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HomeMy WebLinkAbout0075 ROOSEVELT ROAD - Health j 75 Roosevelt Road, Cotuit A = 039 137 \ i LIT s UPC 10334No.2-153L ' aWarpyw�. MV A04- 1 s ceevyl f i c C)kwn) . ... i No. — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compiAer PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPflfation for Mispo8al 6pstem Construction Vrrmit Application for a Permit to Construct( ) Repair( Upgrade(Abandon( ) ❑Complete System Individual Components Location Address or Lot No.,b-40'oaJ'�S-��'!Y 0-0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel9 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. `JOO Type of Building: J1?J d Dwelling No.of Bedrooms oLrt S' !� sq.ft. Garbage Grinder( ) Other Type of Building 4T"4dLf No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) *!9,-e 7 3 6 gpd Design flow provided yl� gpd Plan Date o�L Number of sheets Revision Date Title Size of Septic Tank ✓'T/s�� 15—b o, rrWe of S.A.S. Description of Soil Chrf 4:? Nature of Repairs or Alterations(Answer when applicable) J'ee /0k*'05( 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 ealth. Si Date Application Approved by Date "J -7 Application Disapproved by Date for the following reasons Permit No. — Date Issued I, No. Y (♦ ! a�» ° 7l►_ Fee o THE COMMONWEALTH OF MASSACHUSETTS Entered in comp ter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 'S Rpplicatlon for.)Disposal OpBtem Construction Permit Application for a Permit to Construct( ) Repair(O(}'rUpgrade( Abandon( ), ❑Complete System eindividual Components Location Address or Lot No. �o ,f',�l:',,G'' `? Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ae Type of Building: ��,P 1 ' Dwelling —No.of Bedrooms d ~' oL�t S' L s .ft. Garbage Grinder r q g ( ) * Other Type of Building &r4r,j; No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 7' }ry 13 gpd`� Design flow provided ?L/ gpd Plan.,1 Date & A chi." +� Number of sheets -000" Revision Date b _ Title Size of Septic Tank •�k"�" �i^' � ✓fa + Type of S.A.S. Description of Soil k/V'40' .e4 `'•.. # i Nature of Repairs or Alterations(Answer when applicable) �� • 3 R ' Date last inspected- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in f 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 o ealth. S IggedC t Date `"' W" +� Application Approved by rt I'll Date I Application Disapproved by V Date for the following reasons a Permit No. Date Issued f , - r 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded Abandoned( )by CT--,/J'9 Z e"670 �✓✓, "" � '� C ar'r'1 'e_15--e•C 77 has been constructed in accordance" } with the provisions of Title 5 and the for Disposal System Construction Permit No._[ I t~ datede , Installe+' >yW ., , ��'[.!/�— Designer4b x�? , ,��`�;a.d'� �op A #bedrooms trir '1 _4 D g d re d•r i Approved deli n flow .W Gr- _c� I — I , PP g� ^'� gpd The issuance of this permit shall 'ot be construed as a guarantee that the syste , ill functio' as �e ign d. Date ��20 � Inspectors --------------- No. ')-a I / s �.��� Fee � d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBal *pstem (Construction Permit Permission is hereby granted to Construct( ) Repair,( Upgrade( Abandon( ) System located at �- ax e✓''e-101.0- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Const cti must be completed within three years of the date of this permit. Date IZ"1"LIT, Approved by 5 I Ne � f From: 08/22/2017 13:s7 #990 P.001/001 Town of Barnstable °FV�E'O`''o Regulatory Services Richard V.Scali,Interim Director i MMSTABLL MAn Public Health Division ' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Sewage Permit# Assessor's Map�Pareel Designer: , ,� Installer: ` `` � �� Address: 1t� "� �7 �TJ (, Address: 2- k�2On was issued a permit to install a (date) (installer} septic system at �.. 1� based on a design drawn by g g(address) dated -z' 2. ( esigner) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. 1 certify that the septic system referenced above was installed with major changes (i.e_ greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construe,+ __...,•-Iliance with the terms of the RA approval letters (if applicable) ►'G*1 OF&4,:AVI MASON m staller's Signature) o o No.1066 c G S t E ! \ TAR\ Q(54siggnne �_Mn (Affix Designlr s Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DMSION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH[ THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASepticTesigner Certification Fonn Rev 8-14-13.doc f TOWN OF BARNSTABLE LOCATION �®y�� � �® SEWAGE# VILLAGE C ®TUT ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.0Jm LlW®V'O/o' SEPTIC TANK CAPACITY ��!-r'�/'�� f�'o® 45:,.W Z LEACHING FACILITY: (type) ,�_ / r�p (size) NO.OF BEDROOMS OWNER �lnn/de� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: '01.,0 14-,A+rV06/ is Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ' 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 V� �� ���e&o" G2XAR ®® 3 ®�®, 4�s:� C_ TOWN OF BARNSTABLE - LOCATION T- SEWAGE # ZOed"6« V1 ,LAGE ASSESSOR'S MAP & LOTMq INSTALLER'S NAME&PHONE NO. Jt M AUZZ 7 ° Z SEPTIC TANK CAPACITYs � LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 r Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by kk 3 �� � I Town of Barnstable P# L qq Department of Regulatory Services F s ' � 4'' ,�aT�r� Public Fie F alth Division'. Date id» 200 Main Street,Hyannis MA 02601 rEn - ND Date Scheduled ell ! , ' Tim 4 m Fee Pd. bb 1a Soil Suitability Assessment for S e Dzsposal C, Performed-By: Witnessed By: LOCATION&.GENERAL INFORMATIONS Location Addross�` S°- L�p',O,^J+�-�j Owner's Namo n CC7�U I' 1 /pV 1 VT / Addross Assessor's Map/Parcel Z-331 Engineers Name �� �Q�; ,�✓.Or� girl./' NEW CONSTRUCTION REPAIR Telephone# Land Use- Slopes(96) Surface Stones i Distancea from: Open Water Body ft Possible Wot,Aroa ft Drinking Water Well ft Dralhage Way i ft Property Une ft Other ft SI +''TCHc(Street name,dimensions of lot,exact locations of teat holes&pare testa,locate wetlands in proximity to holes) o_t)E_VVEI�= -' Parent material(geologic) Depth to Bedrock Depth to Oroundwater. Standing Water in Hole: Weeping from Pit an Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL'HIGII WATER TABLE Method Used: Depth Observed standing In oba.hole: In. Depth to soil mottles: ►n,' . Dojith to weeping from aide of obs.hole: In, t roundweter Adjusltddnt ft. Indox Well-# Rending Dato: Indox Well ieval. Adj,•fhetor• A�.0r6u6dwater•1 Avdl.,,•_ PERCOLATION TEST bale 'Thne Observation ' I Hole# Time at D" II p Depth of Pam � Time at 6" 'i Start Pro-soak Time @ Time(9"•6") End Pro-soak L I �Z►M i►� Rate Min./Inoh Site Sultability Aasesament: Sitd Passed Site Failed: Additional Testing Needed(YIN) I Origlual: Public Health Division Observation Bola Data To Ba Completed on Back-----� ' ***If percolation test is to be conducted within 100' of wetland,you must fiirst notify the Barnstable Conservation Division at least one(1)week prior to beginning, i Q:ISBPTIMERCFORM.DOC i I I DEEP.OBSERVATION HOLE LOG Hole# Depth from 1. Sall Horizon Sall Texture Sdil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stonot;Boulders. ts(stancy. Uraval) DEEP OBSERVATION HOLE LOG Bole# Depth from Soil Horizon Soil Texture Soil Color Sall Other Surface(la.) (USDA) (Munsoll) Mottling (Structure,Stones,Boulders. s DEEP OBSERVATION HOLE LOG Holtz# Depth from Sall Horizon Soil Texture Sall Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,SSopes;Boulders. Consistency. QmvjI) • � ll Flood Insurance Rate Map: Above 500 year Mood boundary No_ es V Within 500 year boundary No =+ Yes • e✓ Within 100 year flood boundary No. Yes,, ... pellth of Naturally Occurring Pervious Mit ersal Does at least four feet of naturally occurring pews u titerial exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what Is the depth of naturally occurring pe ious material? Cer'tlff cation I certify that on 'd. (date)I have passed the soil evaluator examination.approved by the Department of Envir n ntal Protection and that the above analysis was performed by me consistent with . the req ed training, p rti an e p rience described In 410 CMR 15.017. Signature Datb Q;1SgpTlG\P111tCPORM.DOC -Comm*nvve;�fth of-Massa - Title 5 jInSpe jon.Form Subsurface Sewage Dispo"I System Form IN for Voluntary.Assessments 75"ROOSEVELT RD Property.Address r HEINE" owner- Owner's Name. �nformatron>5: ". requires#oF CC TUI T every'page. Cityfrdwn State, Zip Code Date of.i iwction inspection results must be submitted on this form. Inspection forms may not be altered in any. way.Please see-corripleteness checklist.at the.end cif the foryn. " Important ". When filling out: A: General Information forms On the.. " computer,use I " .trispector;. only the 6b key . to move your : DOUGLAS A BR€?t1Vl`t. cursor-do.riot" Name of inspector usee the return key. " " . OUGLAS A.BROWN Company Name. Company Address CENTERVILLE- MA Q2632 City/Town State" Zip Code . 