HomeMy WebLinkAbout0844 PUTNAM AVENUE - Health 844 Putnam Avenue
Cotuit P
A = 040 068
ASSESSORS MAPNa
II No. �& THE CQPII�i}C� 4FIU - i�i'TS FEEA�_
BOARD OF HEALTH
1614 of
Appliration for DispnM1 it�ystent Tonstrmftnn Prrmit
Application is hereby made for a Permit to Install (V/ or Repair/Replace ( ) an Individual Sewage Disposal System at:
L—ition-Aikh— or Lot No.
r sy
Address
Designer or Installer Address
Type of Building Size Lot 0 LH a( ,-e_s sq-feet
Dwelling-No.of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other-Type of Building No.of persons Showers (. )-Cafeteria ( )
Other fixtures
Design Flow 1 F,15 gallons per person per day. Calculated daily flow 7?0 gallons.
Septic Tank-Liquid capacity I.500 gallons Length 10'U Width 'VS' Diameter Depth 5'7
Disposal Trench-No. I Width 13►ZN Total Length ZcJ' Total leaching area O b t sq.ft.
Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft.
Other Distribution box ( ✓) Dosing tank ( )
Percolation Test Results Performed by C�.Q,[,A VP R,A J6 l _A, a Date 20-q(0 _P- (v 1
Test Pit No. 1 Z minutes per inch Depth of Test Pit ZD Depth to ground water.
Test Pit No.2 '7.i minutes per inch Depth of Test Pit Depth to ground water
Description of Soil itn Z 0''--61" A �oo_ w- (o w. .512,
CA 2LV" e2 1o(AAA,M���tc� I yr 411,P
Nature of Repairs or Alterations—Answer when applicable
Date Last Inspected
Agreement:—The undersigned agrees to install t aforedescribed Individual Sewage Disposal System in accordance with the
provisions of TITLE 5 of the State Environmen 1 Code.T ersigned further agrees not to place the system in operation
until a Certificate of Compliance has been iss e by the oard of ealth.
Signed
Date
Application Approved B 2_T-7--0
Date
Application Disapproved for the following reasons:
Date
Permit No. � ��Z< Issued
Date
A: I Y fey
3 %No. /y THE COMMONWEALTH OF MACSACHSETTS FEE
f
BOARD OF HEALTH
MO-F cot r
d
Appliration for Dbipviial tyid m Tomitrurtion Prrmif
Application is hereby made for a Permit o Install (4r Repair/Replace ( ) an Individual Sewa e Disposal System at:
1,0Z
it
L ication-Ar dress I or Lot No.
V / Address F
Designer or Installer Address
Type of Building Size Lot D i a C.(A.S S+Zaat
Dwelling—No.of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No.of persons 4D Showers ( )—Cafeteria ( )
Other fixtures
Design Flow :05 gallons per person per day. Calculated daily flow `3,50 gallons.
Septic Tank—Liquid capacity 145DDgallons 1Length _1011y,�Width 1, �� Diameter Depth ' ''
Disposal Trench—No. Width Total Length 'L.
� �� Total area P S S g 14 E5 I sq.ft.
Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft.
Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by Date2 'W-(D —p_
t0
,Test Pit No. I Z minutes per inch D pth of Test Pit `t Depth to ground water —8-
Test Pit No.2 �i minutes per inch Depth of Test Pit " Depth to ground water
Description of Soil ' " ON(.
u
,r_` "
Nature of Repairs or Alterations—Answer when applicable
Date Last Inspected
Agreement:—The undersigned agrees to install t e aforedescribed Individual Sewage Disposal System in accordance with the
provisions of TITLE 5 of the State Environmen Code.T dersigned further agrees not to place the system in operation
until a Certificate of Compliance has been iss e by they and of ealth.
Sign d
Date
Application Approved B
te
Dale
Application Disapproved for the following reasons:
`,.;
Date
Permit No- Issued . 2 7
Date T�
•,. --------.. —.W.— ®--v.----.., -----.a.......... —————— ——— --mac+.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifiratr of Tom fiatta
THIS IS TO CERTIFY, That the On-Site Sewage Disposal S em ins alled ( j/ e aired/ eplaced ( )
on by "
for aG !_? .W 004-p-4 at
has been constructed in accordance+With the provisions of T E 5"'of/T,he`State Environmental Code as described in the
application for Disposal System Construction Permit No. 5•� 1 dated --zy—7
Use of this system is conditioned on compliance with the provisions set forth below:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on
Date
DATE Inspector
-
t No. ./ t4lr THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
�i nn l trm Can r, .rtinn rmit
Permission is herebyranted to V
g
to Construct f`) pr Repa�',r/Rep ace ,( ) an On-Sit ewage Disposal System located at
-street' .
as described on the application for Disposal System Construction Permit.The Applicant recognizes his/her duty to comply
with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
DATE �/`�"
/F / Board of ealth /
' r,.t _,�i'
. — 0#1
FORM 1255 (REV.4/95) H&W HOBBS&WARREN TM PUBLISHERS - BOSTON
THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION
TP�WN OF BARNSTABLE
LOCH ITON' PV t�1�M /�V SEWAGE #
V T,,LAGS C OTV i� ASSESSOR'S MAP & LOT Dy 0 ' 0(*?
