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HomeMy WebLinkAbout0726 PUTNAM AVENUE - Health 726 'Putnam Avenue .t. Lotuit F -- ----- — — 039 081 !i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 726 Putnam Ave Property Address ; Williams Owner Owner's Name r•,_ information is required for every Cotuit Ma 02635 3/3/2021 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. Inspector Information o1I on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. � Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected thesewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3/3/2021 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 f Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams . Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection C.-Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but.not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)) t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes E No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank size Reason for pumping: maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: existing tank Title 5 upgrade in 2007 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: 21 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line 25+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): no signs of poor venting or leakage1. t5insp.doc-rev.7/2 61201 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �9 . 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal H10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8 x5 Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? tape and 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.): tees in place. no major decay visable. tank at working level. pumped for maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. City/Town State Zip Code Date of Inspection D. System Information. (cont) 8. Tight or Holding Tank(cont.) 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 9. 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.): Dbox in good condition. no.major carry overs no major decay. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Cityfrown State Zip Code Date of Inspection D. System. Information (cont.) 10. 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. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is Cotuit Ma 02635 3/3/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): chamber with riser dug up. system dry with no hydraulic failure present. leaching is vented due to depth. in good working condition. leaching is 3 500 gal chambers with 4' stone around them. 32'x13'x2' leaching area 12. 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 Comments (note condition of soil,.signs of hydraulic.failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 726 Putnam Ave Property Address Williams >a Owner Owner's Name information is required for every Cotu'tt Ma 02635 3/3/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t 1AAT . Aa ® o A3 y Sir, Q3 — m•Page 16 of 18 t5insp.doc•rev.728f2018 Title 5 official Inspection Form:Subsurface Sewage Disposal Syste Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments f 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high groundwater: 10+ 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: 2007 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: no GM on test log. bottom of SAS at 6'. system installed and inspected by health dept per title 5 regs. in 2007 permit#2007-482 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Tithe 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 726 Putnam Ave Property Address Williams Owner Owner's Name information is required for every Cotuit Ma 02635 3/3/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. s ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 tT - i Town of Barnstable P# Department of Regulatory Services Public Health Division Date MAE& �f 63 , 200 Main Street,Hyannis MA 02601 Date Schedule O� Time Fee Pd. D Soil Suitability Assessment for $ wage Dis osal Performed By. :Witnessed B Y)a y LOCATION& GENERAL INFORMATION Location Address 7626 P&TAI-i4,,(-AVE CuT'ut-T Owner's Name✓®,qA/ Address bC l"t q A45 Assessor's Ma /Parcel.• 7P� /�d?A/'d A VE CU?�ItT Yp J[J() p ©' 1 —Okl Engineer's Name t.SGit, �V�t6✓.tT�� tom'` NEW CONSTRUCTION REPAIR Telephone# G,I 513 Q670 go Land Use iZer,V6n1 Y r A'l, Slopes(%) /+ Surface Stones /`��p►C r Distances from: Open Water Body ft Possible Wet Area 9. 7® ft Drinking Water Well J�ft Drainage Way ! 