5(38=42t1-453 S1429.7 Telephone-Number License Number B. Certification t certify that I have personatly inspected the sewage.disposal system at this address and that the information reported below ls:true,accurate and complete as of the:tirtie 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 ain a DEP-approved systom it spiecto(putsuant W SectiOn 15.340 Of " Title 5(316 CMR 15.0001.The"system . Passes 0 Conditionally Passes .0 Fails CT "Needs Further Evatuatiort by the Local AOproving Authority Inspector'F• ignature Date The system inspector shall submit a copy of this inspection report to the Approvirig.Atlthority. (800rd: " Of Health or f3EP)Mthin 30 days of compaebnq this inspection, It the system"is a shared system"or. has"a design flow of.40,000"gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of toe DER The original should be-sent to the system owner and copies sent.to the buyer,if"applicable,and the.epprWng.authorlty_ **This report iin4y desrrires conditions at ttae"tfrnc:of inspection and under the conditionsof use: . at that tirrie:This inspection does not"address how the systeran will perform in:the future under. the.saute or different conditions of.use, . i`ii[7s-3ti 3 : "" - ". "" - Tote S"(Jcialfnspes"tiort r'cuir+:Siab$usfsee Sertags 3SitoSaF Systn•'Page 1 ar 97- ormmonwea th Massachusetts Title 5 offidiat IhsPection Form . Subsiwface SaWage Disposal System Form.-Not for Voluntary Assessments Property.Address. . HEINE. - Owner.: Ovvner's Name informatibn is requited'#or Gt T IT MA t2�?� ev�iy par}o. Citylro+nrn. State'. zip Code Date of ittspectiorl B. Certification (cpnt) Inspection Burn Mary_Check A,B,C D or E.I always complete all of section'.G . Ay #ate l:have not found any information which indicates that any of the.failure.criteria described in MO G R 15303 tir in 310 i✓NIR 15.304-mist_ Any failure criteria not evaluated are indicated betow, - Comments.. SYSTEM MET.ALL PASSING REQUIREMENTS AT TIME OF INSPECTION B) System Conditionatly Passes: One or more system components as described in the Coriditivrial Pasts:s�tiori need to he replaced or repaired:The.system,upon completion of the replacement or repair,as approved by the Board of.Health,will pass_ Check the box far oyes",.6eo'or"neat determined'(Y,N, ND)for the following statsinents,.if"not . determined,'please explain: The septic tank is metal and over 20 years tilt!*or the septic tank(whether metal or not)is structurally unsound;exhibits Substantial infiltration or eftrration of tank fallure is iirminent. System Will:pass inspection if.the ex+sting tank is replaced with a complying septic tank as approved.by the Board of Health_ *.A.metal sepfic tank will pass inspection if it.is stnicturally.sound,not leaking and if a Certificate of Compliance iridicatinq:that the tank is lens than 20 yeas old is available- 0 Y 0 N C .ND(Explain below). .?aa Twe 5 O ficw kis�Form_Subsuftee Sftme Disposal System Page 2 ar 17 . Commonwealth of Massachusetts Title ►ffi Inspection Form . Subsurface Sewage Disposal-System Form-Not for Voluntary Msessinari 75 ROOSEVELT R . . Property Address. HEINE owner. ovvne>'s Name � _T- znfratmaton required fir CQTU#T MA _ 12-4-14 every'page• : Citylrown. State Zip Code: Date.of nss ediosi M, Certiff on (co Q Pump Chamber pUmpstalarms not.operatiarsal.System will pass with Board.of Health.approval.if pumpstalariris are repaired. B) System Conditionally Passes(coat.): © Observation of sewage backup or break out or high static water level in the disti ibution box due to broker-or obstructed pipe(s)or due to a broken.,settled or uneven distribution box.System wilt pass inspection it{with approval of Board of Healthy. [ broken pipes)are replaced Y Q 'N NO(Explain:below): 0. obstruction is removed :0 Y E .N 0 No(Explain below), 0 distribution box is leveled or replaced Y N NO(Explain below), The system-required pumping more than 4 times a year due to broken or obstructed pipes) The system,will:pass inspection if(with approval of the Board of Healtl1): broken pipe(s)are:replaced 0 Y 0 N. 0 .NO(Explain belowy. obsti'ciction is removed 0 Y E H [I NO(Explain below) C) .further-Evaluation:Is Required by the Snare-a f Health- . { Conditions exist which require further evaluation by the Board of Heald-:in order to determine if the systeri3 is failing to protect public Health,safety or the environment, 9. Systern trill paw unless Board at Health determines in.accordance with 310:.C.MR that iEhe:system is notAinciffoiuix�fit a manner u"ich.wiff Protect public health, safety.and the environment. n . eSS0601 ofprivy is Wittiio: 5Q fW of a S[ �wSter[ Cesspool'or privy is within 5(l feet of a bordering vegetatedre#land or a salt:-marsh 1:M-3"3 Tit}e 5 Ofi`idw, ai Dann;Sit-face.ttsspectt $eve Die sal System Peg.:3, 1 r Cort'irmoeawealth of Massachusetts Ti Official. Inspection ors Subsurface Sewage Dis ai-Syste M. 1761 -Not fdr Votuntery Assessments . . 75 RflC3S ELT.RQ Property.Address HEINE Owner Owners Name infotmatior rs required for. COTUIT f24-14 - Irmvn .. state Zip Code Dote.of Inspection every.page.. COY Be C€rfification (con-) 2:. System Will fail unless the Board of Health(anti Public Water Supplier,if any) deteratmines that the:systeto is functioning in a manner that protect tine public.fieait#i; . . safety and enviremrament: 0 The system has a septic tank and soil absorption system(SAS)and.the SAS is witliin 100 feet of.a surer water supply or tributary to a surface wafer`supply. 0 The system has a septic tank and SAS and the SAS is within a Zone 1.of a public water. supply: tj 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€r more from a private.water supply well Method used to deterrriine distance. This syste'in.passes if the well water analysis,.perfor€ned.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 s pprri£provided that:no other failure criteria are triggered. A copy of the:analysis must be attached to this foram. 3: Other; D) _System Failure Criteria Applicable to All System. 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 i ufface of they ground or surface watet-s due to an overloaded.or rlc�gged SAS orce5spoo. Static liquid tenet in the distribution box above:butlet invert due try an overloaded . N ckigg,d SAS or cess l Liquid depth in cesspool is less tharp SU below invert or available volume is less than l/ day flow fr 31113 Subsurface S fl spasa(S3 siem*P 6 of r Cloth,"onwealth of Massachusetts u : TRIO 5 Official Inspection For Subsurface Sewage Disposal..System Form-Not.for Voluntary Assessments : 75-ROOSEVELT R[3. Property Andress Owner ownePs Narrre era�rrnafrnrr is. COTUIT A 12.4-'14 . requiied for ,. every page. C-rty/Town state Zip Code crate of tnspedh3n B. Certification.(cont.) Yes No Requ;rred pumping more than 4 times in the last year NOT due to clogged or nbstruded pipes}.Number Of times pumped.- El El Any portion of the SAS,cesspool.or privy is below high ground water elevation. Any portion of cesspool or privy is within 400 feet of a:surface water supply or tributary to a surface water SuPRIy. [� R Any portion of a cesspool or privy is within a Zone 1.of a pukilic well: Q 0 ytriy portion of a cesspool:or privy is within 50 feet of a private watei supply well_: . . Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet: frorna private water supply well with no acceptable:grater quality analysis..tThis_ system passes tine weFl water analysis,performed at a DlEP certified laboratory,for fecal coliform:bacteria.indicates absent and the presence of ammonia nitrogen:and nitrate:nitrogen is equal to or less than 5 0m,. . provided that no other faalure cr eris are"gored.A c4Dpy of the analysis : an chain of custody must be attached to this forrml The system is a cesspool serving a facility with a design flow of 2000gpd- , 1 t3 000gpd. The system failsR l have determined that one or more of the above failure.. criteria exist as described in 310 CMlq 154.303.,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 faellity with a deSrgn flow of 10,000 glad to 16,000:gpd.. 1=16r large systems, you must indicate either"yes"or"nog to each of the Ulowim,in addition to the: questions.:in Section 0: Yes. NO 0 the system is within 400 feet of a surface drinking vrater supply _ . the system is within 200 feet of tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection 0 .0 . Area.