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HomeMy WebLinkAbout0108 ROOSEVELT ROAD - Health "1 08 Roosevelt Road r 039-135 Cotuit i Commonwealth.& Massachusetts .. _ Title 5 Official l spection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments X5 Fla, 108 Roosevelt Rd. . . , p Property Address p Wayne Phipps t Owner. Owner's Name ... ... information is required for every Cotuit Ma 02635 3-1-18 k page. City/Town State Zip Code Date of Inspection r� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end.of the,form. Important:n :ot ms A. General Information filling:out forms LD I—W on the computer, use only the tab: 1. :Inspector key to move your cursor-do not Brett Hickey use the return key. . Name of Inspector B&B Excavation ICI Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 ; S113747 - Telephone Number License Number' . B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The:system: ® Passes.. .... ❑ Conditionally.Passes : ... ❑ Fails Needs Further Evaluation by the Local Approving Authority 3-1-18 . Inspector's Signature Date The system ins ector shall submita copy Of this inspection re ort 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 3tl 3 Title 5 Official Inspection Form:Subsurface Sewage Dispos System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .108 Roosevelt Rd. Property Address Wayne Phipps Owner:. Owner's Name information is required for every Cotuit : Ma ...02635 3-1-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: .... ® I have not found any information which;indicates that any:of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below: .:.: Comments: System was in working order at time of inspection. ... ... ... it 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. 0 Y ❑ N. D.ND (Explain:below). t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments G .108 Roosevelt Rd. .... Property Address Wayne Phipps Owner . Owner's Name. information is Ma 02635 3-1- for Cotuitrequired 18 page. Cltyrrown 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.): El 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): ❑ brokenpipe(s):are replaced ❑ Y ❑ N ❑ ND (Explain below): El obstruction Is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The y i .P p (with pp ) system will ass inspection If with approval of the Board of Health): i ❑ 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 orprivy 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•3113 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 _108 Roosevelt Rd.fin, y0 .... .... .... ... .... Property Address Wayne Phipps Owner Owner's Name information is M 02635 3 1 18 Cotuit.... a _ _ required for: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. El: 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 i ® 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 ElLiquid depth in cesspool is less than 6" below invert or available,volume is less than %day flow l5ins r 31 3 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 ..108 Roosevelt Rd...... Property Address Wayne Phipps Owner Owner's Name. information is required for every Cotuit Ma 02635 3-1-18 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 El 1Z obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z Any portion of cesspool or privy,is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z. Any portion of a cesspool or privy is within a Zone 1 of a:public well.: ET ® Any portion of a cesspoofor privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no.acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm, provided that no other.failure criteria are triggered. A copy of the analysis and chain of custody.must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 101000gpd. . ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as.described in:310 MR. 15.303, thereforethe 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 El El 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 3/.13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form Not for Voluntary Assessments 108 Roosevelt Rd. Property Address Wayne Phipps . Owner Owner's Name information is required for every Cotuit - :Ma 02635 3=1-18 page. CltyrFown 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 ❑ 0 :Pumping information:was provided by the owner, occupant, or Board of Health ❑ Z Were any of the system components pumped out in the previous two weeks? : Z.: ❑ Has the system:received normal flows in previous two:week period? Have.large volumes of water:been introduced to:the system recently or as part of. �.. ® this inspection? ® Were a's built plans of the system:obtained and examined? (If they were not El available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage backup? M ❑ Was the site inspected forsigns 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. El1 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 3.10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5-Official Lnspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ° ....108 Roosevelt Rd.: . . Property Address Wayne Phipps Owner Owner's Name information is Cotuit Ma 02635 3-1-18 required for every page. Cityrrown State Zip Code . Date of Inspection D. System Information Description: . ..... 