0 ft Property Line —Oft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) `J' FE Pa-opo s o �,[/c� SSW',k6 Z--- PLA Oki /j/21/07 trs I f f LJ I Parent material(geologic)R/���� 0V/Pve SLt Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_A11 Weeping from Pit Face /V/yq Estimated Seasonal High Groundwater R/�s4 C 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 Index Well# Reading Date: Index Well level— Adj.factor— AdJ.Groundwater Level,,,e i PERCOLATION TEST Date I v 1 D nwe/0 Observation ` Hole# _ '1"tme at 9" 1030 6 S� r Depth of Perc W7 J 4 Time at 6" �� �o Start Pre-soak Time @ 25 At A4-,b-j f®� 'lime(9"-610) J j D End Pre-soak <� Lb Rate Min./inch C-Pt Site Suitability Assessment: Site Passed X _ Site Failed: Additional Testing Needed(YIN) 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:\SEPTIC%PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoneg;Boulders. istencGravel) `!iO v l0, !y y" t 2.G 7/ ®gc_ ra DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% Z i'-t 8 to A ,aA�n ,t?3/� GSliw�c �1� 3-7 It-(481 C 10 / 6 q hC e -�tA4,eo DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) 12 16 A, LoAAka CAjj 10YR31-1- it . 40 37 60'd l6w. A4 (' DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. 37 9 L o &ti 1.1 Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes ' 1 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? Vels I If not,what is the depth of naturally occurring pervious material? Certification I certify that on �� (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 in' g,expertise and experience.described in 310 CMR 15.017. Signat Date�6 Q23 b �Z Q:\.S.EPTIC%PERCFORM.DOC N%. J 0- 000— , Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for �Dtgozal *pztem Con0truction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. �oZo ' ,TnAh R ve. Owner's Name,Address,and Tel.No. SbS-ya8-3Ci(3 COTt�;T- Ge�a.•,d Lv i((i}Avn�.s Assessor's Map/Parcel O3 /oe 1a is R� r COMB. C C so g• Sa8-36o2- a.ol. Installer's Name,Address,an Tel.No. yu$_ss;iR Designer's Name,Address and Tel.No. l�ruce. 0.C�(l•st 1 'DArC-LA t1e3cr 81 ?o,z( S OSicrr.�l(c I�'O•�o�t 8( �',gr%SAn,�c�„c�� Type of Building: Dwelling No.of Bedrooms 7 Lot Size c2o[d03 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 11410 gpd Design flow provided y�/� gpd Plan Date OC I.I1)QOO t Number of sheets a Revision Date Title Size of Septic Tank /o00 6A1 F—/x(Sf I n Type of S.A.S. 500 GR CK tZ1X?S C3 Description of Soil A ffSol J /DCf on — Nature of Repairs or Alterations(Answer when applicable)?vVAP t7 EYts 1 i sz �eAC+f p t�S �'v�3(�4(�d�[c.�'►�l S( �� ar5_T"G L j_ 3 -,�000PA• CWt OUeS (P1 R 3a X (3` Rr_W Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date CC/- Application Approved by Date 1012 _ Application Disapproved by: Date for the following reasons Permit No. gCI Date Issued / R r W Fee THE COMMONWEALTH OF MASSACHUSETTS G'` 'ntered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for �Ngpoal *patent Con0tructiott amit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. �v�lapt Owner's i rf�Q �Vf:• Owner's Name�Address;and Tel:No. Assessor's Map/Parcel t 6 �Zt� �c F U3 0L, # Cotu',z Installer's Name,Address,and Tel.No. 'Designer's Name,Address andffel:No. C•- 1�.$t�'�C e t�l0.CC.l�• S i er �tarre;v tl c�rr . ,� tt /,•r- . v t� Vta� S t vSYPr� l I c 1'0•�LU�c � ^� !f° ,. I 'Type of Building: Dwelling No.of Bedrooms Lot Size dcX 0Q3 sq.ft. Garbage Grinder (Y-19 Other Type of Building No.of Persons Showers( ) Cafeteria( ) J Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date QC�Q Qo f*j J,-r� Number of sheets Revision Date Title / 4 j Size of Septi6Tank� ro00�,A. Fx i3 i tt ri Type of S.A.S. S00 GA'. i!?S (3 j Description of Soil As P/- S 0; Jo<1 .1 D.' i" — ' Nature of Repairs or Alterations Answer when applicable) i I 1 R b� P ( PP )1",\0I t l�vtslt•XC �vaC41 i�t S ���Slr\1( 1�rt i�t�l Z,22 c l� 3 -.,C�OGA, CF Att3re5 10 A 33 X l It?F�e I 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 of Health. Signed Date r7C 1. o?3 DUB Application Approved by Date Application Disapproved by: Date r for the following reasons ` Permit No. T- Date Issued f'Q oc V a -- -.------ ---.-----------.— --.— _7777 r— —=--- THE COMMONWEALTH OF MASSACHUSETTS I• s .t BARNSTABLE, MASSACHUSETTS ` Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (..