313 scale 30' date 6/16/11 drawn EJP, TJB job number 6038 d`"9 number P19-50 1" = NO. _� '3cq THE COMMONWEALTH OF MASSACHUSE'1fTS FEE�/00. O� BOARD OF HEALTH 6 — OF �� "G� L—Cr APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components '7"W ��..,._. A,,,L ., G�ti- � Dn_a \.A L cation Q Owner's ame Map/Parcel# Address Lot# Telephone# lea - �a1 G~LtSs / Installer's Name Designer's Name Address Address�� Telephone# Telephone# Type of Building: /ZCS,`4-X/4 —c. Lot Size 47, t?W' Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons 2 Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow—;;! ygpd Design flow provided 299Ygpd Plan: Date Y-22-// Number of sheets Zr Revision Date TitleYCO�L a-. fb r' `1�'� AP, A-t- Description of Soil(s) L®ei R" Ste„/. o.,.. s Soil Evaluator Form No. / ��"� Name of Soil Evaluator=Sc� /' �� Date of Evaluation `'i—1/'/i DESCRIPTION OF REPAIRS OR ALTERATIONS �•�-+a �� - n e- S y_ST The undersigned agrees to install tkC above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further, s not to pi the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date I Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 �v""^ s L -s+rrr'^yvyv^tyre+}.ip�.P��,.r., 1c..1^�;.: ,{ti''4..1�•..»�.rr+y�.+}*rs+..gq.';rk+��.i`^rlinsa*vr nay,!" - �.rr,:ti�r +r-vi 7'^Ah"'"F� ,1 k p. -7 r � e °�.,ep'4+art'..•s;fi' •w:•�rj..^ »ya'11S+s'r'...s��ti.-+;�",�i "� � �'+ �. No. THE COMMONWEALTH OF MASSACH'US'E+TS FEE t7� ' BOARD OF HEALTH ) I 6Lt! F O F --'; �� G� G APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components -f` 0 ! y�V a'"wc}.....' ✓°Y� G-d � � C l r^a...��...�� +.-c.---�T�v_�1 Location Owner'srName Map/Parcel# Address /O 8'- W 3 �✓%� Lot# Telephone# if t✓��t �l��C ,L-''v+o'"/tc.— ,l rs1 F1'/EL..S.,� . Installer's Name Designer's Name .� ar• . C E' /�Q �Ea 7K �. Z �G •�r'S/o�G Address Address G Telephone# Telephone# 't Type of Building: Sri�p �" ,�`oer Lot Size 13, P7� Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder ( ) Other—Type of Building No.of persons 7.. Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow ' `7�gpd Design flow provided 3W-Ygpd Plan: Date �� +R.2 �� Number of sheets 2o_ Revision Date Title 6.6's"c, fJi'' `i�i'q Tv G.- {�✓L. J Description of Soil(s) 104)? Soil Evaluator Form No. 03>9'O Name of Soil Evaluator .fe I-A /`7G4c;,u._Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS -��S Vic' ^- a�''� n cu✓ y Sly. �J.rCz �6 �>w IG G✓. LL. 2- S L1y t The undersigned agrees to install V above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further rees not to pla a the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date I a Inspections FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ^'mac, — ———— µNo.�p�t �" I THE COMMONWEALTH OF MASSACHUSETTS FEE ��U Lr, BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: at �'9 1?,T,..,,}r\ Au c !C c>-r,,L (•T has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No2oll -309 dated 1 116/ZO 11 Approved Design Flow 330 (gpd) Installer Designer: Inspector 1'n, _'-" :ziate The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 r No. " THE COMMONWEALTH OF MASSACHUSETTS FEES P0 0. aJ / 4W57i,Q T, L E BOARD OF H EALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct (/ 1 Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at q)-q ry-rA.i T as described in the application for Disposal System Construction Permit No.'70 i 300 dated S i l v t z'0 1 t Provided: Construction shall be completed within three years of the date of this permi.All loc-a-1-c-onditions must be met. Date (� ( Z f I Board of Healt '� �'-- FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARRENrM PUBLISHERS- BOSTON I, 9 Town of Barnstable 0FIHE roy, - Regulatory Services Thomas F. Geiler, Director BARN STABLE, • Public Health