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes Z. No Is laundry:on a separate sewage:system?(Include laundry system inspection information in this report,) El Yes :® . No Laundry.system inspected? ❑ Yes ® No i Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): See below Detail: 2016- 148,000gallons 2017- 144 000gallons Sump pump? p ❑ Yes :® No Last date of occupancy: Current p Y Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CUR 15.203): Gallons per day(god) Basis of design flow(seats/persons/sq.ft.,, etc.): Grease:trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?. ❑ Yes ❑ No Water meter readings, if available: t5ins.•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 108 Roosevelt Rd.: .. 5 Property Address Wayne Phipps Owner Owner's Name information is Cotuit Ma 02635 3-1-18 required for every page. Cltyfrown p 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 Owner-.date of last pump is unknown : 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 r 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts ... F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 108 Roosevelt Rd.' .. s Property Address Wayne Phipps Owner . : Owner's Name information is Ma 02635 3 1 18 required for every Cotult : ... - - page. Cltyrrown State Zip Code,: Date of Inspection D. System Information (cont.) Approximate age;&all components,date installed.(if known)and source of information: Were sewage odors'detected when arriving at the site?. ❑ Yes ® No: Building Sewer(locate on site plan): 1,.8,, Depth below grade; feet Material of construction: i E 40 PVC cast iron El other(explain): Town Distance from private water supply well or feet ... .... .... Comments (on condition of joints, venting, evidence of leakage, etc:): ..... ..... r _ - Septic Tank(locate on site plan): Depth below grade: eet Material of construction: 4. ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other.(explain) If tank is metal,:list.age: years. Is age:confirmed by a Certificate of Compliance? (attach a copy of certificate)' ❑ Yes ❑ No 1000gallons Dimensions:: 101, Sludge depth: t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1,H .108 Roosevelt Rd... sv Property Address Wayne Phipps Owner . : Owner's Name: ... information is required for.every Cotuit. - Ma - 02635 3-1-18. page. CltylTown 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 26 Scum thickness - Distance from top of scum to top of outlet tee or baffle 6 12, Distance from bottom of scum to bottom of outlet tee or baffle Measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid_levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert.Tank is in need of pumping at this time and should be.pumped every two,years for maintenance. Grease Trap(locate on site plan): .. Depth below grade: NA feet Material;of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle I Date of last pumping::. Date t5ins a 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System. Page 10 of 17 i Commonwealth of Massachusetts _ Title 5-Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 108 Roosevelt Rd.:... Property Address Wayne Phipps Owner Owner's Name information is required for every Cotuit Ma 02635 3-1-18 page. City/town 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.): p. Tight or Holding Tank tank must be pumped of time of inspection) locate on site plan): ' 9 9 ( p P. p ) ( P ) NA Depth below grade: Material of construction: El concrete [Imetal ❑fiberglass El 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System-Page 11 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7M 108 Roosevelt Rd...... Property Address Wayne Phipps Owner Owner's Name ... information is required for every Cotuit . - .:Ma 02635 3-1-18 - page. Cltyrrown State Zip Code Date of Inspection D. System_Information (cont.) Distribution Box(if present must be opened):(locate on.site plan): Depth of liquid level above outlet invert :Comments (note if bbk:is level and distribution to outlets equal,:any evidence of solids carryover; any evidence of leakage into or out of box, etc.)` . D-box was in working order at time of inspection with liquid level equal to outlet invert. D-box was video inspected as no asbuilt ties were given from time of inspection. p. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No*- Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc:): NA . 