�, ) R --fired Upgraded ( ) Abandoned( )by S 1-1 Ca?e t c at �c �, ��`T�\c\1"t �4 e . �u(L:1 has been'constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. —4q,2, dated Installer-B-,ice hG..C[; 1L }l�' Designer r1 e j #bedrooms Li Approved design flow gpd The issuance of t is ekit h 1 not b construed as a guarantee that the system wil f nc 'on as designed. p // Date / Inspector //� --`—v------/ -- r yvtr —A—. No.f� ��f Y.bC.r Fee A" ; THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwigoal 6p!6tent Con0truction Permit Permission is hereby granted to Construct ( ) Repair (k'S Upgrade ( ) Abandon , ( ) System located at /o)p ri75AM AVr and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty ! to comply with Title S and the following local provisions or special conditions. f Provided: Con tructio must be completed within three years of the date of this e . Date ' Approved by i 4 I TOWN OF BARNSTABLE LOCATION /a0'�vT�r �l�e, SEWAGE#o?400- 1/8a. VILLAGE Cp�V iT ASSESSOR'S MAP&PARCEL O3q -o& INSTALLERS NAME&PHONE NO. .0/ -AhCrd- r SEPTIC TANK CAPACITY /000 Gib/ rrzi-s%ii LEACHING FACILITY:(type)SOOG'pil J C3 (size) 3a x L3 — Ct NO.OF BEDROOMS OWNER G r A r-d In/l Alas PERMIT DATE: /d'a S-d? COMPLIANCE DATE:. V/Aq//qg Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY i a.. 1 . Ve�� 'c�s/z� LfcS C — � � •%� D �'? f L ✓ �3� off/ Town of Barnstable Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 16, 2007 Mr. &Mrs. Gerard Williams 726 Putnam Avenue Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located,at 726 Putnam Avenue, Cotuit,MA, was last inspected on September 13`h, 2004,by Robert J. Bortolotti, a certified inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Our records indicate that the necessary repairs and upgrades were not done in the two(2)years given you at the time of the Health Departments order, (September 161h 2004). You were asked to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacements of septic system component(s). This plan was to be submitted to the Town of Barnstable Public Health Division Office(regulatory Services) within ninety (90) days of receipt of that letter. If you can provide a compliance certificate showing that this work was done; so that we may update our records we would be grateful; if not you have 60 days from the date of this letter 7/16/07 to bring the system into compliance. r7_1��� Any person who shall fail to comply shall be fined not less than $10.00 nor more than $500.00. Each day's failure to comply with an order shall constitute a separate violation. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health • • . • DELIVERY' N. Is Complete items 1,2,and 3.Also complete Si ature item 4 if Restricted Delivery is desired. '❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. Rimed by(P kited e) C. Da of D livery ■ Attach this card to the back of the mailpiece, ;, l /�Q ® ,s� or on the front if space permits. O A- / YX D. Is delivery address different from item 1 ❑Yes 1. Article Addressed to: If YES,enter delivery address below-. ❑No T76� Ms Gerard Williams tnam Avenue 3. Service Type Cotuit,' `' 02635 [3Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number f :: ;•• s: s s :s s:: s s:• s t (rmnsfer from service labeo 0000 0191 3387 7 '05'i 1`16'0{r PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540', UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 I • Sender. Please print your name, address, and ZIP+4 in this box • i PUBLIC HEALTH DEPARTMENT I TOWN OF BARNSTABLE_ E ' 200 MAIN STREET HYANNIS, MA 02601 I I � CID 1Y1 �. • . . . . .•. m I �r I OFFICIAL USE Postage $ OCertified Fee 5 � p Retum Receipt Fee i �a Po (Endorsement Required) /S y Z 0 Re' Mcted Delivery p) Fee —0 (Endorsement Required) a� Total Postage&Fees N a 4 ID Sept To et,Opt.No., or PO Box No. City State,ZIP+4 104 0a63 — Certified Mail Provides: esianay)z00Zaunf'ooae-o�sd e A mailing receipt o A unique identifier for your mailplece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Pr4rity Vaile. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". 0 If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. Town of Barnstable Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 16, 2007 � .a Mr. &Mrs. Gerard Williams p "� 726 Putnam Avenue \ Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 726 Putnam Avenue, Cotuit,MA, was last inspected on September 13`h, 2004,by Robert J. Bortolotti, a certified inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Our records indicate that the necessary repairs and upgrades were not done in the two(2)years given you at the time of the Health Departments order, (September 16`h 2004). You were asked to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacements of septic system component(s). This plan was to be submitted to the Town of Barnstable Public Health Division Office (regulatory Services) within ninety(90) days of receipt of that letter. If you can provide a compliance certificate showing that this work was done; so that we may update our records we would be grateful; if not you have 60 days from the date of this letter 7/16/07 to bring the system into compliance. i _ - h Any person who shall fail to comply shall be fined not less than $10.00 nor more than $500.00. Each day's failure to comply with an order shall constitute a separate violation. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health i ToN*n of Barnstable I"E, Regulatory Services Thomas F. Geiler, Director • eaxxareSt.s. MAM Public Health Division Thomas NIcKean, Director _ 200 plain Street,Hyannis,NIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: (+ I I0-7 Sewage Permit# a��7`�/802 Assessor's Map\Parcel -08! Designer: ►� �e^ M i"IQ 04-_ Installer: Address: 0 Dui q�1 Address: YNo S I On /D-a D 7 �I c c.ce r(Rc��L;s ter was issued a permit to install a (date) (installer) septic system at 7 Z(o P u l-tjA-K A c- based on a design drawn by nn n n (address) 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 bo: andior septic tank. I certifv that the septic system referenced-above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv 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. OF MgSs9C e__- o DA R N 2�"4­M' �\ E I (Installer's Signature) " 0. 1 0 ' AEG/ST 'W SO I TA' 1 III01Ib v� (Designer's.Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BA STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORNI AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q: Health/Septic/Designer Certification Form 3_26704:1doc FAILED INSPECTION 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION vl CA TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: L2(Q Owner's.Name: Owner's Addre —+ 2z rci Date of Inspection: Z64 y DT M Name of Inspector: lease print) J ((� �Q�ItF( oA M Company Name: .----F0' ;w.�-C ' �C iv . C Mailing Address: -4 o M W -� v Telephone.Number: M CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority t1 Fails Inspector's Signature: �� Date: �) /G (d�' 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of]1 M019I OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address. )91 ��X Owner: Date of ection: 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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: 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 N D.explain:: 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owne Date o spection: O� 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 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 aseptic 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 analvsis,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: 3 Page 4 of I l OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ v Owner. Date of I ection: 1-3 cD6 0 D. System Failure Criteria applicable to all'systems: You must indicate"yes"or"no"to each.of the following for all inspections: Ye 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 clogszed 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V 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 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.] (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 flow 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 — _ 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. 4 Page 5 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM 'PART B CHECKLIST Property Address: Owner: Date of pection: j� Check if the follo�ving 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 V 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 ? V Have large.volumes of water been introduced to the system recently or as part of this inspection? t/ Were as built plans of the system obtained and examined?(If they were not available note as N/A) v _ Was the facility or dwelling inspected for signs of sewage back up — Was the site inspected for signs of break out? t/ Were all system components, excluding the SAS,located on site (/I" 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? v _ `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 / I/ Existing information.For example, a plan.at the Board of Health. t/ 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)J • . 5 Page:6 of 11 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of pection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design),- . Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents:_Q Does residence.have.a garbage grinder(yes or no): Q Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected(yes r no): Seasonal use: (yes or no): ... Water meter readings, if av ilable(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: px-, COMMERCIAL/INDUSTRIAL. Type of establishment:. Design flow(based on 310 CMR.15.203)- gpd Basis of design.flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of th inspection(yes or no): If yes, volume pumped:__gallons--How was quantity pumped determined? Reason for.pumping: TYT OF SYSTEM V Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy —Shared system(yes o 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) _Tight tank —Attach a copy of the DEP.approval —Other(describe): roxiiDate age of all om onents, date