Division MASS. a '°rfnM Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: /0-/8'- Sewage Permit# Assessor's Map/Parcel 31> �ato Installer & Designer Certification Form Designer: U�Wr jown �,Mw (N Installer: Address: Fo Gm 4 Address: rsA On . , <N was issued a permit to install a (date) (installer) septic system at e ?W164 Cw based on a design drawn by (address) S-1%ol nft& 1st dated - 6S 22Ikk (designer) V/I certifythat the septic stem referenced above was installed substantial p Y 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 required) was inspected and the soils were found satisfactory. of A%, (Installer's Signature) Sgcy awe EDWIId H. c� o` GLEES,J'R. N CIVIL (Designer's Signature) (Affix Designer's 're o �� o FG IE ,0 1ST PLEASE RETURN TO BARNS TABLE PUBLIC HEALTH DTVISI 1I TE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS f AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. q:\of)ce forms\designercertification form.doc TOWN OF BARNSTABLE LOCATION A✓2— SEWAGE# 1335'^0 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /.rdo LEACHING FACILITY.(type) 1e4o.fJ- 64.-.fietl (size) /3 X NO.OF BEDROOMS ?- OWNER Qo,, C.- PERMIT DATE: 9-fG -/i COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility el 3, / 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 Owl — (3c- - Z �� At�- � - Z S� '"a yr A U '� e Fo G- - w No......`.�.�. ..... Fnn.... ............... THE COMMONWEALTH OF MASSACHUSETTS E®A R® HEAL T App irativt�t far isputial vr1t � ttot i tt Motif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst .................. ...- .... Locatio • - t ad. Add . Lot N o. ••---•------•---�- -... ..... ......w Address .... ........... ----------------------------- ._...................-•••-••-••----•-...... In aller Address dType of Building/ Size Lot............................Sq. feet Dwelling�"No. of Bedrooms........._�.�..................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ,( ) d Other fixtures .......... Desi-n Flow....................... _._ al s per person per day. Total daily flow.__..___.__._- W , WSeptic Tank Liquid capacity_ _____ all s Length................ Width................ Diameter................ Depth_._.___________. Disposal Trench—N9.----•---•--......--- `Widtk... • n al leachi area......-.............sq. ft. Seepage Pit No.................... Diameter___. ei ___..... o a g area____..____.____...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) !P e-- Percolation Test Results Performed bY............................................... = Date aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit...................Pepth to ground water........................ -•-- - ----------d -•- -----•--- -•---------------------- ---- -..-------------------------------------------------------------- O De"� scription of Soil----...... - -------------- . .....--------------------------------------------------.....--- W ------------------------•••------------------•-•--•------•---------------------•---------•---------•••••••••-•--------...-------•••---•---•------•------------------••-••-•--------•--•.._..........---- VNature of Repairs or Alterations—Answer when applicable......................:......................................................................... -----------------------------•....--•--......----•-•----•--------------------•-----..........................---------------------•------------••--------------------------•------------•--•----•....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue y the board of health. Signe !Date r Application Approved By. . � �- ._._.. - -- .�� I� ....... ............... �___ _D ---- � s Application Disapproved for the following reasons----------------•-------•---...... ............................................................................. -•-••••••.............