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 r.3/13' 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 108 Roosevelt Rd. Property Address Wayne Phipps Owner Owner's Name .... .... information is required for every Cotuit - - Ma 02635 3-1-18 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type; ❑ leaching pits.: number: ® leaching chambers number: (3) 500 gallon ... El 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.): Leaching was in working order.at time of nspection with no sign of hydraulic failure. Chambers had 8" of standing water when viewed. s. s. Cesspools (cesspool must be pumped as part of.inspection) (locate on site plan): Number and configuration NA 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 r 3/.13 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System'•Page 13 of.17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 108 Roosevelt Rd.... Property Address Wayne Phipps Owner _ -Owner's Name information is required for every Cotuit Na 02635 3-1-18 page. City/Town p 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): NA i Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc. : i 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 108 Roosevelt Rd. .... Property Address Wayne Phipps Owner Owner's Name information is required for every Cotuit - - .. - .: Ma . 02635- 3-1-18 page. CltyfTown 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. E drawing attached separately REAR DECK GARAGE Al'.29' : : B1. 25' A2-67' B21 49 2 t5ins a X13' . 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 y 108 Roosevelt Rd. ' Property Address Wayne Phipps Owner Owner's Name. ..... information is a 02635 3 1 18 required for every Cotuit : M _. _ page. City/Town State Zip Code, Date of Inspection D. System Information (cont.) Site;Exam: ® Check Slope s. ® Surface water ® Check cellar ...: ® Shallow wells _ >18; Estimated depth to high ground water: 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 (abutting pro P Y _ ❑ . Observed site abuttin ert /observation hole within 150 feet of SAS) ® Checked with local Board of':Health -explain: An asbuilt card provided by the Board of Health showed ground water to be >18' ❑ Checked with local excavators, installers -(attach documentation) ❑ ...Accessed.USGS database-.explain.- ... You must describe how you established the high ground water elevation: Info on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/.13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 16 of 17 Commonwealth:of Massachusetts H y Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments A °v 108 Roosevelt Rd. SV Property Address Wayne Phipps Owner Owner's Name information is required for every Cotuit " ..Ma 02635 3-1-18 page. Cltyrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection-Sumry: ma 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 a 3/13 " " Title 5 Official Inspection Form:Subsurface Sewage:Disposal System•Page 17 of 17 t ) Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppYication for Migaaf *p6tem (Construction Permit Application for a Permit to Construct Lj�ep ( )Upgrade( )Abandon( ) D Complete System D Individual Components Location Address or Lot No. 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. aA So z7 —3 r6,-z Type of Building: Dwelling No.of Bedrooms 3 Lot Size 2C9, Z ?r sq.ft. Garbage Grinder(K/fO Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,L Design Flow 330 gallons per day. Calculated daily flow ? V- gallons. Plan Date 2- L�- `� Number of sheets Revision Date Title Size of Septic Tank �9c C(l� 9a/ Type of S.A.S. Z-Sad_2r_/ Gk a cn 6�-J Description of Soil It e- 4/cr.n Nature of Repairs or Alterations(Answer when applicable) F -S' 7. ✓G`d Cet /���v c..►%/ 4z t h J-6-4/Le LY Z -5T V SR/ CGL a , 6-410 w/ ' c Z S abAe- a-.?.P Date last inspected: `-X f 3 'r 2 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 Certifi- cate of Compliance has been issued by thi Health. Signed A Patel /,7,6 1,4,q Application Approved b Date Application Disapproved for the following reasons Permit No. s Date Issued 0 L ` No. C� ° a�9.f'{, t Fee f THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: "'f . Yes PUBLIC HEALTH DIVISION.-TOWN OF BARNSTABLES MASSACHUSETTS' +. application for -Mi pooal *p!5tern Congtruction Permit Application for a Permit to Construct( epair( . )Upgrade,( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Y Fl Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer;s Name,Address and Tel.No. .S'O g'-q 17 -J3 7-6-L- ' Type of Building: `Dwelling No.of Bedrooms 3 Lot"Size 2�� Z ?�s q.ft. Garbage Grinder Other Type of Building No.'of Persons Showers( ) Cafeteria( ) • Other Fixtures ' Design Flow 3 3 O gallons per day. Calculated daily flow ? �� gallons. -'y- Plan..Date '7- Z�-°`/ Number of sheets Revision Date Title = '` Size of Septic Tank __-_ Sx /C10� 4a Type of S.A.S. -Sod 9t l CA 0,+1 61-0-.J' Description of Soil f e P/aM Nature of Repairs or Alterations(Answer when applicable) / S . 7 e (o cc y4W A/L ty ok ' o� dale{i is --C, t 41-fV K4", Date last inspected: % X �� '� 'Z_J �J ✓ , 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 Certifi- cate of Compliance has been is ued by this '`har&oHealth. 