installed f if known)and source of information: Were sewage odors detected when arriving.at the site (yes or no): 6 Page of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNi l PART C SYSTEM INFORMATION (continued) Property Address: 7.Xe 9j-;3Um0/\—4v�`r- Owner: Date of pection: v 13, BUILDING SEWER(locate on site plan) /0 Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.); SEPTIC TANK: [/(locate on site plan) Depth below grade: Material of construction: ncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list acre: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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; How were dimensions determined: Comments(on pumping recomme dations; inlet and outlet tee or baffle condition, structural integrity, liquid levels 45-Telated to outlet invert, evidence of leakage, ou GREASE TRAP-/k(locate on site plan) 'L�� Depth below grade:_ 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: 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 Page 8 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: LL Owner:. Date of pection: / 000 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___polyethyleneother(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm.present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and_float switches, etc.): Z(ifDISTRIBUTION BOX: 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. kage into or out of box e_c.): • c PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes.or no): Comments (note condition of pump chamber,condition of pumps and appurtenances;etc.): 8 r Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: -1 JAe Date of ection: �C�Voy SOIL ABSORPTION SYSTEM (SAS): locate on site plan, excavation not required) AS,n t located explai why: Type leaching pits,number:_ 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.): 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 laver: Depth of scum layer: Dimensions of cesspool Materials of construction: Indication ofgroundwater inflow.(yes or no): 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 ofsoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION.(continued). Property Address: Owner. Date of pection: 13- SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference Ian marks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters.the.building. (ii— la c" l� 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) .Property Address: 17p& A Owner: ovm 21), Date of n pection: 13j 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) VAccessed USGS database=explain: You must describe how you established the high ground water elevation: -, W aW zzz 25 ; 11 Permit Number: Date: Completed by: � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 7 ale- Lot No. Owner: ���'kl /�Gl/� s Address: Contractor: Y�c1f /G� / �G�✓`r Address Notes: STEP 1 Measure depth to water table g OG 1 tonearest 1/10 ft. .............................................................................. .Date month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: �'� OAppropriate index well.................................................... G OWater-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to 0 X1,19 � water level for,index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) �J determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water r d levelat site (STEP 1) ............................................................................................................. d Figure 13.--Reproducible computation form. 15 ;,: � r . ,:a,..,,�:G.� � . ; ; ,. �. ,,. . . , _ ....I .... ... � . . - ,h,...�.,.. ,f. �1 - .. � � � i I _ � � - I t 1 1A LO-C-11-1ON �1a y —AGE PERMIT NO. �t A P�T � � - L!R/ VILLAGE J� A N S T A LLER'S NAME & ADDRESS � FF 11yii 1 B U I'L D E R OR OWNER V,D Lv11YW077__ �e DATE PERMIT ISSUED 91131.79 DATE COMPLIANCE ISSUED ��/ ��,� �C U-7 THE COMMONWEALTH OF MASSACHUSETTS BOA S -RD ✓. 11E LT1 ,F . , O F...... ...................................... Application is herp�a �inade for a Permit to Construct (v ) or Repair,,(ZI) an Individual Sewage Disposal ystem at .� ... 1 ...................� .. ..�.. _.►..�- •---•............••------ -_ •...-- .............. " Lo do dd e + or No V ,.�I . V V. F . Fd. C C� 2 J�-TF�- 1...�.._ . Z?� Lys �/ �KA u r&>' Owner Address a ........ V ! ,. . ................................................................................................. R4"�s Installer Address ' d Type ofARui<tding Size Lot.z.�..t_ ...Sq. feet aDwelhng�a: No. of Bedrooms p Attic ( ) Garbage Grinder ( ) Other �T` e of Buildii __._._ No. of persons.......................a_.. Showers — Cafeteria (1, s YP g-------- --- P ( ) ( ) �'s} Other fixtures ... ---------------------------- Q --- Desi Flow`.