Loading...
HomeMy WebLinkAbout0490 PUTNAM AVENUE - Health 496 Putnam Avenue Cotuit - - — _ - A= 038-021 i 4 _ + No. �vo—�� f _ :r � i � � � Fee ~ ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I PUBLIC HEALTH�DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes ZIpplication for Miopogal bpgtem Construction Permit �a Application for a Permit to Construct( )Repair( )Upgrade(()Abandon( ) K Complete System El Individual Components Location Address or Lot No. 46 C.xt Owner's Name,Address and Tel.No. Cc:tV t= 5,ZVr-.-4 Assessor's Map/Parcel r."Cro 06, /kj9 t(;"n= 96, 31. "PLC, p7L 34 'L Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �/f F3iZ i'Vln:n Sf Type of Building: Dwelling No.of Bedrooms hr. Lot Size 5�5�1 sq.ft. Garbage Grinder(AI) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 46}c� gallons. Plan Date /Zom Number of sheets _ Revision Date Titlev Size of Septic Tank I5ca0 C2AkL*%0 Type of S.A.S. Leuivu, Mgt.k Description of Soil P" '_10A (oil 9tc,A Nature of Repairs or Alterations(Answer when applicable) �,A6,_,%&,n 5a F it be shKM G.rssr LS. C:-w�str�cr fV_"Z S:e t-kc. S ._ w 1.�92A c1Z^n i' ':�+2� C�'Hu-;.s.. G V1 &A Jti •rtr-,i LL . 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 Title 5 of a Envir mental Code and not to place the system in operation until a Certifi- cate of Compliance has bee ' _ d hisBeth. Signe � Dat Application Approved by Date 7�d� Application Disapproved for the following reasons Permit No. /3- Date Issued IV f � a��� Fee f J Entered'in computer: . .LrJ J'No. THE COMMON E14¢. H b'F-MASSACHUSETTS k 1 t.Yes PUBLIC HEALTH,DIVISION -TOW 'OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mioozar *p5tem Cou5tructiou hermit 3 . Ape cation for a Permit to Construct( )Repair( .)Upgrade(X Abandon( ) X Complete System ElIndividual Components location Address or Lot No. 40 �� rC Zrr`2 s (.u�tlt Owner's Name,Address and Tel.No. Cof'u� � I'►'larian 14 Savc.r�. Assessor'sMap/Parcel fvdQ 00, Apf4,o3 3r PK.% 37— r ( jLqj2tw Ft 3 oZ. Installe�rp's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4Z3-y 15 WIS �O�W'�q YC✓� . CSFcrvi(tc., mvas 6Z65S , Type of Building: 1 `' Dwelling No.of Bedrooms Frx r- "Lot Size S 9 5Z 1 sq.ft. Garbage Grinder(441) Other Type of Building No. of Persons Showers( ) Cafeteria( Other Fixtures � k Design Flow I In 5g di6dr#A gallons per day. Calculated daily flow gallons. Plan Pate 3�1��Z0ft a-`Number of sheets cam_ Revision Date?: x R. Title �6�`l,- 54c►-ew UpfiyuGu Size of Sep T k 15go 24AL&VO Type of S.A.S. La ci-,L F'islcf Description of Soil P6444 rlr" A. col( kaa u, j2(e.ns } Nature of Repairs or Alterations(Answer when applicable) &t5,h.�) Gesstxm�S. 4„�strvc4 j nC6,J ACIDfRG :54CIZYM 4, { lh lAI41 Li�?tUI lu fjQ W � Y TkC S� Date last inspected: x' Agreement: 'The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage-disposal system in accordance with the provisions �f Title 5 oft a Envir mental Code and not to place the system in operation until a Certifi- cate of Compliance has bee d yyQhis B th. Signe Dat 1 W43t ' Application Approved by �- Date / 7.c7 t r Application Disapproved for the following reasons , Permit No.-?�� z1^ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtficate of Complialfirae THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by aa� at �d Ott ro A E Z r- -j /h , Cri�(�� has been constructed in accordance with the provisions Title 5 and the for Disposal System Construction Permit No._t"6W'/T 7 dated Installer Designer Z The issuance of this pe t sh4ll not be construed as a guarantee that the system wiI)��o`�as det'de Date )/ /3/0 Inspector �� _ _ No. �/"�� —�. -------—-----------Fee �. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS A.r, miopogar *pgteut con.91ructton ver,mtt Permission is hereby granted to Construct )Repair )Upgrade( Abandon( ) System located at k 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:Conr,/7 t ion must be completed within three years of the date of this pe Date: 3 3 Approved b � PP Y �. /0P � TOWN OF BARNSTABLECa Al �� LOCATION SEWAGE # 7 VILLAGE � '1r ASSESSOR'S MAP &LOT 2.79 32 INSTALLER'S NAME&PHONE NO. 146tie— SEPTIC TANK CAPACITY Ad o 0 'q s LEACHING FACILITY: (type) 7�n t' (size) 1�9 j NO.OF BEDROOMS. BUILDER OR OWNER PERMITDATE: 43 ®? 13 —2000 COMPLIANCE DATE: � -� Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any-xetlands exist Feet within 300 feet of leaching facility) Furnished by 97 ' � g 32, 7 ,� 1 i 0 > i ya •a . y' LI g DATE: 10/13/01 PROPERTY ADDRESS: 40 Captain Ezra' s Road Cotuit ------------------------ Mass. ------------------------ On the above date, I inspected the septic system at the above address. This system consists of ,the following: 1 . 1 -6 ' X6 ' block cesspool v � Based on my inspection, I certify the following conditions: 2 . This is not a title five septic system. 3 . This is a sewage system. 45 Plus years old. 4 . The blocks are punky and starting to roll . in. -. � 5 . A new septic system needs to be installed. �6 . Building has been vacant for a long period of time. SIGNATURE:1 _ Name:_J_P J. P . Macomber Jr .______ Company: Josei)h_P. Macomber_& Son ,' Inc . Address: Box 66 -------------------- Centerville , Ma . . 02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. mom Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 �� 775-3338 775-6412 ,per �—\ COMMONWEALTH OF MASSA#HUSE'TTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 40 Captain Ezra ' s Road o ui ,Mass. Owner's Name: Ron Mycock Owner's Address:30 School StrPPf rat1i t, mass 02619 Date of Inspection: 1-9jj3 1n�— Name of Inspector: (please print) J.P. Macomber Jr Company Name:Joseph P. Macomber & Son Inc Mailing Address: P=n= Box 66 rpnf-pr z-11e Mn G2632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information repotted 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 -�Beds Further Evaluation by the Local Approving Authority i �Lras Inspector's Signature: Date: Id-;olF09112M'4 The system inspector shall s bmit a copy of this inspection r port 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 authorit),. Notes and Comments 9 This report only describes conditions at the time of Inspection and under the conditions of use at that t/ -time. This inspection does not address how the system will perform in the future under the same or different conditions of use.. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 I �. 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Captain Ezra' s Road Co ui , ass. Owner: Ron M coc Date of Inspection: 10 1 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 Fin 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Cesspool is 40 plus years old. Blocks are punky and starting to roll in, , A new title five septic system needs to be installed B. System Conditionally Passes: N0 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the . for the following statements. If"not determined" please explain. ��AZlt6he a tic tank s metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, a ibits su stantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: V,0 Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: A0 The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 y Page 3 of 11 y OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Captain Ezras Road Cotuit,Mass. Owner: Ron Mycock Date of Inspection: 1 0/1 3/01 C. Further Evaluation is Required by the Board of Health: 41d 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: te Cesspool or.privy is within 50 feet of a surface water .� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 0 feet or more from a private water supple well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other• " The system consists of one 6 ' X6 ' block cess ool Blocks are punky - r Blocks starting to roll in. 3 I — Page 4 of 1 I g OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Captain Ezra' s Road Cotuit,Mass, Owner: Ron M cock Date of Inspection: 10 1 3 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No kup 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 istribution box bove outlet invert due to an overloaded or clogged SAS or cesspool �iquid depth in cesspool is less than 6"below invert or available volume is less than ''A day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 6 � 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 ,pater supply. _✓y portion of a cesspool or privy is within a Zone I of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) �dd,� /(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no (/the system is within 400 feet of a surface drinking water supply 4/the system is within 200 feet of a tributary to a surface drinking water supply — f' thesystem is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Y:. Page S of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Captain Ezra;s Road Cotuit,Mass. Owner:Ron Mycock Date of Iospection: 1 0/1 3/01 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes NXpurnping _ information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks zHa-s 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 ? l/Were as built plans of the system obtained and examined?(If they were not available note a N�/A) 1/ 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,�4tcluding the SAS, located on site ? Were the�m—aieria manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, f construction,dimensions, depth of liquid, depth of sludge and depth of scum ? Z— Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. _ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 f Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 Captain Ezra' s Road Cotuit,Mass. Owner: Ron Mycock Date of Inspection: 10/13/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Z Number of bedrooms(actual): l �� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): H/Q" I Number of current residents: ) Does residence have a garbage grinder(yes or no):AZ Is laundry on a separate sewage system (yes or no):.t 6 [if yes separate inspection required] Laundry system inspected(yes or no): ,!�O I Seasonal use: (yes or no):/ Auy Yi4, Water meter readings, if available(last 2 years usage(gpd)):I A4/¢� If�well has not- k Sump pump(yes or no): NO , � been tested in the last year Last date of occupancy: it should be done now. See pages 6A & 6B - COMMERCIAL/INDUSTRIAL - - -. - -- -- .