INSTALLER'S NAME&PHONE NO.
•' SEPTIC TANK CAPACITY /S"
,LEACHING FACILITY: (type) �J(�yWLf�S (size) A.
NO.OF BEDROOMS
BUILDER OR OWNER PAv 9 r .Se /a n
PERMTTDATE: COMPLIANCE DATE:.
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by Tnl tt;t'0n �(�r�
T.
O
3
y 31 3°►.6
y �
TO OF BARNSTABLE
LE-ATI01" SEWAGE #
V�!j.AGE ;� ASSJSESSOR'S MAP& LOT YQ 4
INSTALLER'S NAME&PHONE NO. �/ )anLI /''I rAI nt_t l�(a
SEPTIC TANK CAPACTry I.5 D ) 0a]Iron
LEACHING FACII.TTY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER R01 I(x Y- �1 JI' QYl?1 X'VPX�OPr S - �� l7nynn I
PERMTTDATE: II- I`/7"9(o COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility No wQ-�P r Feet
Private Water Supply Well and Leaching Facility (If any wells exist /�y
on site or within 200 feet of leaching facility) - !V ft Feet
Edge of Wetland and Leaching Facility(If any wetlands exist /t
within 300 feet of leaching facility /^I A Feet
Furnished by 11e �i
Ai :: (oil
A3= aa' (0
A+=a Front,
A,5 4 g
BI= al�. (o'' ,
Ba= o 0
83 = 3a'. (d'
'� ?utnam ve ,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
-JUL 3 1 2003
TOWN C=BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 844 Putnam Avenue MAP
Cotuit, MA 02635 a
Owner's Name: Paul Brosnan PARCEL O
Owner's Address: 5276 Robie Avenue LOT `
Spring Hill, FL 34608 •`""�
Date of Inspection: July 15, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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
Nee Further Evaluation by the Local Approving Authority
Fall
Inspector's Signature: S. Date: July 20, 2003
The system inspector shall sub t 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.
eI
Title 5 Inspection Form 6/15/2000 pa g
Page 2 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
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
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
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 an determines that the
Y ( PP + Y)
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 I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria 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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/z 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 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.]
No (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 System:
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
i
Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)).
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):' 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): No� [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
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: Unavailable
Was system pumped as part of the inspection (yes or no): 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)
Tight Tank Attach a copy of the DEP approval
` Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Nov. 21196-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
f
Page 7 of 11
OFFICIAL INSPECTION FORM'- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
BUILDING SEWER(locate on site plan)
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: 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
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.):
7
II
Page 8 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
TIGHT or HOLDING TANK: None (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/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.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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 D-box was level. No solids were present. There were no signs of backup or failure:from.the leach field.
i
PUMP CHAMBER: None (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
I
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 844 Putnam Avenue
Coto, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
✓ leaching chambers,number: 2-500 gal. leach chambers-per as built card
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.):
There were no signs of failure from the leach field. The bottom to grade was approximately 6.
CESSPOOLS: None (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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (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.):
9
Page 10 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, MA
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A a1�
r ►�,b a�.6 �
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 844 Putnam Avenue
Cotuit, AM
Owner: Paul Brosnan
Date of Inspection: July 15, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30' +/- 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: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
30' +/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied; relating to the system, the inspection and/or this report.
1]
' SOIL EVALUATOR&PERCOLATION TEST FORMS
ApIME rq Page 1 of 4
o� Town of Barnstable
BARN M .
ABLE ' Department of Health, Safety, and Environmental Services
9�A,E0
3;.�1. , Public Health Division
( 367 Main Street,Hyannis MA 02601 {
Office: 508-790-6265
FAX: 508-775-3344
Soil Suitability Assessment for Sewage Disposal
r ,
NO. Date:
Performed By: W oLw8 S Date: Zo"`t to
Witnessed By:
Location Address Owner's Name
$L�4 -Pts-�Pc Ave,
Lot#: Address,and �
C�r1rx�hp�e, �
ozU q
Assessor's Map/Parcel: mike Telephone#
NEW CONSTRUCTION 'REPAIR
Office Review
Published Soil Survey Available: No "Yes- `• `''! `
Year Published Publication Scale /:'ZS Qo'i"Soil map unit Z 7
Drainage Class Soil Limitations
Surficial Geological Report Available: No Yes
Year Published Publication Scale
LiOVh/gic MiaLG1i0.l.k".r.ap ,u 1 - _
Landform
r
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes L�
Within 500'year boundary No Yes
Within 100 year flood boundary No - Yes
Wetland Area:
National Wetland Inventory Map(map unit)
Wetlands Conservancy Program Map(map unit)
Current Water Resource Conditions(USGS): Month
Range: Above Normal Normal Below Normal
Other References Reviewed:
DEP APPROVED FORM-12/07/95
� r
sue:
' FORM II - SOIL, I;VAIXATOR FORM
Page 2 of 14.