--•....--••- d W i��...............:.gallons per person per day. Total da>ly flow__._......_.._.'�_......_._........_..__..gallons. 94 Sept Tank—Liquid capacity............gallons Length................. Width---------------- Diameter---------------- Depth_.__.__..__.._.. Disposal':Trench—No..................... Width.....__......___._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inl t.___....._ ..._._ Total leaching area.._...._.._.__.._.sq. ft. Other Distribution box ( ) Dosing tank ) �� // `Z f- 7G Percolation T'est.Result Performed b -. ' ....._4....'._. &............. Date.......-..-•---------.-•----------.-_--- Y Test'Pit No. 1 .._..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---- .................. F _ + T_._ . ..... ;.. . O Description of Soil............ ...�----- •. ----•-..` eP'pn mil. ._.__ .._.-..� v x x -•-•---•----------------------------------------•-•---------------------••-•----•-`----•----------•--------......-----.....----•...-•--•------------------------------•-••----------•--.....-•----•---- 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 iIT?TLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. `Signed -•-- ------ ----•-•----•-•------•-•---•-••............................•-•--- ................................ Date Application Approved B Q f1 r .`... Application Disapproved for the following reasons-........................................--------------......---------------------------•----Date--------••-•-- .........................................................................................-............................................................................................................... Date PermitNo.......................................................- Issued....................................................... Date P e (*701 ' l� No.._._..��._ ....... r . r FElic .... .............. THE.COMMONWEALTH OF MAPACHUSETTS BOARD HE _M gyp, • TH t� OF 7 - ,� pfiration for Uhipoaal Work ' Touvtrurtivn amit Applicatioj is hereby made for a Permit to Construct (,4) or. Repair (N) an Individual Sewage Disposal ystem at:,�/ -- - --A. -----...--•----•-•----• . ----•............... .....•---------•. Lo do ddies� or LoY No. A. ...1 t ............ � ?, t�lL.__ _` ....... ..t. t ..t��.t3.1 r... ._ Owner ? Address ............................ ........................................... ---........._......_........--------------- Installer„ Address Type of Building Size Lot._ = _'`' ?_..Sq. feet a Dwelling—No. of Bedrooms__.___ .... _` ...........Expansion Attic (N Garbage Grinder ( ` ) ;( f�£ x'_:... No. of ersons...._................_ Showers — Cafeteria Other—Type of Building p ( ) ( ) Q' Other fixtures --------•------ --------------•----•--•---------- - - --- -................-•-•-•-•-------- C11 W Design Flow________________ ', ............... ..___..._...__:..gallons per person per day. Total daily flow...__..__._t - ..___..__.___..gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________,_______ Depth................ x Disposal Trench—No. ...................... Width-................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No________ ___________ Diameter........`___.. Depth below inl t_______ _ _,_.__: Total leaching area.. __.__.___._.___sq. ft. Z Other Distribution box ( .) Dosing tank ( '-' Percolation Test.Resul Performed by. c ._ s._____ .ra_ ......... Date... I`a _._ a Test Pit No. minutes per inch Depth of Test Pit __________________ Depth to ground water..___...___._._____.__. Test Pit No 2................minutes per inch Depth of Test Pit.................... Depth to ground w ter._:_:::................. O Description of Soil-------- 4--- e ..__II�L!` l t� Gsn Y ! '�. -- ----~ ............................................................. 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 TIT`E 5.,of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate:of Compliance has been issued by the board of health. igned- - ................................ D ' Date Application Approved By............ " r= i°{ •--.................. 1. � Ile Application Disapproved for the following reasons------------------------------------------------------•-------•-------•-•--•--•-------•-----•--•-•-•---------- ..............................................................r..:.......................•-•--•-----....------•----•--•-•-------•--•----•-•-•----- Date PermitNo......................... _;...--•----------•---•------- Issued--------•---.. fs;i; ----•----•-•-••------•--••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OO, HEALTHf 'Trrtifiratr of Tompfianrr TO ME TIF , 'heat the Individual Sewage Disposal System constructed ( t or Repaired ( ) b . _. ail- . at -• X------ -�./ •• .