—JW A-or a recapped Zone 11 of a public water supply well If you have answered"yes to any question in Section.E the system is considered a significant threat, or answered"yes'in Section d above the large system has failed..The owner or Operator of.any large system considered a_signifieant:threat under Section E or failed. under Section D shall upgrade:the. system in accordance.with 31.0 CMR 15.3041..The system owner should cor tact the appropriate regional office of tllr~.Repar[ment r5jns Y1 Tate 6 OhkI4 h?, ibnFotm Sdsldaca.,Seivage Disgosar 8yaie n Page 5 of 17 Commonwealth of Massachusetts on v.: Title.5.Offictal > Subauirface Sawage Disposal Systel"form Not for Voluntary Assessments 75 Rf34SEV'Eti3§�Q ._' �__ Propoity Address .. Q1Allief _ QWf1e(s;Na t'i2. - inforrrtatiort.is C�3TUIT MA 12-4-I4. required for every page_ CityfTomm Mate Zip Code Bate:of inspection C: Checklist Check if:the following have been done:You must indicate"yes or"nco as to each 4f the following. Yes No 0 0.. . Pumping information was provided€by the owner, occupant,:or Board of Health. Were:i any of the syAevn compdirmecits pumped out.in the previous two weeks? . . 0 . 0 Has the system received normal flows'in the previous two week period? ve Iarge vole ne Qf vuater been introduced to the system recently or as part of: 0. ahis irispectroiz? Wue as built plans of the sys 6rh obtained and examined. (if they wwe no: available note as NIA): 0 0 Was the facility or dwelling inspected€or:signs of sewage back up? ( Was the site inspected for signs of..break.out? Mere.all_system__components,excludiing.the-SAS,iodated on site? 0 Were the septic tank manholes uncovered,.opened,aiicf 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(arid occupants if different from owner)provided with information ors the proper-maintenance of subsurface sewage disposal systems? The size and location of the Sou Absorpt on System(SAS)d the site has been deteMined Based on: Existing information.For exarnoe,:a plan at Vhe Sowd.Of Iiealth, Deter mined in the field:(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310CIVIR:1&3102f 5)) D. System Information Residential f low`Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flown based.on 314 CMR 15203(for example 110 gpd x#of bedrooms)*.. 334 l5irrs,`J93 . .`V, -.5 00i6 7 kwacoion FWM Sutnudace Sewave[Yispasat Systettt•NQ6 6of 17 Coinmn srweafth of Massachusetts - � r F Subi.SU ace Seinrage Disp l Sy orn Fwox_Not for Voluntary Assessments r 75 ROOSEVELT R13 Properly Address. owner: Owner's Marne rnforrna#Jon is MA 12-4-1 required for. _ COTU1T CityfTawn .every page. State _ Zip Coda Date of fnspe on tin:Sys#er�. Infortnatioti Description: ACCORDING TO AS BUILT CARD SYSTEM CONSISTS.OF A 1.500 GALLON TANKD BOX ,AND LEACH Pit Number cif current residents: Does residence have a.garbage grinder? 0 .Yes 0 No 1s ladridry oh a separate.sev�age.!�yttO i�?(lriclude 1a.Undr .s stem►inspection des No. information in this report) Laundry system inspected?. 0 Yes 0. :No Seasonal use'? Yes 0. No Water meter readings,.if available(last 2 years usage(9pd)): D�tai: Sump pump? Yes 0. No. . Last date bf occupancy: Date Comrnemial/frid fstrial flow Conditions: Type'of Estabiish.ment: Design flow(based ran 310 CMR 15_2Q3): Galons per day(gPd), I . Basis of design flow(seats/personsisci t., etc.) Grease trap present? Yes L . No Industrial holding:tankpresent? _ Yes �]: No Non-sanitary waste discharged to the Title 5 system'? Q. Yes Q No Water meter readings,if available: FSir -31i3 rztte 3 fXBaat Farm:5vbsur(ace SaaBeDisRosai.&jrskem Page 7 a€17 E. Commonwealth of:MastachuSetts _ Ti p OfficialInspection. Form . Sub%uffateSeWMfle I LSPOSal SYSte F£Di1t1- Not for Voluntary Assessments ' 75 RU�IS�ELT Rl3 . . .. Prop"Address IHEINE _ Owner Owme's NaMe rnit3ftiTat34tP is GCJTtJl3 MA iu+[ed for @VBtjr FlagB. City/Tow!} aStcite Zip code Bate:of Inspection D. System Infdrmafion (c©nt.) Last date of occupancyluse: Date vier(describe below), General Lnfoffnaifon Dumping Records: Source of information: Vitas systems.prriped as part of the inspection? :Yes .No If yes;volume pumped: . gallons HOW was quantity pumped detei mined? Reason for pumping._ Type.0#system: Septic tank:distribution box=soil absorption system Single cesspool. [3 Overflow cesspool . Shared system(yes or na) (:if yes,atkach previous.inspection records if any, nnovative#Alternative technology Attach a copy of the co rent operation and maintenance'contract(try be.obtained from system cwnerj and a copy of latest inmpection of the ItA systern by system operator under:contract flight tank.Attach a copy of the DEP approval: Other:(describe . fS+cis- t3 Tide 5 offi"lrisp YiarS Form-Subndaw SetzW Disposal System Page-SW 17 Commoirm,641th Qf Massachuse . RI fft i In w Fob` Subsurface'S6wage Disposal System Form Not for Voluntary Assessrnents 75 ROOSEVEL_T RU Property Address. H51NE 'Owner. Dwner s Name . i focmatiarr is MA 12444 . required for . GOTUIT every page. GitylTov Stag Zip Code Date cif#nspet ion . D. Sys" rif WcaMa►b0n (Conti. Approximate age of all components,date installed:(if known)and source of information OCT 2000 AS PER AS BUILT Were sewage odors detected when arriving at the situ : Yes fVo Bading Sewer(40cate irs site plan): Depth lisltiuj grade: Material.of construction: 0.cast.trot' .40 PVC 0 i3tl'r(explain)- Distance:from private water supply well:or suction line: fear Ccirximersts t condtticiri t�foirtts,.veritirtg, evicfertce of leakage,etc.); Septic Tank(focate on site plan: � 5 Dept Below grade.. feet Material of construction: ®concrete metal. 0 fiberglass 0 pi lyeftle:rie. O other(e, ain} If tame is Metaf, listt age yQars is age confirmed by a.Certificate of Compliance?(attach a cagy of cent catoj .Yes.[ Flo fliniensitans_ 1506 T Sludge depth: LtGI-l " 3�a3 Tifte:s(AcW[ F "SWzk;e Smage rival System Page s4Dt 17 +COM MOnwrea m of Massachusetts Tftleci > Inspection . Subsurface Sewage Disposal steep Form-Not for Voluntary Assessments � a 75 ROOSEVELT RID Property Address. . . HEINE Owner` U�nees.Name arfforrrrat are is required for C4TUll 12- R 4 every page:. GitylTo" State. Zip code Date of Inspection r S /STI'! 11fo 't1iQT {ion#. Septic Tarns(Cont.) Distance from tap of sludge to bottom of Nutlet.tee:or baffle - OHT Scurn thickness . Distari from fap of scum to top of c�0et tee or baffle Distance from.bottom of scum to.bottom of outlet tee:or baffleWOODEN POLE - How were.dirriensions determined? Cc rrl nts fan ptirr�fiing recommendations, inlet and outlet tee er baffle condition, structural integrity; liquid levels as related to outlet..invert,.evidence of leakage, TANK.LOOPED STRUCTURALLY SOUND AT TIME OF INSPECTION grease trap tlocate on site plan}: . Iepih t�etor grade. teat Material of construction: El concrete. 0 metal C7 fiberglass 0 polyethylene: other(explain} Dimensions: Scum thickness DiStanCe from top of SCUM to top of outlet tee or baffle Distance from bottom of scurn to bottom of outlet tee or baffle I11p. .9 In _ 47ateaof last.pu Date fr a 'Su i3. i S stem*P a4 e 10 of 4 I t5ans.•�k73 7'd�e S{3 xaaf tip GGan F . . wee 5evaga s�o� � . i� Connmonwea ttn of Massachusetts Title ci l Inspeption Form w �vslstenyli9ct�tar�Asserentses N -Sdsuac g 75 ROOSEVELT R Property Address HEMS wner. C3urner`S Name fa Fn€crrrrrtian isMA 2- -7�4 required for GOTU'T every page. _ . : . .CytTown State dap code flats of inspect" . D.system Inform ation (Cont.). Comments{on purnpmg recommendations,inlet and nutlet tee or*..baffle condition;structural integrity, liquid levels as related to outlet.invert,.evidence of.leakage,etc.}: RECOMMEND PUMPING EVERY 2-3 YRS. 