Location Address or Lot No. 8��{ 71- 7141gAO-e �v t
On-site Review
Deep Hole Number Date: �,�Z O Time: / Weather S"""r
Location (identify on site plan)
Land Use •5 Slope {°!o) Surface Stones
Vegetation ;P„
Landform i
'Posirt'on on landscape (sketch on the back). ;
Distances from: 3.
Open Water Body feet , Drainage way feet
Possible Wet Area feet Property Line feet
Drinking Water-Well feet Other
DEEP OBSERVATION HOLE ,LOG
Depth from f "Soii,Hiiriion Soil Texture Soil Color Soil Other
SL;r4,1cer.11nches) (USDA) (Munsell Mottling (Structure,Stones, Boulders, Consistency, %
Gravel
Lea... '!/
.f t •,
Parent Material(geologic) DepthtoBedrock:
Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: _
Estimated Seasonal High Ground Water: -
ueP APPROVED FORM- 12/07/9s
FORM I I - SOIL LVALUATOR FORM
Page 3 of 4
Location Address or Lot No. y
Determination ,for Seasonal High Water Table
Method Used:
❑+Depth observed standing in observation hole _ inches
_❑ Depth weeping from side of;observation hole inches
LJ Depth to soil mottles
❑ Ground water adjustment feet
Index Well Number Readingg Date .............. Index well level
z3o J�Ur
Adjustment factor Adjusie.d ground water level
tY
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? Xas
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on P Z° ?� 3 (date) I have passed the soil evaluator examination
.a►.pproved by the.Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and expel fence
described in 310 CMR 15..017.
re Lip' ' Date ,,
Signatu ..
4
a
DEP APPROM FORM•12/07/95
FORM 12 - PERCOLATION TEST
Page 4 of 4
74
Location Address or Lot No.
COMMONWEALTH OF MASSACHUSETTS
Massachusetts
Percolation Test*
Date: 2
Time:. /
Observation Hole # /
Depth, of Perc /V '
t
Start Pre-soak
End Pre-soak
Time at 12"
Time at 9"
-------------
Time at 6"
Time (9"-6")
Rate Mein./Inch
Minimum of 1 percolation test must be performed in both the prirhery area AND
reserveearea.re ...................................................._._......_......._
Site Passed L� Site Failed ❑ `'
................................................................................ .
Performed By:
Witnessed By:
Comments: ....::::.:::....:...:...:,.:.:..�..::..:.......:...:.:
DEP APPROVED FORM-12/07/95
" VC11TEM P OFIL E
NOT 7'0 SCALE
TOP FNON.
EL . 6.s FINISH GRADE y �' FINISH GRADE OVER FINISH GRADE OVER FINISH OVER TRENCHES
�a o SEPTIC TANK DIST. BOX �� . �
o..oroo
o :o'••• 12 MAX.-
" ��CQTIr��T1�Y7/�f7/� rTT�°t7/,ZR'C"
', ef.,� •�' .•e::�:�.: �^C•;a�.'i,�:30.•::Q•o�D�.p;o 0'QF'.b'dklp�l,a• 'O �.b� q",r�
„ OUTLET PIPE LEVEL 10
TOTAL LENGTH OF TRENCH r•• "
' �L3
�• b �°• � FOR 2 FT. MIN.
�•O ; •Q .�, .e. V' Ol• a '• .: o.• -�:. •.D;•: "o ':d• b' .•1 6
• .. G••.�'. 49 b0. » 4 •:p: •o o ,?o o' '� %b.: p°pp4Q
•� �p� l0 8�'O A Aa Gc:� � _ Q e n•;'e.:o:. •:b:'.*.:o,° Oo• pp 'w•P ,} � '�P_Q' -
::e,d4 :. C. I. OR PVC TEES
BSMT FL .