1 Signed- A J, Date , 8 Application Approved b Date. Application Disapproved for the following reasons - Permit No. UvL4 ' Date Issued U' ", .. s 7.7 THE COMMONWEALTH OF MASSACHUSETTS Iy 3C�, �3� BARNSTABLE, MASSACHUSETTS Po. L'v',� s�hce '0 ay-N e. t Certificate of Compliance THIS IS TO CERTIFY,that a On-site.Sewa a Disposal System Constructed �eped Upgraded Abandoned by MA/1117 lAfrdf ( ) at /0 l z qr- 400, has been constructed i}�accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. "w- f/ � dated J t) t Installer Designer The issuance of th s permits all not be construed as a guarantee that the system wil f nc 'on as de Date g 1 Inspector No. le2OD ly Fee v THE COMMONWEALTH OF MASSACHUSETTS 03 PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mtgooal 6 item Con5truction Permit Permission is hereby granted to C struct( Re`! ( Up ra_d/e( )Abandon( ) System located at l4e. f x 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:Construdti,, must be completed within three years of the date of this permit. Date: /0 / Approved by I o 1M All C�P(/n f Town of Barnstable Regulatory Services Sl, Thomas F.Geiler,Director • Public Health Division , ►`� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624W Fax: 508-790-6304 Date: 1—3— o Sewage Permit#Zob V -338 Assessor's Map/Parcel 7-i�— Installer&Designer Certification Form Designer: &A^ E• "I kLikcm PeS. Installer: HA-,1�!1 Avy-oc--)5 Address: I-P,dr i,? Address: JM$i) , 10VIIJ lW 046gP On was issued a permit to install a (date) — (installer) septic system at based on a design drawn by (address) GGr.-- Lam, dated T✓!Y Z Z "a 3 (designer) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the.SAS or any ve ion,of any component of the septic system)but in accordance with State& it Plan revision or certified as-built by designer to follow. Stripout(i )was ed and the soils were found satisfactory. o i LEN / ERIC �i ib/i�iv�SS HRNo.1070 N � staller' Signature) i (Designer' Vi' e (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERT11FICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTHTHIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\desigm wrtifkation form.doc I _TARn UGH-r 2l0$L 1 t rL 1712 it 10 9 8 7 & 5 4 . 2 LLaS S_ _ III N ` 1I@ N I Iv I I '4°2EINF CONCR SLC3 - L£VGL- t t " - I — �auEe r3EWC14 _ —•Al r j 6. I SyEETMo. C4,-_ F-(Z 9c>o_R._S__- -{ttl' F132E r3L_iag I&C-Tat F•rrf"A i 0� ° og r t R.-INF CONG� $t_Pg PITGKT2': To OCK) 1 d YET L'J ELECT RirG OPE Ergre�, --- _ J .D M1 O.K. Dco2 q'x 8_C1:�_Doort 2t o W-or 2r 0 gr _o.. 22 d' _fr_v,S--C__FCOo 2 PL O IRAYN'C_ r-:> :p ALE: APPROVED BY: ORAWNM DA*E•APR 4 , ® GA2�r;� - 5�-1oa - - --• ORAwWDNUNBkT �El�'L=E L--O o1Z_eCv,ly- l o F 3 TOWN OF BARNSTABLlE LOCATION ROJ''��L�. c_✓ 61T SEWAGE# VIL_,AGE C®7y/ 7 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. RAI; �sS' SEPTIC TANK CAPACITY eke 5 V 44-7 /O d LEACHING FACILITY.(type) (size) 31,s k /3 A L -NO.OF BEDROOMS OWNER INak(A-e- loh,,a,0 5 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) �✓�� feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). All'4- feet FURNISHED BY I bh L 1=rbn 7 R0 �� r --- TOWN OF BARNSTABLE LOCATION /off SEWAGE # 03—112t, , VA,LAGE Cods/ ASSESSOR'S MAP & LOT CZ9Z35 G 33 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Aeex9 GEC LEACHING FACILITY: (type) /°/r (size) C� NO.OF,BEDROOMS -3 BUILDER OR OWNER A471-"1Zeo0 PERMTTDATE: _a% 83 COMPLIANCE DATE: Separation'Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /2•W 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 facili ) Feet Furnished by / ��> em r � s 10 �' L0 ION SEWAGE . PERMIT NO. vI G E U IN S T A LLER'S NA M E & ADDRESS ! Y C h B U I L D E R OR OWNER DATE PERMIT ISSUED M DAT E C0MPLIA-NCE ISSUED 0 137 n No.._..trt.. ....// �D f t •} r S s{ r,Eg...THE COMMONWEALTH OF MASSACHUS)RE BOAR® OF HEALTH ............._..........................oF.....�.oT V o-?�........ F3.�4._R.►�1 T aL E� , � �b AllpfirFation for Utip,a i ai Vork,5 Tomitrurtuan runtit Application is hereby made for a Permit to Construct INNA or Repair ( ) an Individual Sewage Disposal System at: / ` _` ....... L? VC.T...... . E7 D. CO 1"V I T ( �---------------------------Lo T 3 R .. �. - ........... ................................... Location-Address or Lot No. "-----cR ......�z.f=.......cf-KIS....K qi. =......... JA...kIP..Py.... �vE�. l�$�ti....�.�......Q: i68 a ----------------••------..............---.-----.`at .. ......................... ....................................41�436.------.............------.. Installer Address dType of Building Size Lot._O.L.?..�.._..Sq. feet Dwelling—No. of Bedrooms......3................:..:............Expansion Attic ( ) Garbage Grinder (11 Other—Type of Building No. of persons............................ Showers (� YP g ----------•-------•--------• P ( ) — Cafeteria ( ) P� Other fixtures ...