•-••••••-•--•-•-------------•--•---------....._......_..---------------•--......................_...... .......------------------. ........................... Date PermitNo......................................................... Issued......A- /�¢ 7 ........... Date No......................... FEic.•..,r ,.,............... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALT O F. . . ......... Appliration.$nr Dispuiittl Igor onstrudi n Vamit Application is hereby made for a Permit to Construct ( ')'or Repair ( ) an Individual Sewage Disposal syst j.. ...•---- - ° Locatio Addr � -• --or Lot No.--�.�t- , • �, ��'�- W +........... ... �!'6!!'S�! _ y_ t Address ................................................................................................ I_ aller Address Type of,Buildii Size Lot............................Sq. feet U Dwelling-No of Bedrooms__..._ � "'* * - __ Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building p� yp g ............... No of persons: .............. Showers ( ) — Cafeteria ( ) Other fixtures -................................................. . ....... Design Flow - p p p y. y gallons. W __ ________________ er erson er day. Total daily flow_____._ ______._: .__..____ lions. WSeptic Tank L>quid capacity gall s Length ______________ Width___ Diameter ___.. -------- Depth................ x Disposal Trench N Wad en al lea i area....................sq. ft. Seepage Prt No. Diameter. 1.. o e :.______ o a din area__________________s ft. g , q. Other Distributiontbox Dosing tank Percolation Test Results Performed by:..................................................... Date_______________ .............. ,4 Test Pit No. L................minutes'per.inch Depth of Test Pit ............... Depth to ground water........................ 0:4 Test Pit No. 2................minutes per inch Depth of Test Pit................... epth to ground water........................ .............................................................. O rt Description of Soil......... - :. .. =••:; ---- ----- _WA ....... x .. UW •--------------------•-------•• ----•-•-----------------......---- -------------------------------- --•------- ------ ------------------------------..........-•----....---...... Nature of Repairs or Alterations Answer when-applicable..........____________ r =::.____._._____ .__.:_:.___._.______.______________..___.___ _ .........................................t.._..._._...::.._..............::............._.................._._............_____ Agreement: 1 The undersigned agrees to install the aforedescrilied, Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been slue y the board of heaIt. Slime --- Date Application Approved BY . • .: .•! :. ........ .:.:.. ............... ._ ~_. . /---77 " Application Disapproved for the following reasons:-----_------------------------------- =---------•-----•-••--------------------.......----•-----•-----.--- ------•------•........---•-•---..:---••--•-••------------•-----•------------- ---•----•--•. .................................... ------------- Date t ._/ .. r Permit No........................... Issued.. ! _! , ,r+ Date THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH .............O F..... r,..... r?. '£ ....K '......................... a Ukri�ir�t n �gn� littnre � THIS IS TO CERTIFY., That the Individual Sewage Disposal System'constructed ( �) or Repaired ..-- • . Installer ------- , - - �- has be'n installed in accordance with the//provisions of Article X,I?'of The,e State Sanitary Co e di6othe apple ion for Disposal.Works Construction Permit`No________________f7_4.____-_•- dated____ .._.. -._ _.. ........ IIHE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A C ARANT E THAT THE SYSTEM WILL FUNCT19N SATISFACTORY. , �' DATE ........... ----_ .. Inspector.-_ ---- ------------- ------. THE COMMONWEALTH OF MASSACHUSETTS t. BOARD OF HEALTH rF^ � t .:.. ...........:A. �f NO...... .. ...... FEE...R' 1 Permission,is hereby granted::---. „ : ......._... _ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo........................... --�•--.---.. .. ..-- ........- •. - - -e' .-•-- f Street .. , as shown on the application for Disposal Works Construction r at No )ated..... .. .. •- • t.... oard o Health . E?ATE...... J)(f /�J ......................... FORM 1255 H BBS & ARREN• INCPUBLjjKt4•r=RS F - f , No.Q-��::.. � Fss. J ` THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 039" O 1 t TOWN OF BARNSTABLE Appfiration for Disposal Works Tonotrurtivivramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: Location- d ss --• •- •••-_••-•-••-••-•-•--or Lot No. �• Owner a Address�GILf.. .c...... -----.....••--••• ••---•-•----•-••••--•...............•-••••••••------•-•-•---•---••-•-••-•-••••.....••••-•••....... Installer Address d Type of Building Size Lot___________________________S q. feet U 1:1Dwelling—No. of Bedrooms________________________________ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............._.............. Showers — Cafeteria Q' Other fixtures -------------------------------• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid"capacityt�rv__gallons Length................ Width................ Diameter__-_____________ Depth................ x Disposal Trench—N9_ _________ _________ Width ------- Total Length.________.__I�_ Total leaching area....................sq. ft. Seepage Pit No---------- D ameter.__.__Q_-...__.___ Depth below inlet__ __. ____.__ Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. I________________minutes per inch Depth of Test Pit____________________ Depth to ground water_____________________--- G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •=•••-•-••-••-••••-••-••-•••-............................... -••--------------------- --------------•---------------------- •------------------------------- -•- 0 Description of Soil........................................................................................................................................................................ "W V -••-•••-•-•-•-•••-•--------••-•--•-._...--•-•••-•----•••••••••---•-•-----•--••--•-•-....-•--...•-••••-•-.....------•••--•-•---••------••--•----......._•-•••----•-••-•.................••••--••••-_•••-• W ••--••••-•-•.....................•-•-••••-------•--•••--•-•--...--•••-•-•••••••-•---•--•-•--••••--••---•---••-••------- __ ____ ---------- U N ur�f epairs or Alterations—Answer when a plicable_ _GG� 4______G --o T T�� ---------------------------------- a a=s °`rl-) •--9 2;'� `3- l STD ---•-------------------------------------------------------•••• 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 issu by the board o hea Signe - ---------- ��............�� Date Application Approved By ----------- .... �w- �'�� ..... .... ....... ............................................................. Date Application Disapproved for the following reasons• --------- ------- -------------------------------------------------------------------------------------------------------- v, � � / 5 Date Permit No. Issued --.•... .. .. Date 'f Fps. ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH 039 TOWN OF BARNSTABLE A liration for Dig usal arks Tonstru.rtiun r mit �� r Application is hereby made for a Permit to Construct ( ) or Repair (1, an Individual Sewage Disposal System at: ... .�........... .... .. � ! --:Location- d ess _______________•._.-----------_-----.---_-or Lot No. / ownyr Address W ��21 fig C O ..�S % ( 0_.....