•oo:po. �• o
1500 GA L L ON D D. S TRI UTION BOX
EL . INSTALL ON LEVEL BASE "500 GALLON DR Yy✓EL L S "
o j • o�ti: o `'v : PRECAST CONCRETE
ob H— / 0 REINFORCED
Q: ao•
p D•
�••:bO-'O��b�_•p O�P p b.%O.b•:�'p e:�Yfl:gCP,•r 0� • R
✓/I/!"V•a•..'.✓.+ ,.r+.::•.;v^'rrr�1`...\Y.�^atiw,p.�'r,•rq,r'�+ly�^s'ru`,•.�'�y Tr4ENCH SECTION
SEP TI C TA NK t _ 7 ;?�'00 X A
INSTALL ON LEVEL BASE NOTE• EXCAVATE TO ELEV. IV-� OR
LOWER TD REMOVE ALL IMPERVIOUS ,
MA TERIAL BENEA TH THE L EACHING AREA 4" DIAM.
REPLA CE EXCA VA TED MA TERIAL )VI TH 3 to OF 1/8"-1/2 of
CLEAN, CLA Y FREE SAND
b. WASHED PEA STONE
�O 7� Z - :•O :� O
3/4 1-112" WASHED °, ••
CRUSHED STONE .e$U _ /__.._G._G._ i c
` /3 +GE ERAL NO TES TRENCH WIDTH
1. ALL EL E VA TIONS SHOHN ARE BASED ON A SSUMED NUMBER OF TRENCHES,1
ti 2. ALL PIPES` IN THE SY S TER MUST BE CAST IRON NUMBER OF DRYWEL L S 2 —
OR SCHEDULE 40 PVC. OB E ? T. P, T
3. THE BOARD OF HEA L TH MUS T BE NO TIFIE D
C,' WHEN CONSTRUCTION IS COMPLETE PRIOR P—B761
TO BA CKFIL L ING PERCOL A TION RATE. „/o G.,�d_/iv7/ ,,
APPROVED T I 4. ANY CHANGES MIN./IN. _ p sad,•. >`/ ,E/, G/, o
--____---- - � > I'Wt��'SITHIS PLAN MUST
,�G BY THE BOARD OF HEAL Ti-, AND CAPE G ISLANDS
�,�,�� .,,.. G.._ ., SURVEYING CO., INC.
. AIA TERIAL S AND INSTAL L A TIDN SHAL L BE IN EDWARD BA PP Y
COMPL IANCE HI TH THE STA TE SA NI TARY BAR,NS BRO. OF HEALTH DESIGN DA TA
CODE - TITLE V - 'AN LOCAL APPLICABLE DATE• AUG. 0, 1996
- - - - -
- RULES AND REGULATIONS TH 1 ti 2 SAME NUMBER OF BEDROOMS 3
6. NORTH ARROW IS FROM RECORD PLANS AND 0 iI
IS NO TO BE USED FOR SOL AR PURPOSES =A= �� GARBAGE DISPOSAL N�
=-_______ m 7. FL 000 HAZARD ZONE C (NON—HA ZARD) LOAM 1z DAILY FLOW 330 GAL .
8. HA TER SUPPL Y TOWN WA TER a
_ 1500 GAL .
a _ ProPos-� 2 �, =B- LOAMY SAND SEPTIC TANK REO D.
a " 3 �ry"" ~'s` � ' ' 24" r/- SEPTIC TANK PROVIDED
.1500 GAL .
7y_.,• ro ,� d 330 GPD.
L EA CHING REGUIRED
•..,. .3 s z a p a V
- — N Ci z- - ��.� 7 Z =C= MEDIUM
,Z. N iM•
SAND SIDEWAL L AREA - -52
S.F.
152 S.F.XO. 74 G/S.F. = 112 GPD.
10
°° v / BOTTOM AREA =329 S.F.
-LEGEND 329 74
S.F.X0 G/S.F. =243GPD
-,- � LEACHING PROVIDED 355 GPD
PROPOSED ELEVA TIDN 120 " NO GROUNDWA TER e,, o
7 ——7 V" —— EXISTING CON TOUR
— ,�.,�• ,�° Z , OBSERVA TIDN PIT SINGLE FA MIL Y RESIDENCE C
1w ar 7 z--- ® DISTRIBUTION BOX qs,,
�c PROPOSED SEX AGE GE DISPOSAL SYSTEM
FICIIARD
J NO ES
r^n _
,J c, QcR i'FiliNf)
uo1
b PREPARED FOR
c
O 0 SEPTIC TANK
DREAM DE VEL OPERS
" ~" HOUSE NO. B44 PUTNAM AVE.
RESERVE AREA 0jri-oF
0" CO TUI T —BA RNS TA BL E—MA SS.
��, L,� PIPE IN EEVA TIDN Avl►C
I sANlc t DA TL:• -Zl CAPE 6 ISLANDS ENGINEERING �3-•G
PLOT PLAN
SCALE. 1 30 ,�� - �, ,� ' /Lf �, , l r` � ; SCALE AS NOTED 133 FALMOUTH ROAD SUITE RE S2
�~.
_ C # �. t 07 . I-M17 � , '°" PL AN NO.so E_- � MASHPEE, MASS.