--•-------------•-----------•----------------------.-••••••-•-••-•-•-•••--••••••--------•-••••--•••-......--•••---................................ W Design Flow..........1_1.Q./�D.96001.__gallons per person per;,ay. Total daily flow................. tea_ ............galllo s. r R: Septic Tank—Liquid capacityID.O.b.gallons Length8__,6...... Width..`' !p.... Diameter................ Depth.�.._.y.... Disposal Trench—No. .................... Width ....... Total Length.................... Total leaching area............ ft. Seepage Pit No..................... Diameter....6•..6_._..... Depth below inlet........ _........ Total leaching area..2�?.'..7_...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) FI Date------.2-- Percolation Test Results Performed by___..QS..__E,ug. ..................... ......_-.; Test Pit No. I.......�-----minutes'per inch Depth of Test Pit....it!.......__.. Depth to ground .water__11. G14 Test Pit No. 2................minutes per inch Depth of Test Pit..../.`�.......... Depth to ground water. _ - P�1H OF MgsS O Description of Soil_...A._ .___NP.TED_._._._._._ !V.._..__PI!91�.._--.._.. ' " _ °ivG/ LAWRENCE ......................... _�,.__ ......RTI F 55 MARTIN I ---• BI A'ff- ..--••••••••-•-----•------------------------•........--••----------••-------•---•---•-•----•--••-•-••---•••••••------•------......-•••••............•--••-•--••••••• --•- ------- U Nature of Repairs or Alterations—Answer when applicable...................................................................... ......'� , go -•---------------------------------------------•-------------------------------•--..........--------------------------------------------•----------••••••-•--•-•••••••-•••......••• S tit' z Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i the provisions of'TT y g g p 5 of the State Sanitary Code— The undersigned further agrees not to lace t operation until a Certificate of Compliance has a issue y t 'd of health. 3 Signed...................................................................................... ................................ � Date Application Approved By.. . :.. .../�_._Z�:"�., . ----•-----•----••........................ Date Application Disapproved for the following real ns:.............................................................................................................. ---•-•-••---•--•-••-•--•--•-•••••----•••••-••-•••--•••••----•----•••--......--••-----•---•--••----•...•-•••----•---•-•-••--•-•-••-•---••.........•••--••---••••••-••••-•------••-••••......•----------- Date PermitNo......................................................... Issued........................................................ Date No �`", �..� tj FEn ........_..... . THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH J ...............................OF.--=:...G®T�...- --..... h Appliration for Bhivogttl 10orkii Tomitrtirtion ramit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: ............�..bO VF,L T (ZoR P GOTU1) LoT 3 3 •---------•.........................................• --••-••••-•----•-.................---••................- '- •.- a ion Addr-ss - ...... !s y U 7- ..................... to Owner Address Installer Address °� zo 25 Type of Building 3 Size Lot........... .............Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( , p` 1, Other—Type of Building ............................ No. of persons....................;.......... Showers ( ) — Cafeteria ( ) a Other fixtures ..------•--•••-••--••-•-•-......-- W Design Flow........:....I0.�rV !?'l.gallons per person ey d,3y. Total daipy flow.......... v._..................galllon„ W Septic Tank—Liquid capacity.IDQ.0..gallons Length... ....6.... Width..`f.� '_.„.. Diameter................ Depth_..�r..���... .. x Disposal Trench—No. .................... Width-.r._..rl_.__..... Total Length..........._...f...- Tott l leaching area....................sq. ft. 3 Seepage Pit No----------!---------- Diameter......(0.... .... Depth below inlet..........'?_....... ToY-jl leaching area...28."/_._.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '' ` aPercolation Test Results Performed by---- 05_.__ N&P_: ...... ----------••._•. Date...........2.' .................... a Test Pit No. 1........L.....minutes per inch Depth of Test Pit ���7JJ .. Depth to`ground water-__ti'.a Test Pit No. 2................minutes per inch Depth of Test Pit ...... .... Depth to ground water.... . �. ... x ............... -------•--•- .............................................................. =... t' ...----- O -- �c Description of Soil..----ff. ._1Y :7rC�......��.....P��1 .........................................S -/ 4 ve J --- LAWRENCE MARTIN --•-•-••-•••-•---•••••---•-•--•••••-••••---•-----------•--...----••------••-•---•••••-••-•••--•................••-••••••---•••••--••----•------••-•-••............................ SEALS v x -•---•--....------•--...--•---•-••••••...........•............. •... .....N .