�ia.. G. F Installer� # Address d Type of Building 'f Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—,Klype of Building No. of persons............................ Showers — Cafeteria dOther fixtures -----•---------------------------------------------------------------------------•-----------------•...•----•--.............•--•-----•--....--------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitylD�v__gallons Length---------_...... Width-------------_- Diameter:............... Depth................ �! x Disposal Trench—N _ ------------_------- Width.................... Total Length.................... Total leaching area....................sq. ft. -Seepage Pit No..._-_-•-!----_____- Diameter...... Depth below inlet__.............. Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) '-. Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------___--. fi Test Pit No. 2................minutes per inch Depth of Test Pit__________••-_••_•-- Depth to ground water........................ Descriptionof Soil...............................................................................•........................................................................................ x W ---•---------------- ------------•----••••--•-----------------•----------------------....----•-•••---••-----•----••----•--•-------•• ------------------- UNature f epairs or Alterations—Answer when applicable.vf� GGL =____�_ .___ .T_� .__ �___. A�------------�°.o a-•-s-._____._._�-•'"""/-..----d.-D!. C�,r�/ .3 r STI�.•r�,V 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 issu d by the board of,hea h. Signed�� `��Z' ------------ --------------------------------------- Dam Application Approved Bp ....��1� J ........... .... .... ., - _ ...... - --............--Date...... .....'7.. Application Disapproved for the following reasons- ---------------------- ---------------------------------- -------------------- ------------------ ----- -------------------'---------------- ......... ................................ .............................................................................................. ---------------------------------------- Dace Permit No. .... ",'.- ...............------- Issued ....... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE.. Cer#ifira e of Graylinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by Installer ------------------- ----------- 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. .... -- .-.r--�,� -- dated ..1,W. ... -- .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 134 AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1,�711) DATE. . /. Inspector.... �1�.�''}! ..�' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE14i.", �i��ru,sttlurk� �uu�tr�tiun rrmit Permission is hereby granted........ . ........_/`'� to Construct ( ) or Repair,�_-y an Individual Sewage Disposal System at No.............. 7.�-/-... !! , !� �....... vim•--...--- Street as shown on the application for Disposal Works Construction LPerm24 No.00, Dated... �........... .. 1 Board of Health pDATE........._...��_....'.. ..................................... FORM I /J FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS - 1 l� TOWN OF BARNSTABLE LOC' TION l �y� '� � SEWAGE # 3 VILL kGE ��"/ J L � ASSESSOR'S MAP LOT INSTALLER'S NAME Et PHONE NO. �z'-G �y` S l3 6 SEPTIC TANK CAPACITY LEACHING FACILITY:(type),&CAST �l� (size)G6�'G'��STo NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 1 - d DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ( , �t� �� <� I ,, °�� ` ��L �� J � � \ � _ � �� .�-,,�� ;-, ,11 G'r� r � L00 14 PLd� N �ol� G3� WL V2." RDUNDA-rION g Tw2145to TW2A+3(, _N a I p u m 5 (u12Y a - 1 - - - - - - — - m 3'/2,, m 1 I M QCl S P F D N 51�-j P5o IQ LLl� I �9 11i o _ �- � aw I 4N I.ED�� 5I Dl✓�. @,12. 