-------- ------------------------•-----...---........-------------- has been installed in accordance with the provisions of TI97 .�f j of The-State Sanitary Code as described in the application for Disposal Works Construction-Permit No`- /.................. dated- ...a-.7;'.__............... THE ISSUANCE`OF,TH S CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.-. DATE.... f `;/l"".�-• � ? ---- .._.. Inspector.- - ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH q No. .................. FEE..._._. o 1 Arks on , rn Uan rrmi# Permission •s eby granted_!!. t�ty��='- a`� .-A....----- •-------•----------- --•-•--- to Constrfu or Rep an Indivu21+ ewage sal ystem atNo. «' jam --• •... ..•y '........................................................................... Street as shown on the application for Disposal Works Construction Permit,, ............ ... Dat. .__ __.'`� "__ '............ {-/ iv ,•,� Y < .......... .... 4.l� ._ __. __ _9_________________ {` Board of.Health DATE......`.......................................=.........= •--------------:---- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r ' ---- -----------------" ----- ----- - - LO• CA 'TION SEWAGE PERMIT NO. AA VILLAGE r- TU/TT INSTALLER'S NAME & ADDRESS all �F 1�A1vz h , x R U I'L D E R OR OWNER Lv#y/No 777 DATE PERMIT ISSUED 11 9 � I DATE COMPLIANCE ISSUED i I �\ a Al /l 000 I /►�1 W I i►1 U t" �s 9 3 75 e 4 . Go7- 003 Al Iry .4►U THOMAS E. KELLEY CO. J � ENGINEERS—EURVEYORS �SSLJ /E� ECc�11/�//O�U E.^:/— 346 LONG POND DRIVE � iit1 1141 ;:Wr �� IIOU t'H YARMOU'3'H, MASS. 02664 �T CERTIFIED PLOT PLAN ,H OF s�O P�-:tk DF MgsS LOCATION .YL.I4,�!717.��S , t 3� •i i foo fwo E.�shs a . S �'� SCALE . �. .- . l�. . . DATE . . .9/.:�/ G K PLAN REFERENCE . � !?14;?. oCJrPr.T... . . No.244a F ISTE� ,g. • 9p �G/STE H�SURV �FSS/ONALtiN6\� let SHOWN ON THIS PLAN IS LOCATED ON T �MTHE d AS SHOWN HEREON AND THAT IT CO MS SETBACK REQUIREMENTS OFTHE TOWN OF / . . WHEN CONSTRUCTED. DATE . . PETITIONER: r C _•� f TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS • 4"CAST IRON 7rnr7rrrrr • 12"MAX. ,'; PIPE (OR 12"MAX. 4"ORANGEBURG(OR EQUIV.) . ' ITCH )- MIN. PIPE- MIN. LEAPH PITCH I/4"PER. PITCH 1/4'PER.FT. PIT PRECAST NVER • J LEACHING e �ad INVERT INVERT o . PIT OR n EL..;. SEPTIC TANK z3 DIST. w ';. TOR INVERT EL Q�o�. . . . BOX ELF)9 �D�I>. .. GAL. INV��j�jT a e, EL.7�?s39.. EL`t.<v.�Qo� INVERT ,• ww Q. :'�: 3/4"TOII/2� EL�,5Z6. 'LIZ� WASHED w STONE IA /!/b 47 - �' PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM JO/G G�jG NO SCALE ,,��// SOIL LOG WITNESSED BY : DATEX4!/G,"-2 TIME.�I�,�J� BOARD OF HEALTH TEST HOLE I TEST HOLE 2 /ADS, ENGINEER ELEV. As-m';-o LEV. .- A ravi DESIGN DATA '. �.. Sv S NUMBER OF BEDROOMS mom (3 pl(_ ! TOTAL ESTIMATED FLOW . -�� � . GALLONS/DAY PAIL' BOTTOM LEACHING AREA 7S' �? . SQ.FT. /PIT SIDE LEACHING AREA . � 'B.�S SQ.FT./ PIT ^^// GARBAGE DISPOSAL _ .` 0. . .(--500% AREA INCREASE) TOTAL LEACHING AREA . .Z�?!•.Qfl SQ.FT PERCOLATION RATE . . . . !u MIN/INCH �/ LEACHING AREA PER PERCOLATION RATED/ 4�. SQ.FT. fVD. .WATER ENCOUNTERED 2 ` NUMBER OF LEACHING Pp APPROVED . . . . . . . . . . . BOARD OF HEALTH DATE. . . . . THOMAS E.KELLEY CO. AGENT OR INSPECTOR ENGINEERS-SURVEYORS 346 LONG POND DRIVE SOUTH YARMOUTH,MASS. OF M°ISs 02664 ?3� T140L � �j ? �.. 1 /1v @o.214N O H l . At PETITIONER PETITIONERS/��j� r 0 1 of LEGEND PROPOSED CONTOUR a, BENCH MARK 1 o D R �R ® PROPOSED SPOT GRADE WA No. 1140 "' -- g$ -- EXISTING CONTOUR 1 6 G chi PAINT SPOT IN DRIVEWAY 1 m 0 ELEVATION = 43. 41 / EEO + 96.52 EXISTING SPOT GRADE S 1XI0 COR BARNSTABLE -CIS DATUM SNITA0 W— EXISTING WATER SERVICE 16 I TEST PIT /45 160.00 ft lV Z� I ,�' ----------------L---------------- -- ---------------- t,.� ---------- j i i LOT 2 z RD AREA = 22003 sf LOCUS MAP N.T.S. ° TH-2 , / ! --------- --------TEL LINE---------GAS LINE _rl!/ , ° ---;�=— ---------------------- — i GENERAL NOTES: 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL PAVED DRIVEWAY j BOARD OF HEALTH AND THE DESIGN ENGINEER. 45-4'' o I / j 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. EXCEPT AS NOTED BELOW: ! 13' I j — 310 CMR 15.405 (1) (B): 1) A 1.25 FT. VARIANCE FROM 310 CMR 15.211 TO ALLOW j TH-4 20 ft I ! LEACHING TO BE 4.25 FT BELOW GRADE VS. REQUIRED 3 FT. (vent provided) _ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR I ! TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 44 TH-3 0z + ! DESIGN ENGINEER. Existln j Leach Pit z O W 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 9i \ z — Z LO ! FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. LO (Seel Note O) \ I— l� :1 WATER __I N E !_ z 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. \ �_ z O _______ - --! 