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Home My WebLink About0590 PUTNAM AVENUE - Health 590 PUTNAM AVENUE COtUlt, A= 038 - 013 - - - - - - -- j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments X'l M 590 Putnam ;ry Property Address Robert Foster f Owner Owner's Name information is X required for every Cotuit Ma. 02635 04/18/2018 r page. Cityrrown 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 A. General Information filling out forms (57# /a 9770 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections � Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Citylrown State Zip Code 508-280-3356 S13938 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 04/19/2018 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 has a design flow of 10,000 gpd or_greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Z695 0 Us Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. City/Town 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: This 2 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding two 500 gallon leaching chambers. At the time of the inspection there were no visible signs of past hydraulic failure. Note this is a 3 bedroom leaching system. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. Cityfrown 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M syey'�. 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 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): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Plus GPD t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w W -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,• 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Fa112017Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203)-" Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 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): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 590 Putnam Property Address Robert Foster Owner Owner's Name information is Cotuit Ma. 02635 04/18/2018 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3611 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 221f feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon septic tank Sludge depth: 1° t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewag e.Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 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 36" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5„ Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): F *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •y'`y 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 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.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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 the time of the inspection the leaching was dry and there were no visible signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 it Commonwealth of Massachusetts 4 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - 2 = 3 y u✓� XT a OF t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 590 Putnam M Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet 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: I augered a hole to ten feet to show 5 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 590 Putnam Property Address Robert Foster Owner Owner's Name information is required for every Cotuit Ma. 02635 04/18/2018 page. City/Town State Zip Code Date of Inspection' E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE# of VILLAGE �'a�o�7" ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)Coy-«?t7e- (size) --"f X.,X rX oY NO.OF BEDROOMS 3 OWNER -,A-- PERMIT DATE: —'�� COMPLIANCE DATE: Separation Distance Between the: ® �✓ y�� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist uff, site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY I soA,,d ; Al t •�i dgar Via: �,►t�me�� o �- ,, II I_I No. (� i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Bisposal 6pstem ConstCUttion J)rrmit Application for a Permit to Construct(Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.6 9a p�v7/ri¢/��g�". O is N e Address and Tel.No. Assessor's Map/Parcel O-3 (? Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Gc-P Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided `� �/ `� gpd Plan Date �" J�` �� Number of sheets / Revision Date Title el Size of Septic Tank 67 /10° 19 64� ype of S.A.S. Description of Soil .��ul P Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board Health. Signed Date Application Approved by JL> Date Application Disapproved by Date for the following reasons Permit No.,201 Lf^ Date Issued �'�� L' - � No. '� - r qu ..�, j' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zpplication for Disposal *pstem Construction Permit Application for a Permit to Construct(Repair( ) Upgrade( ) Abandon( ) ❑Complete System A Individual Components Location Address or Lot No.6-9t9 Ow is Name Address and Tel.No. Assessor's Map/Parcel n r3 (� } — oz� Installer's Name,Address,and Te1."N`: Designer's Name,Address,and Tel.No. Type of Building: wl Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building -4r" No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided S/-9 gpd Plan Date Number of sheets / - Revision Date Title !!