-- " -- Type of establishment: Design flow(based on 310 CMR 15.203): 4M gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):&vf Non-sanitary waste discharged to the Title 5 s stem(yes or no): Water meter readings, if available: Last date of occupancy/use: A OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Awlt Was system pumped as part of the inspection(yes or no);_ If yes, volume pumped: O gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM AU eptic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Vd 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 sysltq owner) �ight tank " Attach a copy of the DEP approval her(describe): Approximate ae all components,date installed(if known) and source of information: ` Were sewage odors detected when arriving at the site(yes or no): 40 6 Page 7 of I 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Captain Ezra' s Road Cotuit,Mass Owner: Ron Mycoek Date of Inspection: 10/13/01 BUILDING SEWER(locate on site plan) Depth below grade: M t1 Materials of construction: _cast iron X640 PVC�ott (explain): Distance from private water supply well or suction line:f�7 t' Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight Nn Pvidancp of leakage System vented through house vents. SEPTIC TANK4,6t&(locate on site plan) Depth below grade: A),4 Material of construction:,tl/t'concrete V,#meta A1#9 fiberglass /,polyethylene ,�*ther(explain) QFR If tank is metal list age: dg Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: ,U Distance from top of sludge to bottom of outlet tee or baffle: AA Scum thickness: AM Distance from top of scum to top of outlet tee or baffle: _ A1,4 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: A14 Comments (on pumping recommendations, inlet:and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Once new septic system is installed The sept_ir- tank shntj d hepumped Pverr2-3 years. GREASE TRAP (locate on site plan) Depth below grade*1 Material of construction:A0 concrete 41A meta I /ai fiberglass&2fpolyethylenemother (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: /,)/? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Captain Ezra' s Road Cotuit,Mass. Owner: R� Date of Inspection: TIGHT or HOLDING TANM4 &(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: /»} Material of construction: concrete A/4 metalIL4 fiberglass .r//I Polyethylene.t1/¢ other(explain): 1 Dimensions: Capacity: allons Design Flow: 101 gallons/day _ ' J, Alarm present(yes or no): ,I Alarm level: f),$ Alarm in working order(yes or no): Date of last pumping: W4 Comments(condition of alarm and float switches, etc.): Tight or holding tanks are . DISTRIBUTION BOX4)A! ,(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Distribution box is no presen . PUMP CHAMBERO/oWL(locate on site plan) Pumps in working order(yes or no): Vl Alarms in working order(yes or no): ,1411 Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not present. 8 f Page 9 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Captain Ezra' s Road Cotuit,Mass. Owner: Ron Mycoek Date of Inspection: 1 0/1 3/01 SOIL ABSORPTION SYSTEM (SAS):Zlocate on site plan,excavation not required) 1 -6 'X6 ' block cesspool If SAS not located explain why: T.nnAtAd see pave # 10 Type , 4)Q leaching pits, number: O W,Q leaching chambers,number: O Cl?) leaching galleries,number: wlej leaching trenches,number, length: .a Alp leaching fields,number,dimensions: d 4)Ooverflow cesspool, number: Q A.)D innovative/alternative system Type/name of technology: crll Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to fine sand.No signs of hydraulic failure or ponding.Soils are dry. Vegetation is normal. CESSPOOLS (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): !