0,G. . I 1 �. � '7� W IN DONS,FIZAI- . Nsw . �0P1✓NINGrC3.P,0RMER pN DOW ►-UG/T I o KI a`FL`( W'P.. F II.L i r o EDEtER I `AA( L Po RE41%P, 77 tEIJ� D ?b Z o d f-t 1 (2) 5" L�DEiE12 WOK �oizEyJS I 1 O 2 26 Z i f ® Ito" O,G.�ST A6idrEe6 D• 1 I C _ _ _ W ° p (2)2 x 9►�/�¢,"P;'Y V- 1-I F-A DER Awe T I I I I a QL EY4 GREW I.6 FA419 i 2 RoVIDE MIP41IHUM 2-4'x'16 I- zE�(IST1I•IGf.POGR I I pG,G655 OPE�III�GrTb ► 1 �1 �[ m N I I�fIZAHE INSTAUL W NI~ L I N6I-L G(LA1-41.- PEE, 1 _ V P-2 I !-OGAT 10 IJ W p 0tJ Ito I ca � to a �- F I i D Ll►J DATI c f l A?fAG NM E N T 1 I T- I I m D = 1�.'' 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PvI.Y � I p.Rat.lNp PERIrt�TE=e E-- • e ' 4''- to" GIIUSNE D 5Teo 02GGttPP'GTC-D SANIp ?ILL � 1 MAP 38 LOT 09 t.t �r iit Eegte Pond r BARNSTABLE TOWN OF S 88°12'30" E L=73,27 _ 4 SEPTIC SETBACKS (MIN.) f5' s5 =�CUS EX. DRIVE \ �� LEACHING TRENCHES PROPERTY LINES 10' BUILDINGS 20' 1 � W < SEPTIC TANKS AP 38 ❑ T 10 /1 PROPERTY LINES 10,10' 'f � Q w 1 878 S . - A IN H WBENCHMA �� \ CAP STONE AND LOCU S MAP z W BASEMENT RK FACE EXPOSED WALL NOT TO SCALE, M CD CD �, SLAB RELOCATE EL=50,4 N TOP ❑F WALL EL= 52:0' O_ EXISTING ❑R INV, OUT �\ �/' �^ PR❑VIDE NEW - 54,3± ✓ Nei 8°x 16" BLOCK FINISH GRADE z _j 1500 GALTANK o OR APPROVED EQUAL EX, DRIVE CRAW t" �VARIES SO SPACE PR❑VIDE AT �'� SAS SAND 2 MIN /IN, GRADE CLEAN DE DRB❑X 'N �� OUT 40 MIL POLY / N INV. IN COMMON BACKFILL TORRIER EL 48'❑M N. TO 0 -O —__51i5± STONE LEVELING PREVENT BREAKOUT w EX. 1000 PAD -� 1 EX. °o° o' 12" BEARING ON SUITABLE L TAN MATERIAL EX, PIT A D 15,o'I 1 I 0 O I i ° GARDEN ° TYPICAL BLOCK 8" D-B❑X T❑ BE �/ I MIN, I RETAINING WALL PUMPED ND 46.0' I NOT TO SCALE REMOVED I ° N TES s Ln rP I L6 1. CURRENT OWNER, O CAMPBELL D❑NALD G & KATHLEEN R L=143,02 CBDH TOP DEED BOOK 9182 PG. 108 ro ❑F os �. FND WALL aj N N 88'12'30" W PLAN BOOK 211 PG. 8783 EL=52 MAP 38 L❑T 11 CBDH 5' OVERDIG OF /F PROPOSED 12.83' WIDE FND 2, ALL DIMENSI❑NS ARE PERPENDICULAR TO THE PROPERTY LINES, EXCAVATI❑N �� c WRENCE 3. TOPOGRAPHY AND PROPERTY LINES BASED ON FILED SURVEY BY EGI AREA 0 LONG LEACHING LIMITS (SEE NOTE �� E Hw N A TTE 07/05/2011, VERTICAL DATUM ASSUMED. 13) cam, GLESS 4, PROPERTY IS LOCATED IN FLOOD ZONE C PER FLOOD INSURANCE 1H oFMgs ,o No.39045� RATE MAP PANEL NO. 250001-0018D REVISED JULY 2, 1992. P Existing Grade Inc. EDWIN SS%��Q� 5. EXISTING SEPTIC SYSTEM PER BOARD OF HEALTH RECORDS. 14s1_R1 5urveyor5 � CVVII Encgmeer5 uR PROJECT No. FriPO Box G 12 GLESS, JR• SC CLIENT SEPTIC DESIGN PLAN 1451 Dennl5port, MA 02G39 CIVIL 5 10 20 NCS CONSTRUCTION FOR DATE: 08 22 11 774-2 12-0454 No.412.94 22 CAPTAIN TOWNE RD 479 PUTNAM AVE SHEET No. 0 0'° c�STER� � # DATE REVISIONS SANDWICH, MASSACHUSETTS 02537 COTUTT,MASSACHUSETTS 1 of 2 ANAL , e % S❑IL LOG TEST HOLE #I- ELEV.=49.4' NOTES,- DESIGN FORMULA: 1. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN COMPLIANCE WITH THE STATE SANITARY CODE DEPTH FROM OTHER (STRUCTURE, TITLE V AND THE TOWN OF BARNSTABLE BOARD OF HEALTH REQUIREMENTS. SYSTEM REQUIRED PROVIDED SURFACE ELEVATION SOIL SOIL TEXTURE SOIL COLOR SOIL STONES,BOULDERS, (INCHES) (FEET) HORIZON (USDA) (MUNSELL) MOTTLING ONSISTENCY, %GRAVEL) 2, ANY CHANGE TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND DESIGN ENGINEER. DAILY FLOW, 0'-22' 47,57' FILL 3. HEAVY EQUIPMENT SHALL NOT TRAVEL OVER DISPOSAL SYSTEM DURING OR AFTER CONSTRUCTION. 3 BEDROOMS @ 110 GPD/BEDROOM 330 GPD 22'-34' 46.57' OA LOAM 2.5 YR 4/1 NONE FRIABLE 34'-58' 44.57' B SANDY LOAM 10 YR 5/6 NONE V. FRIABLE 4, TIGHT JOINT (T.J.) PIPING SHALL CONSIST OF POLYVINYL CHLORIDE (PVC) PIPE, SCHEDULE 40. SEPTIC TANKS: IF 58-120' 39.4' C MED SAND 2.5 YR 5/6 NONE LOOSE <5% GRAVEL ALL PIPES TO BE LAID ON FIRM BASE AND TO BE WATERTIGHT. ALL CONNECTIONS AND JOINTS 330 GPD x 200% 660 GAL 1,000 GAL SHALL BE MECHANICALLY SOUND AND TIGHT. 