�� Size of Septic Tank ��/.�'��i'' ��o "Type of S.A.S. Description of Soil T Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board Health. G Signed Date '�� Application Approved by Date air r L� Application Disapproved by Date for the following reasons Permit No."?0j L'^ Date Issued TH1 COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of Compiianre THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( •) Upgraded( ) Abandoned( )by �1 .Z4Z-130",/C at _ //ar//' ,� 4.0,e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,2 _jGq dated Installer //�j .G�c��pC��/� Designer�} yi'L7 /,�/r1f-f'G/�' %00r'r #bedrooms Approved des ' w .�,'%f� /j� , gp The issuance of this permitsh 1 n(a c/o trued as a guarantee that the system wi"Cunctil /designed. / Date ( % �l�T Inspector /// C� - --� ----- ---------- - --- - J �- ✓ No.Pal`-f Fee cro THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS d Disposal *pstem Construction permit Permission is hereby granted to Construct(b� Repair(y� Upgrade( ) Abandon( ) System located at / and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b completed within three years of the date of this permit�� n Date — ( r i I Approved by Town ®f Barnstable Regulatory Services r Richard V. Scali, Interim Director BARNSTABLE, MASS. g Public Health Division 16,39.AlFD r��A Thomas McKean, Director 200 Fain Street,Hyannis, TNIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form " Date: � 1q Lot Sewage Permit;4 ��Assessor's Map\Parcel �C3 V"Z!N Designer: p�,,jjInstaller:101/A Address: Address; On l was issued a permit to install a (date) (ins Taller) septic system at based based on a design drawn by (nnaddress) 1 t YL dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in com liance with the terms of the IAA approval letters (if applicable) �j� r� DNViDB. ;T fia1NSON #to ( sta er's Signature) � ;Jo. less 1 z % ( In afore) (Affix Desib p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COIIIPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM Al'•tD AS- BUILT CARD ARE DECEIVED BY THE BARINSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\septicTesigner Certification Form Rev 8-14-13.doc I Town of Barnstable P# ' Department of Regulatory Services Public Health Division Date MAM 1639 200 Main Street,Hya nis MA 02601 Date Scheduled— Time / Fee Pd. Soil Suitability Assessment foe-Sew Dis s Performed By: Witnessed By: LOCATION&GENERAL INFORMATION Location Address ,I �U�.�¢/,j �!/�" Owner's Name G orU Address90 Engineer's Assessor's Map/Parcel:Q, O f� Name f NEW CONSTRUCTION REPAIR Telephone Land Use. Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft. Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) T 1 z' co M r7l Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: _ Depth Observed standing in obs.hole: In. Depth to soil mottles: In, -� Depth to weeping from side of obs,hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor AtIj.Groundwater Level, m PERCOLATION TEST bate ._ Time,__ , Observation Hole# »>ttt Time at h" Depth of Pere Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Z. t Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: public Health Division Observation Hole Data To Be Completed on Back----=------ ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Consefvation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION BOLE LOG Bole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ortsistencY %Gravell DEEP O.BSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cansistency,% ra --------------------- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c Gravel) DEEP OBSERVATION DOLE LOG Bole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Cons' ten Flood Insurance Rate Map: 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 perviQu terial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring Per material? Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Enviro ntal P L that the above analysis was perfo ed by me onsistent with the required training, p rde described in 510 CMR 15.017. Signature Date G �o-,� Q:ISEPTICkPERCPORM.DOC �� - �: -- ✓ Y /��y�/ �� r 1 ,C3 `� r! �j ter, r H u vS e r THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA- TH -------.OF........... ... . ........... ....................... Appliratinn -for Uhapmal Works Tongtrnrtinn Fermi# t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ! Q S 1 ryn . --.. ._�.`.../-_v..-�------------------- --•---.._�C.' - ........................................................... Locaf -Add s r Lot N ` 1 �1 JJ Owner / Address Ins er Address Q Type of Building Size Lot.5.0{._M� ---Sq. feet Dwelling_No. of Bedrooms.--_-.-.