/d Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Same as above PRIVY(locate on site plan) Materials of construction: .U/9 Dimensions: ,4/A Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present. 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Captain Ezra' s Road Cotuit,Mass. Owner: Ron Mycock Date of Inspection: 15 1 3/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �d CW Cz cas 'eA CA t 121 �A I 10 I Page 1 1 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Captain Ezra' s Road Cotuit,Mass, Owner: Ron Mycock Date of Inspection: 10 1 3 01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: _Obtained from system design plans on record - If checked,date of design plan reviewed: _Observed site(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: Used; Gahrety & Model 12/16/94 Ground contours above sea- level USGS 92-000-1 Plate # 2 USGS )bservation Well Data Top of Ground ------------ Leaching Pit 'eet Ground water04eet Below Bottom of Pit Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is 67o& feet. 11 . 'TOWN OF Barnstable BOARD OF HEALTH SOBSURFACF ,SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION ^•T!• �T••.'•.: �T,II^�TTI tt T.T11'R.ITi TIRiRYfTT.Tt'rC'I r1tT1�171IT17TT1tA'I��'1R7 7wRH �IrT'T•1• -. J -TYPO OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS 40 Captain Ezra' s Road Cotuit,Mass. ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Ron Mycock• PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & S.Qn Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or City State i►P COMPANY TELEPHONE (508 ) 775 3338 FAX ( 508 ) 790 - 1578 - CERTIFICATION STATEMENT - I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regardi►Ig' upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* \ The inspection which I have con acted has found that the system fails to Protect the public health and the environment in accordance with Title 6 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date _ .�, m&Z ecopy ofia", his c t.ification must be provided tothe OWNER, the BUYER On where applible and the 130ARD OF HEALTII, * If the inspection FAILED , the owner or'"operator shall u within one year of the date of the inspection , unless allowed dortrequiredm otherwise as provided in 3.10 CmR 16 . 305 , partd . doc TOWN OF BA.RNSTABLE ' �� LOCATION SEWAGE # ' "7 VIT"LAGE ASSESSOR'S MAP & LOT!!�e 39 'Z( 3-' P4STALLER'S NAME&PHONE NO. 400c— Grrl.-IC "1'20 1 4'?-2I SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) (size) 12.X 36 0 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: S —H "2ee2 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility" - Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any etlands exist V within 300 feet of leaching facility) Feet Furnished by o'. 320 r 4 h , ® 0 ` . 4 Ja 96 ,E >; �- At Z7 3g e �. .� � � .� �D C��� �z��s � �3� �e 3� �,� d CapA Co+r,t �-- im OC 2' s IIaa ./ o EXISTING LEGEND PROPOSED .