'fight or Holding Tank(tarok trust be pumped at time of inspection)(locate on site plea) Depth below grade. Nlateriat of construction: 0 concrete . metal 0 fiberglass polyethyleiae . . .Q outer explain Dimensions; = Capacity gallons Design Flow. �ati�rss per day Ala"present : 0 Yes 0 No Alarm level: AiarrTi in va in titi3 r:: . Yas ' No £datee of fast pumping: Comments(condition of alarm and float switches; etc.j` Attach-copy of current pumping contrad(requires.. is copy attached? Yes ❑ No F5kas 3Fi3 Tii(e 5officrat#mpacf on>=o=Substoface Savage Disposal Sgs.em. Fags 11 of 17 Commonwealth of Massachusetts: : Subsurface Sewage. isp+asai;aysti iFotrt,-Ndt for Vbfuntaty Assessrrients 75 RbOSEVELT RC?: Property Address. Owner Qw trees Name . Wtira»aLonbs COTUfT MA ?2-4-1 required for e rY P Otytfow€t state. Zip'—'We Date of Inspection D. SY441- n 100"n.atllon (coraf. Distribution Box(if present must be opened)(locate on site plani): Depth of liquid level_above outlet invert f}u - Corrirriebts(note.it box is level ant distribution to outlets equal, any evidence of srilids carryover;any: evidence of leakage into or out of box,.etc:):. Pump Chamber(locate on,site plan*) - Pumps in vvvsiiicing order :Yes [] Now Alarms in working order. Yes tgoa Comments(note condition of pump chamber,condition of pumps and appurtenances etc:}: If pumps or alarms are not in working order,system is a.conditional pass: Soil Absorption.System(SAS)(late on site plan; excavation not.required): if SAS not located, explain why.: F nn. a Di"osf#S: 'rtz Pa 1 b#1 Tide 5 ot�i F en o ace'. c'ral Subsuf ystc: 45s tSrns 2'dY3 � 9 $P COrnnno nwoeffi of Massathuse# s 6 Official Ins :Foy Subsurface Sewage rsposai.System Fott+n Not for voluntary Assesthients: :"T5 ROOSEVELT RO Property Address. � . owner: Owners dame �. it brMaim is. regWre!fi , GOTUIT n _ i2 -�every"page. Gityffown State Zip Code Date of Inspection D.Sptem.Infomation (cent.). Type:.". leaching pits n.urnber: - Q . " leaching chambers number... leavhing gatteeies number: teaching trenches number,length., - --- " leaching fields number,dimensions [ overflow cesspool number" �. nnovativelatternative system Type/name of technology. Comments(note condition of snit, signs of hydraulic failure,level of ponding,damp:soil,condition of vegetation,etc)" PIT HAD ABOUT 3"FT Of"LIQUID.WITH NO SIGNS OF i AILURE AT TIME OF INSPECTION Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):. Number and configuration. Depth top Of fi'uid to inlet invert Depth of sotldS layer_ Qeltt7 ofscurn layer Dimensidns of cesspool .Materials of construction indication of groundwater inflow . [ " Yes Igo 35atiS:"3t13 Tt td 5 off,"(Inwwt-'70M"st&-ft'ce S-ne sposat SyStM Page 13 of 47 £oinmonwealth ofMassachusetts ui Title 5 ffidi Sukiswage VcaAwrace Disposal System Form-Aoiar sSessmenfs 75 R€ OSEVELT M . Property Addre&s . . HEINE .. Owner Owners Name information rs required for COTUfT MA _ 12-4-1 every page.. . Cityfrown State Zip Code Date of inspection t3.. System Info 't'aflon (cont.) Cc>mm6nts(note condition of soil;signs of hydraulic failure;level of pond%rig,condition of vegetation etc. : I Privy(locate on site.plan}: Materials of construction. Depth;of.solids : Comments(note condition of sal#,signs of hydraulic failure,level 6f ponding; imnditbfl of vegetation, etc.):: fSYis 3'}' Title 5 offica hwecgw F*-S§UbsuP[S Sewage 6'�05M Sys sm Page U�f 1 i : Gz rnrn4nwea of Ma"actau e r . r� ion rM Subsurface:Sewage. isposal_System F6ym id4t:fail Voluntary Assessments. 75 ROOSEVELT T Property Ad dress HEINE T Oin�ner C3sninefs Name, in€arrnat"ran is. : . GOTUIT MA_ €- _. requi Md for every Page.. _ '. Cty/Tawn . State p code Date.bf Itisp4cEion System Informlatlolh (cont. Sketch Of Sewage Disposal System, Provide a view of the sewn ge d;sPosai system,including tins to at.least two permanent.reference landmarks or benchmarks. locate all wells:withir l00 feet Locate where public eater supply enters the building.Check one of the boxes betovv. .0 hand-sketch in the area bellow .drav+rirag attached separately . Page t� t.1Ue S Qffca Fwm uCskxaeSeag� €sPwSyatm is omanon eaith of Massachusetts Title .OfficiaM InspeCtIon. Foy Q Subsurface Sewage disposal.System Farm-Not for Voluntary Assessments.. 75 R008EVEh:T RID Pfo(3". Address HEINE OWner oWnerS NaMe information is: C"OTUIT2- -�4 required:#at - every page. cityrroWn State" : .Zfp Code Date of Inspection . D, Sys#em Informati, (cont. Site EjiAm' .Check Slope. Surface water. . Check cellar :Shallow wells AT LEAST 5 Estimated depth to high ground water: fW Please indicate.all methods used to determine the high"ground water elevation.. Obtained from system design titans on record." IfcheckiW date of design plan reviewed. Date [ Observed site(abutting property/observation Mile within 150 feet of"SAS} " Checked with local Board of Health-explain. Checked w th Jocal excavators,installers.-"(attach documentatl©n). " Accessed USGS database-,explain- You must describe how you established the high.ground water elevation: More ii g this 1n peclaor Repa�t,please see Reps► Completeness"Checklist on next 9e t5ir�-a/a3 :" �+�S c�Er�ciei tnsaec�ar��arm�Subsurtsce$ekvase tia��psieri, Pala t6 or A 7 Commonwealth Of Massachusetts R ,. i 1ion. r0rm- sabiuif e Serage 1Dis ry posaf System -Not fbr Volunta Assessments 75 ROOSEVELT RD.. Property Address HONE Owner Owner's Name information is required far COTU(T MA 92444 every page. City/Town . . State Zip Code Date oflri*eetion E. Report.Co . leteness:Checklist .Inspection Summary:A,Sr.C; D,or E checked Inspection Summary D(System Failure Criteria Applicable to Alt Systems)wrnpleted Z System infof natton—Estimated depth to high groundwater ig Swch,4.Sewage Disposal System etttie-f drawn on page 15 cis attaehesi in separate ate t5n5.3193 Tate 5 Offidai:inspsctlan Potm:Sc?isir face Saurase Aispersai Sygte�n.=:Page 1.7 of 17 TO f}FBAi31+ISAB{.E . L 'TV, SEWAGE OCA a TAUERS SAME racmE140:-./rye VILLAGE- ASSESSOR'S um SEEMC TANK CAPACrrY.IVJ5,00 LEACE[ING FAC]IM:{typed ) NO.OF.BEciROOW a D OR OWNER. Ps rDAIE. C oMPLLANCE DAM. I' ftlyakwaw Supply Wenmd LmbingFwAty {If aay weus exig. . . e�si�is s?fglfcsiaf ie�chis�g�}3 ! . .. Edge of Wtdad and t4acbing Facility(If any wtdm&exssc ,tea Mfeet of leachin.raeilicy) Furaiah�d.. i Al. 411 141 a ` ! _ Z" f.. http:'/www.townofbamstable.us/Assessing/HMdispI asp?mappar-�13 7&seq l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a< 75 ROOSEVELT RDA Property Address HEINEl Owner Owners Name I"`a information is 12-4-14 required for COTUIT MA c' every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in a 'y` way. Please see completeness checklist at the end of the form. - Important: When filling out A. General Information forms on the computer,use 1. Inspector: �I only the tab key v s to move your , DOUGLAS A BROWN cursor-do not use the return Namq of Inspector - key. DOUGLAS A BROWN ;x Company Name _ P.O.BOX Alf Company Address CENTERVILLE MA 02632 City/Town State Zip Code. 508-420-4534 S14297 Telephone Number License Number K B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation'by the Local Approving Authority 12-4-14 Inspect ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the. report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies°sent to the buyer,'if applicable, and the approving authority. ***"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 OV1nspeFsurface Sewage Disposal System-Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 5 75 ROOSEVELT RD - Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section.D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION . .p B) System Conditionally,Passes: - ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System_ will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' . , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): - ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):, ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. . Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes. No' , ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an-overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 75 ROOSEVELT RD . Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Cityrrown State Zip Code _ Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet r from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd., ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate'either:"yes"or"no"to each of the following, in-addition to the questions in Section D. Yes No - - ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑' the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•ill Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ fs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is UIT MA. 12-4-14 required for COT .: - ' every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each`of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere as built plans of the•system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? • ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: ` Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r< 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK,D-BOX , AND LEACH PIT Number of current residents: Does residence have a garbage grinder? El Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? El-'Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: r , Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR.15.203):- Ganons'per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No 1 Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information .Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared.system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8of 17 1 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) Approximate age of all components, date installed (if known) and source of information: OCT 2000 AS PER AS BUILT Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: r ❑ cast.iron ❑40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) _ I If tank is metal, list age:' years , Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: LIGHT t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 75 ROOSEVELT RD ' Property Address HEINE ` Owner Owner's Name information is required for COTUIT MA 124-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT 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? WOODEN POLE Comments (on pumping recommendations, inlet and outleftee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK LOOKED STRUCTURALLY SOUND AT TIME OF INSPECTION Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 1:5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: , Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑•Yes - ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): r o { " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No . r t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s. 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT ' MA 12-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): p„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): . PumpChamber b (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: El Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,',etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 75 ROOSEVELT RD Property Address HEINE Owner Owners Name i information is required for COTUIT MA 12-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): PIT HAD ABOUT 3 FT OF LIQUID WITH NO SIGNS-OF FAILURE AT TIME OF INSPECTION r Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 't 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): J t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,4 M 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name - information is required for COTUIT MA 12 4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) ~ Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells ` Estimated depth to high ground water: AT LEAST 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators,,installers'-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: j Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5im-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts 4 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 ROOSEVELT RD Property Address HEINE Owner Owner's Name information is required for COTUIT MA 12-4-14 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 2 of 2 r , http://www.townofbamstable.us/Assessing4lMdisplay.asp?mappar=03913 7&seq=1 12/5/2014 ' Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE G' ' LOCATION SEWAGE# V U-bl3 VILLAGE o ASSESSOR'S MAP&LOT 065 INSTALLER'S NAME&PHONE NO. >1 t m Hoccer- #10�DZBO SEPTIC TANK CAPACITY /L5 C� LEACHING FACILITY:(type) (size) ` NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: t'��1 COMPLIANCE DATE: 0 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 A I �31 � • � zq 2 3� • 3 2r� " 4 http://www.townofbamn table.us/Assessing/HMdisplay.asp?mappar=039137&seq=1 12/5/2014 r Doi 1 r26,Os374 12�17� 2014:; 16Z:;: 7 L'.ARMSTAOLE "LAND -'CO.UkT "�bUSTFY DEED IUSTR.ICTION' WHEREAS;Ji11 A:.Herne,of 22C I:eiahton Gave NW`52t}P London LTIC"and Ssat%H. Stephens,of'1`044 So.Euctci Park;Oak Park,IL,603(}4,are ithe owners af'7S Roosevelt Road' located at Cotuit MA and:being,shown>.on a plan emitled`$.4bdiV ston.Plan ofT and in Barmtable,MA,.duly recorded in Barnstable.County Registry of D"eeds iM I.Ah .Court Plan Number 36608-C' F 'UV'HEFiW Jill A Heine"&Susan H.",Steghens;as the otivners of sand lot weed uirth the Totivri of Barnstable Board of Health to&,restrictron<as to thelnumber of,bed!rooms which.can be ,included many home buiffon sari lot as:a pre-condition to obtaining a disposal'works;. . construction permrf in cainpi�ance wrth,3l0 CMR 15.000 State Eiivironrnent Code;Title"V Minimum R'egirirements for the'Subsurface Disposal of'Sanitary Sewage;'. WHEREAS,'.a Town-of Barnstable Board:of Health,.as a pre-"cond ition to grant:Mg a sposal.' works construction:perinit for a s"eptic system in comply nce with 310 PWt 15106, State; Environment:Cod'e,:Title V,Mrnimum1equirementsfor"the.Subsurface'Dispvsal of.Sanitary Sewage,and`authorizing the rsauarrce of a btiiltltng permit;for the construction,of`a single,family`' home on this property,is requiring that the agreement f' the restriction on the number of" bedrooms in any hoixse"consttucted qn the lot> e put"o r record with the Barnstable Bounty. Regrsiry of'Deeds,by recortirng this document; W. THEREFORE,Jill A Heine&SusanH. Stgphens do hereby place the.foliowing restriction:on liis"alsave referenced land in accordance with"their„agreement with'the.Town of BairistableBoard ofHealth which restriction sllall,ruz wrth the lari and be;biriding upot}all` "successors�n`t�tie ; 1.bf 5 Roosevelt Road1o'cdt6d:if Cotuit MA,may have constructed"upon the lot"a.house contarrng nomore than three(:3)bedrooms :Jill A.Heine&Susan H."Stephens agrees"that this; shall.be permanent'deed testrictian"affecting.the property located ciri" 5"Rc+osevelt.Raad"located atCotrrit: 'NiA.and:,being shown on"I.an .Court Plan 36608=C,Lot3S' For title of Jill A",Berne&Susan H. Stephens sce the�follow%ng deed .andCourt,Certrcate of Title I`lumber1 006` l Executed as a sealed instrument, da cif' op-' ,Jill APk Susan'ITT Stephens, ,bjt4liiiONWEA THb MASS:AC;HUSETTS COUNTY"OF'BARNSTAB'J On this Deceinber:IS,14 t,4'before me,the undersigned Notary Pubic,,personally' appeared Jilf x. Heine,proved to me`through satisfactory evidence of`�denti cation;which.was- rlrtvem license;to be the,person whose;name is s gned.on this locumlent and stated that..,.he acicriowledge nt to be his truedct-and°ded::e f g e Witness,rny'handanc!official seal. Notary ublic 'my iiii won Scpi ►� _ o. ��, : TOWN OFB�AR(N�STABLE LOCATION _T ' �U�-�L� SEWAGE # VILLAGE fA/SSESSOR'S MAP & LOT �.J INSTALLER'S NAME&PHONE NO. i r1 1��� 420 6 2-FO ; SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO OF L?EDRC%+m BUILDER OR OWNER PERMIT DATE: COMPLIANCE_DATE: C J Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet I 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 __.._----- - . �rZ � �� Z f. DEED RESTRICTION. . {5 1uHEREAS Jli A, Heine;at 22C.Lei ton Grov'e NW52QP :London;CJK.and Susan H., eens: of 1044 S© Euclid Park,Oak Park'.1L 60304arethe owners.of.75 Roosevelt Road located it Cotuit, MA and being shown,on a,plan entitled"SubdiYisitin Plan of.Land in Barnstable;-MA duly recorded;in Barnstable:County Registry of:Deeds in Land'CourtI?lan Number 36608=C 5�t WHEREAS,A A:Heine&Susari;H.