-�------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures Q - w Design Flow---------------3-__--.....................gallons per person per day. Total daily flow------------- ---------------------gallons. WSeptic Tank—Liquid capacitv../ll2V_gallons Length---------------- Width..---..-__.-. Diameter.-------------.- Deptli..---._-...._. x Disposal Trench—No----------------- -- Width.................... Total Length.._-_-..-_ Total leaching area.. ------ ....sq. ft. Seepage Pit No-------/----------- Diameter.......�......... Depth below inl -_._t�__-_.__-_ To al aching are. ..........sq. it. z Other Distribution box ( ) Dosing tank ( ) /01.a Q �l a Percolation Test Results Performed bY.......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit........._.......... Depth to ground water....-..---- -----------. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.-.-------.__-_----_ Depth to ground water.-.-..-..--..-..-.---_- 0 Description of Soil-------dam -Sty'-_-_5�1� --------•---------•-•--------------•-------------------------•------------..........------.-•--.....--------------- x w U Nature 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 p p has been i .ued by �Oard of health. Si ` '� ..__. operation until a Certificate o Compliance e d__ __ _ ___________ _ T 1� Date Application Approved BY / ---------------------- ✓- ate Application Disapproved for the following reasons:..........................................-----•••••..._....-••__•••----------------------------•----•-------•-- ...............•-•--------------•-----••-----•-------------------._..--...--•---. ------------•--••-------------•--•------------•---------------=--------....--- ---------------• --- - -------------- �j i Date Permit No......................................................... Issued-e,l• ----�---�-TL// ...--•- Date No......... ........ FEs.. 0... ...✓ THE COMMONWEALTH OF MASSACHUSETTS BOARD O,.F HEALTH ........._OF............. Z6......... ................... Applirtttion for M_q#viitt1 Works Tutuitrurtiott Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy.stem at: ( 0�� Hof •..•• -----------•--------------•-------•-------..•----------••••-•----••---•-------....._..... ................... ----------.-�.....................--................................... Locatio -Add r, Lo N .-------------------------- --•--•.....---- --- --12 ---•---••......•-•............. Owner Address l / Y -•-••-------••---...-••-••--••-•--•-•--•--- Insta 17 er Address U Type of Building Size Lot_5A..`f?�P.....Sq. feet Dwelling—No. of Bedrooms------------ Attic ( ) Garbage Grinder� ( ) aOther—Type of Building -------------_.............. No. of persons--__________________________ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------------------------------- W Design Flow............................................... per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv__/>? _gallons Length---------------- Width................ Diameter------.-------.. Depth_-_--_-______--- x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area-----------•.--.....sq. ft. Seepage Pit No.......Z---------- Diameter.......L•-_......... Depth below inlet... Total leaching area-_ sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- ,4 Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water--------------------- (T, Test Pit No. 2_...............minutes per inch Depth of Test Pit-________.__________ Depth to ground water_.-_______________----.. W 0 Description of Soil------- ` - S ------------------ x V --------------------------------------------------------------•-•--•-•----•-••-•-•-------•-----_._..__..__._...-•---------------•------------•••-•---•------------------..-..._._._.._..---•-------- W UNature 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 i,§ ued by the board of health. . ,•,._ —„ - Date Application Approved� By------- . --••-L. 4�•�'+'-� --------------------- �-r /�=f•' ate Application Disapproved for the following reasons:.. ---..._..---•-------------------•---._..._---•----------------___._._._...-----------------__...----•-•--..-•--•--•-•-------....._._.....---•---•----..--•-•------------- ............................. Date Permit No......................................................... Issued.--- .._... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH d'r-x ......O F. Trrtif irtttr of ThIm Iittnrr T IS TO CERTI Y,.,Tha e't•ndividual Sewage Disposal System constructed ( or, Repaired ( ) by ._.. -•- •. ---• .......-•---- -- - -----•......--••-•---• -------•----•---••---••- - " Installer V__ `r� • t� at----- - ._••I ------ '"` /!f�... --•----••--------------- has been installed in accordance with t e provisions'of :Article XI o The State Sanitary Code as described in the application for Disposal Works Construction Permit10._�_______________ _______________ dated._...�.: ,j°" z._x:.____-.___.__ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL_ FU� TI �AT FACTORY. - - Inspector/ __-------•--•--------------•-----DATE --� _. - -•----------------•. 