� N Doso�o schodub ELEVATION dC�'�l(�hko area R ' - Edge of Pavement - oo FIRST FLOOR - 22.7 4 BEDROOMS AT 110 GPD/BEDROOM = 440 GPD FINISHED BASEMENT FLOOR NA - - Wcter Pipe w - otio EAGLE FINISHED GARAGE FLOOR NA. ADDITIONAL 50% FOR GARBAGE DISPOSAL N.A. O O Septic Tank ® ® o� R0. POND O SEWER INVERT AT FOUNDATION (ADJ. AT TIME OF INSTALLATION) 20.0 Distribution Box o �S M��� J O SEWER INVERT INTO SEPTIC TANK SEE PUMP SYSTEM NOTE 4 19.8 PERC RATE = 2 /1 MIN. / INCH (CLASS 1 ) ° 2C0 Contours 20o SP�P�o tio�S a SEWER INVERT OUT OF SEPTIC TANK SEE PUMP SYSTEM NOTE 4 19.5 LTAR = 0.74 GPD/S.F. 20000 Spot Grade 200.o O INVERT INTO PUMP CHAMBER (SEE PUMP SYSTEM NOTE # 4) 19.2 Test Pit a INVERT OUT OF PUMP CHAMBER (SEE PUMP SYSTEM NOTE # 4) 19.5 MIN. LEACHING AREA OF S.A.S. La►N� O 20.3 QIS LOCU � �� SEWER INVERT INTO DISTRIBUTION BOX 26.7 440 GPO/ 0.74 GPD/S.F. = 595 S.F. MIN. SEWER INVERT OUT OF DISTRIBUTION BOX 26.5 Ap?N 18.6 PROPOSED SYSTEM : SIDEWALL: (12'+35')x2'x2'=188 S.F `' J���� SEWER INVERT INTO LEACHING SYSTEM 26.4 BOTTOM: 12'x35' - 420 S.F ,Soy �a.��w LOT 47 �O�Ijn� (� jn(� BOTTOM OF LEACHING SYSTEM 24.4 608 S.F. LOT 12 O 20.6 ! R 2.50b S�A52• 19 MICHAEL do DAVID STUSSE TR. BUJ �U'IJ[rtJ(f PETER M. do JANICE V. DESESA 1 y e RI & AP WATER TABLE (ADJUSTED) 19.4 e MINIMUMS SCALE 1 2„000' WATER TABLE (OBSERVED) 14.4 I C ASSESSORS 19.7 �, °r AREA = 43,560 S.F. MAP 38 .8 FRONTAGE = 20' PARCEL 32 WIDTH = 125' "C.N.S." ��o ,� �30"`II 19.5 FRONT SETBACK = 30' C.B. 0 ,�D 019.5 �4'�8 headwall SIDE SETBACKS = 15' ��IdLd�®��. LOT 39 FND. \ 19. A19.2 REAR SETBACK = 15' ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH a \20.6 JOHN N. do NORMA C. ANDERSEN 2' �o `�' 0 \ LOT 461 C.B.s \ " TITLE V OF THE STATE SANITARY CODE DATED BUILDING HEIGHT = 30' ' 1° 12' MARCH 31, 1995 & ANY LOCAL RULES APPLICABLE.' 1 53521 SQ.FT. ` FND 18.6 �I 0. . _ FINISHED GRADE 1.23 ACRES `� vNE ;\0 CHRISTOPHER T. do THERESA A. HILLS I 36"MAX.- 9'M►N. CP �E u ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING PEAST1. 0 21.0 20.2 �� .y 2-t 4. 3/4' TO 1 1/2 ' BY THE DESIGNING ENGINEER. + `' '. DOUBLE \ Ct 1 9.1 `� . w » " .'+ '.°.. "'•` •'' ' WASHED STONE \5� P 20.9 ✓ ,age 20.1D I C.N.S. 0 9 I,/ y 1 t•y C.B. 3D 5 KFILLIN , \ 8oX o eX,st,�g 20 3�. l s'. ' t, a WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BAC G .+ 0: i l L a . P _ 0, o ) r• FND. 2- "•y, :•. ' NOTIFY THE ENGINEER & BOARD OF HEALTH AGENT I s.B. FND. QUM of e1 �0.1 $�' \Y ` y o P L FOR INSPECTION. BENCHMARK a N \0 25.6 i,TOP OF S.Bi G 7z 0 19.9 19.6 17.4 417.7 �Ag".� $ j DEL.=23.59' It t 20.9 20 1 `,, 19.7 19.2 •0° p� �" G SECTION IT MAY BE NEB TO REROUTE EXISTING INTERIOR HOUSE \ IN.G.V.D. o , ` 17• ( -3 17 : PLUMBING FOR THIS SEPTIC SYSTEM UPGRADE: \ 21.4 21.10 21.1 / 18.4 17Y ' \ 21. 199.• 19 20 O 1✓� drweway THESE ELEVATIONS MUST NOT BE CHANGED WITHOUT WRITTEN l r' 21 ouch 21 2 (�! 19 2 �a g 0 paved-_ 17 4� 5�4 APPROVAL BY THE DESIGNING ENGINEER. � P /\\ 17.5 17. 5 TOTAL UN17S 1 STARTER,1 END, do 3 INTERMEDIATES 24.8 i \.00, \ ` t 8 9 17 8 11 ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4" PVC. SCH.40. ` ee s U 1 7 ems,'. „•,.•' •y 20.8 RL STONE•'::: `���• --, � •� ex1stm9 e�2 �0 18.8 I I .,, 9.4 LP. FND• iD , .;? EXISTING CESSPOOLS TO BE PUMPED AND FILLED WITH CLEAN SAND. a ". LOT 40 ♦ o `,1 {.f. - r 19.7 �� N. �, ... . ..•. 22.2 15.6 JAMES A do CAROL A. LYNCH EXCAVATE AND REPLACE ALL UNSUITABLE MATERIAL SURROUNDING \�, 35' SURROUNDING THE LEACHING FIELD FOR A DISTANCE OF 5', PER 0 25.O,y ' ;' =' 15.8 PLAN OF LEACH CHAMBERS 310 CMR 15.255. / 1 N NO SCALE \ - 15.8 PRIMARY BENCHMARK : N.G.V.D. 4 PROJECT BENCHMARK : SEE PLAN till � LOT 3 1 i J10-3 n s\ / N CL jr II °� 16.3, c LOCATION OF UNf' ;AND UTILITIES ARE APPROXIMATE AND N � �. / MARUW F. SAVERY TR. SHOULD BE,;VEF 'THE FIELD BY THE APPROPRIATE ' i +� i ^ ' y. TO �N i I i<�S i RUCTION. ° 3' / �13.5 ^ 2 - UTILITY COO ' C 0 I 16.9 POND • •\ it / I 13.4 NOTES: GENERAL NOTES FOR PUMP SYSTEM 'l 1. THE CONTRACTOR IS TO SECURE ALL APPROPRIATE PERMITS. 