&iris as the owners of gaid:lot ag eed witki the'Town.of Barnstable Board of'Health to a restriction as;to the number,of bedrooms which eanxe included' n any home built on said lat as a,pre-coddition fo obtaining a disposa works construction;.permit in`eoMpliance with 3I0 CM.R 15,Ot14 State Environment�Codex Title'V,Muiimum;Requirennants; for the:Substirface:Disposal of Sanitary`Sewa WHEREAS,`fhe,Town of.F3arnstat le Board of Health,as a pse=condition to granting a,d sposal works construction permit:for a septic systemjn compliaince with,:31 Q CMR:l a 2Q0:,State Environment Code,Title V,Minirrium Reluirerients for the Subsurface Disposal i;f Satiitarr}r Sewage,and.authorizing the issuance of a butli3i g permit it he construction"of : ifigle`family. hpme' on this property;is..requiri.ng that it e.agreement far the restriction on the nurriber ofz :bedrooms,rn:any house"constructed on the;lot he'put on:record'with the Barnstable County Registry of Deus byrecording this document; NOV+J;`THEREFME,.111 A'Heine&'Susan l T, St sdoherej.by place the;following restnctiori x on his above-referenced lanai in"accordance with,their agreement with the Town of:Barristalale -=+ Board of Health,which restriction shall run"wtth the land.a�nd be binding,upon all suecessors,in u° 1 of75�Roosevelt Road ibcated at Cotuit' M;4may have constructed,vpon.t la,;a.h ser containing no:mare than three(3")bedrooms.Jill A Heine&:Susan I1. ��gre that tW a shall be permanent deed restrictiari`affecting the property located on 75 Roosevelt-Road located -at Cotuif, MA,and being shown on Land Lour Plan 36608 C` 3S: y For fide"ofJill A.Heine&Susan H.�ssee the follaw�n�deed"I azid Gvurt�ertifcate of m ,o "Tale Mumberl99626 o N Executed as a seated nstniment da of 12r ', 11 ::Jill A,;l=leme�.............. , :Susan-kls: 14 STATE OF t LINI S, )' Co,,OK'000W On this 6Q4 Y, 2Q°14,Sussn Hefnre:rrie personally appeared who proved bY °k' f,�if % i be the individual whose name is subscribed.to.the foregoinginstrument,and acknowledged that he executed the sair�e as hits free act and"deed for tlie'-purposes therein contained: Wm itness,My hand,and official seat Notary"Public My Corn issiomExpires �M FFICIAL"SEAL" " NlariBn ne W HuMmerch f�ntary Public,State of,fllinois '' Iuiy Commission Expires 412pi7, BARN"LEREGI. l)F pEEDS jots �,Meade,Register , i + t ` f 1 } i �Ovib� 1 , » , �CODNn+ i tj , , 1 , t a I t , , i it k P t � SQ' LOOP � i , I , I f ' f i I I / I r : r I ri , , i } , t , I I , , I - i wo wa �S F I No. ��� �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 3pplication for Mf.5po5ar *p.5tem Construction Permit Application for a Permit to Construct(,. )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. �L �Z� Owner's Name,Address and Tel.No. Assessor's Map/Parcel CA128l- 5"DL�� Flo G (3 Installer's Name,Address,and Tel.No. �4.0�$YD Designer's Name,Address and Tel.No. � ii 70 ,us 141 u-S Type of Building: Dwelling No.of Bedrooms -1 Lot Size 2_ o_ b�sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when plicable) "Vora bDt? 64-L- SUPTtC 7A7A9ie_1 ZoL,o C4Ta= `Go 1,5-00 (tie S,. -TA-?Jjt , `rr C— l tj-rD &YIS-nM 6 Date last inspected: 9 a Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions ofle of the Environme tal Code and not to place the system in operation until a,Certifi- cate of Compliance has been issued Boazd of Healt-. Signed Date M 1 t, d b Application Approved byc Date 144,e XZ- Application Disapproved for the following reasons Permit No. Date Issued ld—Zl`"" � No:4; �'404 L� f/ Fee s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ke, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEa MASSACHUSETTS ZIpapYtcation for Mfigpozar *pftem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. "7 Owner's Name Address and Tel.No. t L 5"Dt.5 Assessor's Map/Parcel �^ O .l fry' Installer's Name,Address,and Tel.No. I ' Q 0`?-r; Designer's Name,Address and Tel.No. .�A—✓►� E5 f-�-awe-- ;rc , 70 Z- /►.tA-2S'f0 uS dot I l.(.-S Type of Building: Dwelling No.of Bedrooms Lot Size 2D1660 sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures F v Design Flow gallons per day. Calculated daily flow I gallons. r �y " Plan Date Number of sheets ' Revision Date Title Size of Septic Tank - .Type of S.A.S. Description of Soil Nature of Repairs Alterations Answer when plicable) A6A'�D b O (b00 641- S E PriG 7,41014, �o Tip t oo (Nr" � S, "Tqj11e_ , Tt lIJTo E-)crsTiN6 t 1t'-i4�tE ply' Date last inspected: 1 9 Q Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions ofI of the Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued Board of Healt . Signed Z7 Date !U' 8` QD Application Approved liy `" Date/O' °' Application Disapproved for the following reasons Permit No. ' ow4:1 7 Date Issued d'�-1001`* � --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY that the n-jie Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by -Cj t VtAHe Ile V' at S ose-ve-R )�_>a ca has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe o'O'o dated /10 Installer Designer n The issuance of this ermit,hall-no be construed as a guarantee that the system will function aslesign Date �� --� Inspector ! ;�1+1 Ul!' ✓ ---------------------------- - --------- No.�* Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEa MASSACHUSETTS Ii.0p0ar 6potem Congtructton Perth Permission is hereby granted to Cons�ct( )Repair( )Upgrade )Abandon( ) System located at �� 1���"�L��GI -'" �n o- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by a r tsu Ttm r i , IzS, o0 1 •� 1 � i 1`�roPc;ecQ I _ � � r 0 peck , 1 I W ooD f -47S or ; o.r 3S TO THE( MORTGAGE INSPECTION PUN AND ITS TITLE INSURERS, I CERTIFY THAT THE BUILDINGS SHOW DO ( ) CCg�N!PppRR��11 LpCAEb � IT I.E. (FRONT. SLOE, «REM TO SETBACK REQUIREMENTS SETBACK ONLY) OF BaI�nSY.able Co T V �CAI ED� Oi,r�MS�nVA ENFORCEMENT AcnoH UNDER w�ss c� MASSACHUSETTS I NRTNER CERWY THAT THIS PROPERTY Is riot LOCATED IN THE ESTAiUSHEU FLOOD RAIARO AREA.OOMMUNITY PANEL NO.: 25n0o1 n018C DATE fl-19-85 DEED THIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUENT TO THE RECORDED BOOK DATE OF THE LATEST DEXD OF RED=. PAGE wNENEVU BUILDINGS ARE SHOW LESS THAN CNE FOOT FROM THE PROPERTY LINE IT IS ADVISED CERT. NO. THAT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE MEASUNO RE]1fN1� p., ,�.` IM C LOCATION IS BASED ON THE OF SURVEY MARKER t�luao,r� 'DOES NOT PLAN BK. —�,PACE-- R IT A PROPERTY SURVEY. AD11F1CATION OF SURVEY M AS SHOVM. �� 7,6nA DATED MAY BE AO�COyM,PLISIIED ONLY BY AN Alxt1RATE, INSTRUMENT SUR VEWAYS t DEPICTED ^ T% GI:RTIFlCATION TO BE USED FOR MORTGA P Y. 24 199`j OFFSETS AS SHOWN ARE NOT TO 99 OQUGGII,ODUKAS °'i• scALE F" USED FOR THE ESTABLISHMENT OF PR LU.NN 4, BRADFORD . •. ,/_o( SII{2`��.. ENGINEERING CO. . K P.O. BOX 1244 HAM74*11 MA. 01E31 JA►IES W. B0001OUKAS R.LS. #9529 TEL (") =--2306 . -.-4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary AItGEO PAUL CELLUCCI DAVID Governor rr�l i n�ra s � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A ' CERTIFICATION �O� Property Address: 75 ROOSEVELT RD. COTUIT MAP 39 PAR 137 LOT 35 N ro Name of Owner CHALES Address of Owner: C/O REMAX 3860 RT.26 MARSTONS MILLS MA.ATT.DEB SHILLING b or�� `9,9 Date of Inspection: 4/19/99 l Name of Inspector:(Please Print)JOHN GRACI '� r 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a - Mailing Address: n/a Telephone Number: nla 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Passes' code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority, performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. /j, Inspector's Signature: JaV Date:4/20/99 < The System Inspector shall s bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4119/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. . Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced nta The system required pumping more than four 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 i revised 9/2/98 Page 2 of 11 a f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35, - Owner: CHALES Date of Inspection:4/19/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. E . 