1`HE�COMMONWEALTH OF MASSACHUSETTS . .w BOARD OF EA 'LTH ... 1....:.OF............. et, 'Z:-..: -....---- .:.. No......,/ ----- FEE.... . - Permission s ere by granted__-------- ___ ___ __________________ �..�1'1_. . _ to Constru ( or R r )�a Indiv• 1 Sewage Dispo ste at No. ~ 2 /�. - '-•-=-------- __emu---- t j/ tree' as shown on the a plication for Disposal Works Construction ef' it No. __ ._ _._. ated------ __:��-----17�____ ----- .._: of He/ Board alth • .{ DATE. -h--.........------ ------••----•-••••--••--.:-...... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Assessor's° dp'arm~ lov number `/ :. Sewage Permit number % (// (/(/�y .. ... . R.: ,• , C *THE IDNSTABLE ` 4 1. i PAUSTME, BOUDIN. W P Eft 0 j. ' ;APPLICATION FOR PERMIT TO / '.111 r v�.:s f't l r ,'' b„'''A"4AfP ! TYPE OF CONSTRUCTION .:....... ti-° *".: : ..., . • _ } - ' 4 '1 x. tee t `,.. "i A n 7� �'�' r a�y fir' l(� /�y ,. .......17..J.'!. _ TO THE INSPECTOR OF BUILDING:=-.--�' + t The`;undersigned hereby applies for ar permit according to the following information:, locationD J i" t... ,�:..�.... ....... .......`!............................... .... ........ . ..:. ...... 4 Pro osed Use ti` !g°� ..} . `.s° .��'c�F.:1. ¢ `.`�.:. . °'r �`� ...................... Zoning District . .. , <, ............................' Fire Qistrict , .... ...................... Name of. Owner .. � '� '& * � �� . ttt` '.Adds ..... . r`a Name' of. Bu{Ider• �, 1 F.�'.. S ya ..�!J�!�'.f � ..�. ddr'ess .G . 7" �'. .. f� Name of Architect: Address ... Number, of Rooms: Fouindation 4 � x'�F'�?� . Exierior} q °� `� ` ?// l ..a t . . Roofng ?`' Floors .. Interior,! ...�` ... .. .. . t In erio Y. 1 sv r, , Heating �'°3'� �> ��;� �� Plumbing ......" .$ .... " Fireplace ...'. 1......, .............................................Approxima'te Cost '. `....... Definitive Plan',Approved*by Planning Board' ' ___L'______:=19 __1.d:— Area-.: i... Diagram of Lot_. and Building with ,Dimensions 1 a Fee .y. i $ SUBJECT TO`.APPROVAL OF BOARD OF HEALTH i A . e t �cts, , ,y '3 :i1 ..Y'--J..�,..e_.�.-_,x.. _ r •:`ti ,r.•i,,rt 1 , 1 1, h 2 Y � �r ) • ; "t 1 S. ' �,� 1 t ,. `.• t '.4t �l �� {r � � { '� t .;j S 4 .'; , d��. 1q , t „! .4:� G,. �. .'3 Oft " " .XS}..� S�•.'s+ .�' ' `' ' t'' ,�.a'`t•: c ':r+ , �. .,s f i .: rt .9f I hereby,agree to`'"conform to all the Rules ,and rRegulations of the Town of Barristable.[egarding,,the-above construction: / t Name .... AsBuilt Page 1 of 1 /6 - / 7 3, 5 3� 3� �b� ra big f HooSc http://issgl2/intranet/propdata/prebuilt.aspx?mappar--038013&seq=1 5/l/2014 - I ASSESSORS MAP : PARCEL: TEST HOLE LOGS � (� 1) The installation shall conii. ; with Title V and 'Down o oard of. FLOOD ZONE: � SOIL EVALUATORt f' 6 Ilealth Regulations. ��I�u�� REFERENCE : WITNESS : ) 2) The installer shall verify the location of utilities, sewer inverts and septic 9 DATE:- zc>I components prior to installation and setting base elevations. I Z 3 All gravity se piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first PERCOLA2Tq I ON RATE. ..-�, , � / ) 6 y septic p p g two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other TH- I TN-2 purpose other than the proposed system installation. � 5) All septic components must meet Title V specifications. J> . � ,C ---- - - - �� A 0 �, 6) Parking shall not be constructed over I-I10 septic components. -G � 7) The property is bounded by property corners and property lines. ►t 8) The property owner shall.review design considerations to approve of total LOCATION MAP Z A '1�p� �'' design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed c ,t✓1 , / approval of the design flow by the owner. � '6 , 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall { be removed aloe with contaminated soil and replaced with clean sand per 1 g p , Title V specs. l � L4%M1� 1� 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SC1140 PVC With ends grouted if applicable. The proposed SAS is being installed below the water service 4 line. The line is to be sleeved as aforementioned and maintained in place.' SEPTIC SYSTEM ! DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such FLOW ESTIMATE i exists. 13)The installer shall.verify the location, quantity and elevation of the sewer i BEDROOMS �'.T Ib GAL/DAY/BEDROOM - GAL/DAY lines exiting the dweliing`prior to the installation. -- _ 14)This plan is representative only that a system can fit on a property meeting SEPTIC TANK I Title V requirements. �jGAL/DAY x 2 DAYS GAL r' USE I� GALLON SEPTIC TANK ElC)0I I)4 0 ABSORPTION SYSTEM��L-._�1�-("._.� 5cb eT,�f, 61449 s gADVID 9�y G l rm SIDE AREA: ZIM3ZJ- = //, q7o.,_ BOTTOM AREA: X zZj� s7E N T SEPTIC SYSTEM SECTION /LMA "Nu J i o C� I Nil- �, ►o l9 Qs\ SEPTIC TANK Gf --1�zy- vC It► H . �j3D o 0 7,0Z ✓� / SITE AND SEWAGE PLAN LOCATION M PREPARED FOR : T1 (� T �� . SCALE• DAV I D B . MASON,P\S DATE: Ib Ol DBC ENVIRONMENTAL DESIGNS J NS Z EAST SANDWICH . MA _ DATE I HEALTH AGENT ( 508 ) 833- 2177