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 0 X !! - THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF N01 O J j j HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. LLJ I—W I Q 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED I w TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. Q 10 O 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 16 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Q __ s CONSTRUCTION. LLJ \\y I 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED > �� ! Ld 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY UNE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 1 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. � --- 1 I 15. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPECIFIED) I MAP., 039 — — '----- LOT.' 081 ----- --------- --- - LCPW..'C76721 — 42 I PROPOSED SEPTIC SYSTEM UPGRADE PLAN � —_— \ 761 93 ft 726 PUTNAM AVENUE, COTUIT, MA I Prepared for: Gerard Williams -�---------- I Engineering by: Surveying by: SCALE DRAWN JOB. NO. SURVEY REFERENCE: 42' --1--_-��----1 DARRENM.MEYER,R.S. Boo-Tech h2vironmente! 1"=20' DMM 3 PLAN OF LAND BY THOMAS KELLEY CO., SURVEYORS t: 44 PO BOX981 (508) 364-0894 EAST SANDWICH,MA 02537 DATE CHECKED SHEET NO. DATED: DECEMBER 21, 1972 ! 50"2-2922 10/21/07 DMM 1 of 2 X ELEV. TOP FOUNDATION i vent required (Existing) FINISH GRADE=45.5-44.5 = 45.56�A �F.G.EL: 45.0 F.G.EL: 44.0 F.G. EL: 44.50 MAINTAIN 2% MIN SLOPE OVER LEACHING AREA COVER OVER LEACHING = 4.25 �AX- COVERS TO WITHIN 6 7GRADE _ :r 2" OF 3/8" DOUBLETEMM 7ME '' HED S 0 „ DOUBLE WASHED STONE6" „ 4" SCH 40 PVCtr 4" SCH 40 PVC ®S=2% 10"I S= 1% MIN. a ®®(MIN.) TEE'S ARE TO BE 14„ ( ) © S= 1 (MINL .) ENLIO®4" SCH 40 PVC 2 EFF. DEPTH ® IN V.41 .60 . . , INV.40.93 3.25' 3 X 8.5' 3.25' E�IST. OUTLET: BAFFLE PfZOPOSED DB-3 - N . H-1(1 DISTRIBUTION BOXCIS& CM 2ft AM EFFECTIVE LENGTH 32' _ d INV. 41 .85 EXISITING 1,000 GALLON SEPTIC TANK ! INV. ELEV.= 40.83 GAS BAFFLE TO BE INSTALLED ON BREAKOUT OUTLET TEE AS MANUFACTURED BY ELEV.= 41 .25 TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 41 .62 .. ., INV. ELEV.= 40.830 ®® aE3aE3E3E3E3 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING 3) INSTALL INLET & OUTLET TEES AS REQUIRED ®®®®®®113 ®®IH®®®® PIPE INVERTS PRIOR TO CONSTRUCTION 4) REPLACE EXISTING 1,000 GALLON SEPTIC BOTTOM EL.= 38.83W4' ®®®®®®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TO TANK WITH 1500 GALLON SEPTIC TANK 5 FT. 4' GRADE ON A MECHANICALL COMPACTED SIX IF FAILED, DAMAGED, OR UNDERSIZED. INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) SEPARATION 6.88 FT. EFFECTIVE WIDTH = 13' SEPTIC SYSTEM PROFILE BOTTOM OF TEST HOLE EL: 31 .95 _ SOIL ABSORPTION SYSTEM (SECTION) OF �gsf��y N.r.s. (500 GALLON LEACH CHAMBER (H-20) LOADING) (/ o D R� SOIL LOGS - DESIGN CRITERIA H 1140 NUMBER OF BEDROOMS: 3 BEDROOM ACTUAL/ 4 BEDROOM DESIGN (Not in Zone II) DATE: OCTOBER 10, 2007 d� SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN NITAR�a� �� SOIL EVALUATOR: DARREN MEYER, R.S., CSE DAILY FLOW: 110 G.P.D. DESIGN FLOW: 440 G.P.D. �b 1' WITNESS: DONNA MIORANDI, BARNS. BOH GARBAGE GRINDER: NO (not designed for garbage grinder) SEPTIC TANK (VOL. REQUIRED): 440 gpd x 2 = 880 gpd (USE 1,000G EXIST. SEPTIC TANK) Elev. TH-1 Depth Elev. TH-2 Depth Elev. ` TH-4 Depth LEACHING AREA REQUIRED: (440) = 594.6 S.F. _� -� TH-3 Depth Elev. �t 45.10 0" 44.95 0" 43.95 0" 44.20 0" 74 FILL Flu- FILL I FILL USE THREE (3)-500 GALLON PRECAST LEACH CHAMBERS (H-20 LOADING) 44.10 12" 43.95 12" 42.95 12" 43.20' 12" WITH 3.25 FT. OF STONE ON ENDS & 4.0 FT. O STONE ON SIDES: A LOAMY SAND A LOAMY SAND A LOAMY SAND A LOAMY SAND 321 X 1 3'W X 2'D 10YR 3/2 10YR 3/2 10YR 3/2 10YR 3/2 43.60 18" 43.45 18" 42.45 18" 42.70 18" BOTTOM AREA: 32' X 13' = 416 SF B LOAMY SAND B LOAMY SAND B LOAMY SAND LOAMY SAND 10YR 5/8 10YR 5/8 10YR 5/8 10YR 5/8 SIDE AREA: (32 + 13) X 2 X 2 = 180 SF 42.02 C1 37" 41.87 C1 37" 40.87 C1 37" 41.12 37" TOTAL SQUARE FEET PROVIDED = 596 vs. 594.6 REQ'D 1 LOAMY SAND LOAMY SAND LOAMY SANDE7 LOAMY SAND TOTAL G.P.D. PROVIDED: 441 gpd vs. 440 gpd required 10 YR 6/8 PERC®40.60 10 YR 6/8 10 YR 6/8 PERC®39.45 10 YR 6/8 40.10 60" 39.95 60" 38.95 60" 39.20 60" PROPOSED SEPTIC SYSTEM UPGRADE PLAN MEDIUM MEDIUM MEDIUM MEDIUM 726 PUTNAM AVENUE, COTUIT, MA SAND SAND SAND SAND 2.5 Y 7/4 2.5 Y 7/4 2.5 Y 7/4 2.5 Y 7/4 Prepared for: Gerard Williams Engineering by: Surveying by: SCALE DRAWN JOB. NO. 33.10 144" 32.95 144" 31.95 144" 32.20 144" DARRENM.MEYER,R.S. Eco-Tech Mzrb»nmenteJ N.T.S. DMM PERC RATE <5 MIN/IN. (-Cl- HORIZON) PERC RATE <5 MIN/IN. ("Cl" HORIZON) Po Box 981 (508) 364-0894 NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED EAST SANDWICH,MA02537 DATE CHECKED SHEET NO. 50"62--2922 10/21/07 DMM 2 of 2