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nLa-(approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4/19/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: r I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid.level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,00.0 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply," X the system is within 200 feet of a tributary to a surface drinking water supply . X-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), The owner or operator of any such system shall upgrade the system in accordance with 310 CMR.15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98_ Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 , Owner: CHALES Date of Inspection:4/19/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H; X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)1 X The facility owner(and occupants,if different from owner)were provided with information on the,proper maintenance of SubSurface Disposal Systems. P revised 9/2/98 Page 5 of 11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION- Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4/19/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):3. Total DESIGN flow: $,1Q Number of current residents:Q Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):�LQ Water meter readings,if available(last two year's usage(gpd): nla Sump Pump(yes or no): NO Last date of occupancy: 4/15199 COMMERCIALANDUSTRIAL Type of establishment: nta Design flow: nla gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nta Last date of occupancy: Ella •. OTHER: (Describe) Ella r Last date of occupancy: Ella GENERAL INFORMATION ' PUMPING RECORDS and source of information: nla System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n/a- gallons Reason for pumping: nla TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval, Other: Ella APPROXIMATE AGE of all components,date installed(if known)and source of information: 1983 PEMIT#83-643 Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION('continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4/19/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2,6.. Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: Y' Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No); UQ n/a Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: IL" Scum thickness: Distance from top of scum to top of outlet tee or baffle:SL Distance from bottom of scum to bottom of outlet tee or baffle: Jr How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nm Dimensions: Wa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:jila Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nta revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 ROOSEVELT RD.,COTUIT MAP 39 PAR 137,LOT 35. Owner: CHALES Date of Inspection:4/19/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) ` (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Dimensions: nLa - Capacity: nta gallons Design flow: nLa gallons/day Alarm present: N4 Alarm level:jita- Alarm in working order:Yes_No_: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:Wa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa E PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): N_Q Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.)' Wa revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4/19/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods). If not located,explain: nta Type leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jiLa leaching galleries,number: _n(a leaching trenches,number,length: n& leaching fields,number,dimensions: Wa overflow cesspool,number: nLa Alternative system: nLa Name of Technology: ji& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY PIT WAS EMPTY AT THE TIME OF THE INSPECTION NEVER MORE THAN V O CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) D& PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:Wa Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4/19/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 5 et--,e^ peck Oc AA Ac, 33 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 ROOSEVELT RD.COTUIT MAP 39 PAR 137 LOT 35 Owner: CHALES Date of Inspection:4/19/99 NRCS Report name: nLa Soil Type: n& Typical depth to groundwater: nLa USGS Date website visited: nta Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet 4 Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.). Determined from local conditions _ Checked with local Board of health Checked FEMA Maps ' _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET , revised 9/2/98 Page 11 of 11 L 0 C A T I SEWAGE PERMIT NO. Qtwu VILLAGE S IN A ,[R'S N E i ADDRESS t �p BUILDER OR OWNER 42g-�Z!�' DATE PERMI ISSUED DATE COMPLIANCE ISSUED -col s � _ F t „ t Nof rw FEB ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �c 0.................OF....... �.�,1�.`�. tt4� Appliratioo for Uiiposal Works Tiluarortiott Frrutit Application is hereby.made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........... . ............................ ...................................... . --•-••----------------......_..------------------. Location- ddres or Lot No. i S.rl, .... t✓.c: �- �'- .. ..... ..................•-----------..O�Z ?T............................................... Owner Address �...�1._---.A_ .i,5-? ------------------------------------- ................................ ---------------------------------------------------------- Installer Address d Type of Building Size Lot... d. O0 Sq. feet U �--- :---.. 0-4 Dwelling—No. of Bedrooms......._....................................Expansion Attic (Ab Garbage Grinder (ilk) 04 Other—T e of Building oo9............ No. of persons_.....�,_................ Showers — Cafeteria Q' Other fixtures ...................................................... Design Flow............yr. .....................gallons per person per day. Total dail}' flow____.__......3.__...._.._.._---______gallons. WSeptic Tank—Liquid ca acity-100•-gallons Length....l0...... Width....._._(e._... Diameter--------(_.... Depth.... . ....... x Disposal Trench—No.__'�.iwev... Width.................... Total Length.................... Total leaching area....Ot42 _...sq. ft. Seepage Pit No..................... Diameter.._................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution-box (� Dosing tojk ( Aest Percolation Test Results Performed by.._� 4e /9' e.......��- L_ `e� ....... Date........_? L._� m ...mutes per inch Depth Test Pit No. I___ Pit........O.-,._ Depth to ground wat r.... ........ ..-. fa, Test Pit No. 2---�_.,)­.minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' P T.._....._ - - ----------- ® Descri -- j... 'N tion of Soil-••----Q ....... `��---.....La&W-- t� _�. 1�---- ----. U; ........................................................-------------------------------------------------------------------------•----------------------------------------------... ------------- 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued by the board of health. ed ----- --8 ��l�....; 6s.1 Applic ton Approved By....-- • •• -- ----•--- no�4I .l . •• --- ate Application Disapproved t e ollowing reasons:............................................................................................................... Date PermitNo.................•-----................----.............. Issued.............................................:......... Date FEB... V.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD dF HEALTH ..--...4... WN..................OF.... Z A --=- --------------------------------------- AVVjirafl,6tt1vr Disposal .orks 'Ton,strurdian ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: !T UD.Se V e l"" (_v7".cJJI` ... - ......- ------ ............................ ...................................... ................................................ Locati -Address E or Lot No. .L ! !!..`a .GS �� / .- C-?_...... �`e1-�!-t'"_..----•--•----•............................... W Owner Address Installer Address UType of Building Size Lot___ _ f_--- -----__Sq. feet 1-1 Dwelling—No. of Bedrooms__ ________________________________________Expansion Attic (tb •�,? Garbage Grinder pa, Other—Type of Building _ fir'________________ No. of persons......:................. Showers Q�7) — Cafeteria (W) Pa Other fixtures -----•••.--•--•-----•---•-----•- - W Design Flow_____________��........_......__._.._gallons per person per day. Total dail floes..._._.__._.. _3_.......................gallons. WSeptic Tank—Liquid'ca�Facit _ 00__gallons Length___.�v....... Width_____________ Diameter........ Depth_ ____________ x Disposal Trench—No. _AI 9. .___ Width.................... Total Length.___..________.._.__ Total leaching area �?_ -----sq. ft. Seepage Pit No............... Diameter.................... Depth below inlet.................... Total leaching area................:.sq. ft. Z Other Distribution box ( Dosin to ( Percolation Test Results f Performed b ., Gf `� Date_._..__. Y -•••-- W ..� Test Pit No. 1...4.____.