1) PUMP TO BE SIZED BY PUMP SUPPLIER. of M Assgc I 2. REMOVE UNSUITABLE SOILS BENEATH PROPOSED SYSTEM, <� ti ( 18.1 2) PUMP TO MEET GENERAL SPECIFICATIONS OF 310 CMR •� 17.5 BACKFILL WITH CLEAN GRANULAR MATERIAL FILL TO BE sTeP N• GRADED AS FOLLOWS: NOT MORE THAN 15% RETAINED ON No.. 15.231. 6.0 - -+ No. � LOT 2 4 SIEVE, NOT MORE THAN 90% RETAINED ON No. 50 SIEVE, y 3 MAINTAIN CONSTANT PITCH FROM DISTRIBUTION BOX BACK •O 9��-0 � S.B. FND. ROBERT L, HOCK OF FRACTION PASSING No. 4, 10% OR LESS TO PASS No. 1010 TO PUMP CHAMBER TO ALLOW FORCE MAIN TO DRAIN SIEVE AND 5% OR LESS TO PASS No. 200 SIEVE, SOIL TO BE BETWEEN PUMPING. FSS/ONAt,E��' LOT 41 APPROVED BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING JAMES F. & ELEANOR JOHNSON ON SITE. y6 � 4) INVERTS ON SEPTIC TANKS AND PUMP CHAMBER TO BE �� •tip 3. LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST FIELD ADJUSTED AS NEEDED TO ACCOMMODATE EXISTING 72 HOURS PRIOR TO ANY EXCAVATION FOR THIS PROJECT PLUMBING AT HOUSE. LOT 45 CONTRACTOR SHALL MAKE THE REQUIRED NOTIFICATION TO DIG SAFE (1-888-344-7233) AND APPROPRIATE WATER 5) LEACHING FACILITY TO BE VENTED. Septic System Upgrade LESTER J. do ANNE C. WADE SCALE: 1 = 30, DISTRICT TO DETERMINE UTILITY LOCATIONS. 6) VISUAL ALARM TO BE MOUNTED ON THE EXTERIOR OF THE At Cap'n Ezra's Lane & Putnam Ave. 30 0 30 60 4. ALL STRUCTURES BURIED DEEPER THAN 4' OR SUBJECT TO HOUSE FACING THE STREET. ?milli iii;;R VEHICLE TRAFFIC SHALL BE H-20 LOADING. Cotuit, Massachusetts SCALE IN FEET 5. SEPTIC TANKS AND PUMP CHAMBER SHALL BE -- WATERPROOFED PRIOR TO DELIVERY TO THE PROJECT SITE. PREPARED FOR LOT 44 CERTIFICATE REFERENCE: #143853 ADDITIONAL WATERPROOFING AT TANK JOINT SHALL BE DOUGLAS C. do PHILLIP D. JACKSON PLAN REFERENCE; L.C.C. 34.623E SHEET 3 OF 4 PERFORMED AT THE SITE PRIOR TO BACKFILLING. MARIAH F■ SAWERY TITLE Sanitary Disposal System TYPICAL SYSTEM PROFILE TO SCALE o G;l�n1 u ERY EYE E o WOO wGREN wc. NOT C.I. COVER FIRST FLOOR = 22.7 ADJUSTED TO VENT F.G. ��2n MN12 M p n/� 2�n INC.FINISHED GRADE OVER LEACHING TRENCH = 28.0 t o li,Un1 U ER y EYE 15 o W umfl�LSUUy N Fogineen one Land ksuffefyeirs FINISHED GRADE OVER TANK = 21.0 FINISHED GRADE OVER D. BOX = 28.0 812 Main��P(�(�Q9 OJlll�u UO��ISy me. B2655 FINIS 12" (min) Cover �oo� �0� DATE. 11���0�� 32" max Cover Phone. (508)420-9131 Fu w Q508j 420»3750 8"MIN. » 3 (mi . PROVIDE INLET TEE REMOVEABLE COVER OUTLET PIPES ' FOR PUMP SYSTEM .• 2"Layer 1/8"tot/2" TEST PIT 1 (AS REQD.) Peastone LEACHING CHAMBERS 4" SOH. 40 PVC (TYPICAL) G.S.E. = 21.7 " Slope = 0.005 min 2 6'(ruin PV 10" cl cbnlc� = 8' 6" / O O O O • O • • • • O O O 0 LOAM & SUB SOIL INLET PIPE - t 2" O O O O O O DATE MARCH 1 2000 RAFFLE" INV O O O O • 'CO. O • O O O O O • MEDIUM SAND 3 -_ 6 CRUSHED REINFORCED CON CR STONE BASE PUMP CHAMBER & GRAVEL FOOTING SEE PUMP NOTES BOTTOM ELEV. 24.4 3fi" REV. DATE: REMARKS - .w,.. .,,,, „:. ., MEDIUM SAND 5' MIN 60„ 1 8/20/2001 REVISE SEPTIC FINE SAND 1500 GALLON SEPTIC TANK DISTRIBUTION BOX -ADJUSTED WATER LEVEL EL = 19.4 88" DRAWING NUMBI.JZ TO BE INSTALLED ON A LEVEL STABLE BASE TO BE INSTALLED ON A LEVEL STABLE BASE SEPTIC TANK TO BE INSPECTED do CLEANED ANNUALLY PERC OUTLETS REQUIRED WATER ENCOUNTERED EL. 14.4' PERC © - 48 H:\1999\99113\survey\99113csp.dwg RATE= < 2 MIN/IN 991 13CSP.DWG