5. DISTRIBUTION BOX SHALL BE WATER TESTED FOR LEVELNESS. LEACHING AREAS: S❑IL LOG TEST HOLE #2- ELEV.=50,6' 6, NO GARBAGE GRINDER IS ALLOWED. 2 CHAMBERS @ 8.5' LONG x 4.83' WIDE 2' EFFECTIVE DEPTH - 4 STONE DEPTH FROM OTHER (STRUCTURE, 7. DISTRIBUTION BOX SHALL HAVE AN INLET TEE EXTENDING TO ONE INCH ABOVE THE SIDEWALL:((12.83'x2)'+(25.0'X2'))x2 151.3 SF SURFACE ELEVATION SOIL SOIL TEXTURE SOIL COLOR SOIL STONES,BOULDERS, OUTLET INVERT ELEVATION. (INCHES) (FEET) HORIZON (USDA) (MUNSELL) MOTTLING ONSISTENCY, %GRAVEL) BOTTOM: (12.53'x 25.0') 320.8 SF 0'-18, 49.1' FILL 8, SEPTIC TANK SHALL BE EMBOSSED WITH SEAL STATING CONFORMANCE WITH ASTM C 1227-94, TOTAL: 472.1 S.F. 18'-30' 48.1' CA LOAM 2.5 YR 4/1 NONE FRIABLE 9, ALL SEPTIC SYSTEM COMPONENTS SHALL BE DESIGNED TO WITHSTAND H-10 LOADINGS. LEACHING CAPACITY: 30'-58' 45,77' B SANDY LOAM 10 YR 5/6 NONE V. FRIABLE SIDEWALL: 151.3 SF x 0.74 GAL/SF 112.0 GAL 58'-120' 40,6' C MED SAND 2.5 YR 5/6 NONE LOOSE <5% GRAVEL 10. SEPTIC TANKS SHALL BE PROVIDED WITH AT LEAST THREE 20' DIAMETER MANHOLES WITH READILY BOTTOM: 320.8 SF x 0.74 GAL/SF 237.4 GAL REMOVABLE IMPERMEABLE COVERS OF DURABLE MATERIAL. TOTAL' 330 GAL 349.4 GAL 11. BEFORE BACKFILLING THE SYSTEM THE CONTRACTOR SHALL NOTIFY THE BOARD OF HEALTH TO INSPECT, 12. ALL UNSUITABLE SOIL MATERIAL IN AREA OF AND BELOW PROPOSED SOIL PERCOLATION # 13350 ABSORPTION SYSTEM (S.A,SJ SHALL BE REMOVED AND REPLACED WITH CLEAN, PERCOLATION TEST BY, SCOTT McGANN COARSE SAND WITH A PECULATION RATE OF 2 MIN/INCH TO TOP OF C2 LAYER. FOR, EXISTING GRADE, INC. WITNESSED BY, DESMARAIS, R.S. 13. AREA 5 FEET BEYOND LIMIT OF SOIL ABSORPTION SYSTEM (S.A.S.) SHALL BE DATE, 07/19/2011 EXCAVATED OF UNSUITABLE MATERIAL TO TOP OF C LAYER, PERC RATE, 2 MIN/IN IN C SOILS HOLE DEPTH=72', EL=44.6' STANDING WATER 114' EL=39.9'. FRIMPTER ADJUTMENT EL=43.1' GROUNDWATER ENCOUNTERED THREE MANHOLE COVERS. BRING A MINIMUM OF ONE NOTES, OF 1/8' -1/2' COVER TO WITHIN 6' OF FINISHED GRADE. BRING ❑THER 1, SEPTIC TANK SHALL BE EMBOSSED WITH SEAL /2' DOUBLE WASHED COVERS TO WITHIN 12' OF FINISH GRADE, STATING CONFORMANCE WITH ASTM C 1227-94.4' (TYP) 4(TYP) PEA GRAVEL (1) ROW ❑F C2> 4.83'x8,5' LEACHING CHAMBERS 2, CORROSION RESISTANT GAS BAFFLE SHALL BE WITH MINIMUM ONE ACCESS PORT PER CHAMBE INSTALLED ON SEPTIC TANK OUTLET TEE, INVERT = .4 a 3/4" TO 1-1/2" ° ° ° 4, ° DOUBLE WASHED STONE 35" 24" o p a 4' PVC FILTER FABRIC OR 2' OF SEWE4-0" 4,-t0., . 4'-0 I 54,3R LINE DOUBLE WASHED PEASTONE 1Y TOP OF PEASTDNE ELEV=51.38' �j INV. IN 1,500 GALLON 4' PVC 3/, 6' SUMP y F,G.=52,0t in 51,5' SEPTIC TANK INV, OUT 4' TYP, TYP 5' MINIMUM 51.25' PVC @ 3Y SEPARATION c o 0 o co o c o a o 0 0 0 DISTANCE d a d a ° ° D ` 0 0 0 0 o c o C o 0 BOTTOM OF TRENCH FROM 29 0 0 °° o `o o °° INV, I c ° INV. IN ' LEVEL FOR ENTIRE = GROUNDWATER LEVEL STABLE 6' 51.15' INV. OUT 38 25.0' LENGTH CRUSHED STONE BASE 3' S0.920 3/4' - 1-1/2' DOUBLE BOTTOM OF MAINTAIN 10.0' TYPICAL LEACHING CHAMBER BOTTOM ❑F 3' MIN. t TRENCH 48,38' �20" MIN USE CONCRETE PRODUCT, INC. 1500 GAL- WASHED CRUSHED STONE TRENCH 48.38' FROM CR❑SS-SECTION I -ram /SEPTIC TANK OR APPROVED EQUAL RESERVE NOT TO SCALE r-6' MIN. ( 2 MIN. 1 CORROSION RESISTANT GAS BAFFLE 431 ADJUSTED BY TUFTITE OR APPROVED EQUAL WATER TABLE 1 --10' MIN. MIN, TYPICAL SEPTIC SYSTEM PR❑FILE �� E o Existing Grade Inc. L GLESS, JR. E WIN CIVIL � 1451 Rt Surveyors * Civil Encglneer5 -o O. CLIENT PROJECT N0. PO Box G 12 �' '� �o �, SCALE SEPTIC DESIGN PLAN 1451 /sT�R ��``' NCS CONSTRUCTION FOR DATE: Os 22 11 774-2 1 2- MA 02639 NG 22 CAPTAIN TOWNE RD 479 PUTNAM AV E SHEET N0. , 774-2 12-0454 SANDWICH, MASSACHUSETTS 02537 COTUTT,MASSACHUSETTS # DATE REVISIONS 2 OF 2