___minutes per inch Depth o Test Pit________ _...... Depth to ground water____ ---- Test Pit No. 2...4__:)--._minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------ ---------------------------••-- ...................4._••-•••••••-•.......... D Description of Soil------�'� ` '--.... ) ........C)A�._... -----.. 4? .1 .? � 1 :V:b x 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 TITTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha>been issued by the board of health. r Application Approved By_ �_____ .................. h F =_ C' ------------------------------ ,� Date Application Disapproved f. t. "following reasons-----------------------------------------------------------------•••-•-••••••-••--•-•----..---•-•-••••••-_...._ ----------•------- Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. :.........OF.......1 -? .................................. Cirrfif iratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed t(�r Repaired ( ) •- •• . .............. .............•-----•-----•-------....---------••-------.._...---•••-•--•----•--•-••-- •-----•-••-•--•._..._. ......••-••-••••-•••-- ..... by-••---`'s•� �"�.. �_�l `..�C _ Installer r �a at ? `^� �" ��_ '""�v ram _ r.. has been installed in accordance with the provisions of T �"' S�o t�e State Sanitary o e as d, c�' ed in the application for Disposal Works Construction Permit No. _ ?'a........................ da.ted_- !'� ... --------------------- THE ISSII NCE OF THIS CERTIFICATE SHALL NOT YCO ED AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. DATE..... � � ........................................................ Inspect ----------------------------------------------------•••••-•-•-••-•.....-- THE COMMONWEALTH OF MASSACHUSETTS 'J BOARD OF HEALTH ............ ..... .. ............ N FEE ................... DW11rr11 1 arks �nnstr inn rrntit Permission i hereby granted...____ _____` r 49�Z� ..__.:7A__._ l� _ !___._ ••••...... to Constct (�' ) or epair ( ) an Individual Sev)age Dis osal System at No. F , tee ._--- ------• .. Street ll as shown on the application for Disposal Works Construction Permi�N , ___ ________ Dated_..____�` .._........_••-__••-•- ----------------------------------------------------------•••-- F 4 f {i .mot Board of Health DATE -•--•--------•-y-.--,-"-✓---------------•----••------ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i r ahl 1 0 j r. 0 I � p G S �•:D -- +eAeE ,— y I J 'ems¢�E o, Dc�o 'P, -A Zoo ( i � ��' i 1vEWAY-� _W rood•G/lloh sePnc rq c PQoFtijge p 6Q J �I�T..r3ox WATe rJE Q 11 6 M A L N o. I W L=j v V i � 9b N U� 94 OF n 3 ,v ammm $ w 1q P � 43, 5�o S'. F. 4 15a' FQ �-. I�ER pQ 30' FQ�rJT 'sEr et'&C--K. SURV�y I S' S rDE .. ASSVAAED PPrSi�ciatil urv0e� n-er nL, `•jE_c"r,I:L ., LEGEND �_E,:.. C Au��7lIC['_ crnvsE .. -\r/DF M� EX(9TING SPOT ELEVATION OAO ��.P`' s CERTIFIED PLOT PLAN EXISTING CONTOUR --- p --- o� : A ti� �o-r 3 -S �vvs�v��-r FINISHED SPOT ELEVATION FINISHED CONTOUR 0 ---- o Rs N C vT�i No.lop51 O APPROVED t BOARD OF HEALTH yo��sG157a�\��, . IN i SIONAI. DATE AGENT ! SCALE, I "�-`30'- DATE= L DREDGE ENGINEERING CQ /N i3A Ysi aE CLIENT_._____._. 08 STERE REGISTERED Zo I CERTIFY THAT THE PROPOSED CIVIL LAND J09 N0. BUILDING SHOWN ON THIS PLAN EN®1 EER RVE OR.BY� - %�'/• CONFORMS TO THE ZONING LAWS OF BARNSTAB E ASS. ccr 712 MAIN STREET CH. BYE HYANNIS, MASS. SHEET—L OF .-�= DATE R 0. LAND SURVEYOR i1fOTE. /F TA ,VE/TNeR T/,IE S- T/G OR 20 FT. M/N• ap Cr. 4=/T .4Re MORE T/'IA-V /2" SELOh/ I 14 Or. M/� I SHALL 9E BROUG.SLT To G.q,4 pipiri CpAICR&TL ,•.!/M. A TCN f t4E,avy CA ST /RON c c�E.� :,yam L L OR/✓E i1/A Y E��v.•g�s COrERs /s ��Fr. ! sr I 2..�• ,+INN. CO,vC.2� ` - - i L /O LEY a t IAYE.z I l 40 of S'' a1 •a NAsrc4 HIM.oiT D/s • • • • I a 74 aPSR Pr. STuNE 1( . i • •EFFECT"/YC ' • . , �f 4 _ I �2� • • • • • Dt�PTJ+I ' • • •` •40 1VASJiED STJNE -'- 7 • • • o • • • • • r • } PREG45 T SF.EvAG z' p?T CARS G`y "S 48 `GAL /o�Y 1 �.� • • • • • . • • +' ••s • EL, 0/7 OR E 411V.. I NN��T �L EYAT/GW 8 S _ _ �fT D/ftJ�►l. IA VZA-r•AT BulLD wi6 9 SS O /U FT. O/141N. � C�SF�TADLL.�T N• c IA/tET •S'E/�I'IC. TiF/VIeC;_ 5,3 i � F1?TlC T.4111it 9=f FL`` Ot6TLET S • t , GRpt/NO Je�TEiT TMLf IJVLFI'D/STR/1flIT/ON 801�C vJ�;y .T4FCT14AiF OF SZWASff-.AP/3POTAL SYST.ffM lXLFI LfACAFIN4 PJ'77 94,5 F7C LEAGflIN�, PdT Ti�dllL�4TlDN . SltrW .CRI7'EAIA D/�E�►S/o�V ��-FT N/IJMBER OF eE�ooMs SOlL LOG � . WR6AGF DISP0,5Al- UN/T /vv�✓� TOTAL E.?T1AlXrE4 FLOI4/ 3 3 � G.At.IQ�►Y $Q /L TEST ,PI SOIL 7FST402 SD/L TF3T i{lUMBER G1F L.C•lCKfN6 P/TS_ J �`GrL& _996. /"ELEY. GA-rL- OF SO/L TFST 9/�3 SIDE LEACH/NG_PER PIT IV-E- sa rr. (� -� ' .+tPS[JLTS .4vJT/VESS,ED dY J X E J A c-v 3 .9GTTOM LFa•►CN1NG PER PIT 7 S4. fT wv o D. Ll7A'y PER COL AT/ON RATS TOTiRL 1cTACN//yG AREA 26 b SQ. fT f-• �U L PEA CO.LAT/ON RA7X 1�2 T 2 �v M/N.�/NCR ESFRVIC LFAC'Iv/N6 ARE.!►. z b S4. iT. P�ZH OF Al C49 v L a T 3 S ZN OF t q U rnl as , • ARSE 0 No. O Q EL D>�EDGE Fi1/G/NEEfl/NG CD711 :`.e ca J29874 STEa`� Etc V_ 8Q / 712 MAIN ST. , NYA.t/,viS. MAst. ru FSc�NAL � E�' +OQ ® R _ NO G�tOL/NJ vYi4TCtT ENCDU�VTf�EO CL/EIt/T;g„Ys,r�� D,q-rE : �' SU � GRD UN0 wATE.? AT EL�V JOB ND•• Fla Z-04- SHEFT?Of /v2 `fo�9 - L D T 2D� ODO S � . •. � SEWiJG� CDNI�°D/i1�N?S (� - - O � Q) ti ,3, ° z /3 R5 .33 S 2 ti`° I OWAID zo�u/i�/6 •D/sTRi�T- �PF . - CZRT. OF T/TL .. LAND cavc'T PGA / it/O, 3�GoB-�c - !/9'A/1D JOF414 Nl9P 3 9 /k1fPfZL /37 ' P. ;5 ROOSEt/EL.7- AD2XD OOYLE,III v i No.38589 BAiPNsTi9�L �, hYX �4�FcrER�°� ' ✓OHN:DDYL.E� PGS .5D8-,5"�3- /99 j ASSESSORS MAP:_ 2� -— --- - --- - TEST N 0 L E L 0 G S' .M PARCEL: ��j r " I) The installation shall cornt�ly tvillt `Title V tut�l 'Town u ► I Ilow of SOIL EVALUATOR k) M l�� FLOOD ZONE: �� _ I� l.lC. 1.,�/.. R ts. , __.pP .�J W I TNE5S s t � I Itallh Itt ulultot , , REFERENCE: -- - q \ 2) 'I'lie installer shall verily tite locnlion ol'ulilitics, sewer III VCI'(!t anal ycptic REFERENCE: __ �,�',J' \ 1�(�7.�0.__ _ - DATE: O� components prior to installation and selling base elevations. PERGOLA�Dl I0 RATE: .G 1►U�1 , 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per loot: The first ?. 6 Y p p p g p, MT5 �' �� two feet out of the d-box to the teaching shall be level. 4) This plan is not to be utilized for property line determination nor any other TH- I TH-2 purpose other than the proposed system installation. � t ,R 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over.1-110 septic,components. j lv�` - 7) The property is bounded by property corners and property lines. 14(a ! 8) The property owner shall review design considerations to approve of total I LOCATION MAP design flow and number of bedrooms to be considered for design. Receipt l Wl of payment for the plan and installation based on the plan shall be deemed /- approval of the design flow by the owner. "cJ � 9) The existing leaching or cesspools shall be pumped and filled with material nL{t2'I per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per .� IZWh (i`l"t ''\\11� to ( It��� U �' Title V specs. \ 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if ' applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as ar6iementioned and maintained in place. L SEPT] C SYSTEM DES I GN 11) If a garbage grinder exists it is to be removed and is the responsibility of the Zsf`Dy " 20 ,L /1S, eoo P Y i /U owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such ' exists. I / BEDROOMS AT I O GAL/DAY/BEDROOM -�2 GAL/DAY 13)The installer sliall verify the location, quantity and elevation of the sewer �+ L 9 T �D, 2 S lines exiting the dwelling"rior to the installation. ZD� DDD ,g; SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting — Title V requirements. .. / "✓ GAL/DAY x 2 DAYS GAh _.�_. ..,. USE'150D GALLON SEPTIC TANKi(r4�jl>� -OIL ABSORP iON. SYSTE Aj%OF DAVID SIDE AREA: 1V�� ��� sq ! 6. BOTTOM AREA i ' �. 12 X bt'i ��, co No.1066 'y 1 j I Po.FGH 3.4' G'/gT SEPT I C SYSTEM S EGT 1 ON /3.2 l � I O i tv 0 to I //.7' 2'8 2, 3. �• /os' fb f (7n� 14 y,, EXis 7'/1v G 10'� ''"4 to ►`"l 6� ,, yo vs� 0 0 0 ` I � .t .. tit 6 q,r - - N U . , 3eµK�, 0 Z 2' amy d - rS 2 2./3'3 y N ' GAL ? t ' n v; ll '( 1 �• SEPTIC TANK �V,/ % x Z G►�S 6'0*rP�M � T�T Hdt "U 29 C SITE AND SEWAGE PLAN s 2 ° o 'Zo"/,� ZS; oo LOCATION 00�yc�1 j �+4 RoosEVE�T ,�o.�� PREPARED. F 0 R : -'Et '� C, a - SCAL : _ _ ..... . - DAV I D B.. MASONt?6 DATE: S L b 1 U13C ENV I IIONW~N 1'Al_ DCn I CtIJO EAST SANDWICH . MA Z DATE ' HEALTH AGENT ( SOS ) ' 833= 2 177