--7760 U Nature":°aof Repairs or Alterations—Answer when applicable............................................................................ ......Fcas,Eat ...........................--------------------•------------------------------------•--•--------------------•---------------------------------•-••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor V the provisions of T.iT :;=. S� p S of the State Sanitary Code—The undersigned further agrees not to place operation until a Certificate of Compliance has bee ed b the d of health. Z3/8-3 Signed w .... 4103 ApplicationApproved By......................................--••------ -------------- _V----------------------------------------------------- -- --------- ---------------------- Date Application Disapproved for the following reasons:.............................................................................................................. ---------------•----•----.................•-----••-•-----------...---......-•--------------•-------......-•••••-•-----•-••-••---•-•----•••••---•-•-•-••-••--------•----•••-......----•-......-••-•.----- Date .... PermitNo.......................................................- Issued--------------••---•------- Date .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrfifiratr of Toutpliatta THISp CERTIFY, the Individu 1 Sewa e Diosal System constructed ( ) or Repaired { ) +, b ,r .- --...... -• ......... •-•••----...•••..-•-• y-•-•--•---- = ' Installer at..............................................................................................................................- has been installed in accordance with the provisions of TITLE j of The*State Sanitary. Code as described in the application for Disposal Works Construction Permit No.__�ln?-1'':>P-_.__-__- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALLkNOT`BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................................1'?�... S.: I Inspector.......... .......................................... t: t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH #: Q .................O F................. �/ - ',r'.�,7 ......................... No....::....-•-.......... FEE... 09� Permission is ereby granted....::_ .,, to Construg15� Repair ( n Individual Sewage Dis osah-"System Street as shown on the a/plit* for Disposal Works Construction Permit No.._...�.........._. Daled.....................................Boa..................••.......d of Health DATE.. .. ..1- ..-•-•---••-•--•••...............•---••...... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS `� APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS - `-- LOCATION L©"r .ti O S�V t _'_�, ��: NO.Z'/ VILLAGE_- "°j'U /'T DATE t-E8/0,. .APPLICANT ' QO "Q "'i L1A-�'�J FEE .�S•®0 i (.Non-refundable) 1 4 ADDRESS ���, n ,-r �, CA37 ;-� q. TELEPHONE NO. . ENGINEER • Q 's ©ci JAJ TELEPHONE NO.4-7 DATE SCHEDULED (AppldcantIs signature) • • • • • • • o 0 0 0 0 0 • 0 •0 0 0 0 0 • • • • • • • 0 0 0 • 0 • • • • • • • • o • • • • • • •�• • • • 0 • • • • • • • • • • 0 • • • • • • • • • • • • • • • SOIL LOG SUB-DIVISION NAME to O-rU t i f&I eS DATE 1 S 11813 TIME tO �M EXPANSION AREA: YES NO I�I Er�u,vJ�E�1N4 I1es� c ENGINEER:'7�, ITOWN WATER,/ PRIVATE WELL BOARD OF HEALTH ft*to7T� EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and j percolation tests, locate wetlands in proximity to test holes) - - NpOTE S: I L.o7-3-3 f • i y o' 75' j PERCOLATION RATE: 'lJTEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 1 � 1 =3 ` � 3 I 4 Cc��� efc.v 2i 4 5 5 y ' 6 1 �LQ +o t� r c So'A 6 9 � �`� 9 { 10 10 11 12 12 13 13 14 14 15 15 16 16 ; SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING. FIELD LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION - ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH , t COPY: • RETAINED BY APPLICANT CERTIFIED SEPTIC SYSTEM REPORT LOCATION 108 ROOSEVELT RD . COTUIT, MA ,. MAP 039 PARCEL 135 LOT 33 PREPARED FOR SELLER HATFIELD PROPERTIES LIMITED C/O NATIONAL WEST BANK ATTN : MR. PETE SONDEFFAN 54 EAST RIDGEWOOD AVE RIDGEWOOD, NJ 07450 BUYER MR. & MRS . WAYNE PHIPPS 111 KNOWLTON LANE MARSTONS MILLS, MA 02648 PREPARED BY HILLIARD HILLER, JR. P .O . BOX 250 CENTERVILLE , MA 02632 508-778-1472 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property owner's name //!1Ti1Zz4 Date of Inspection PART A CHECKLIST Check if the following have been done: _l�Pumping information was requested of the owner, occupant, and Board of Health. 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. 4/ ' f the As built plans have been obtained and examined. Note i y are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. y All system components, HIV luding the SAS, have been located on the site. 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. r/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms o_ number of current residents UFq garbage grinder, yes or no, e,7 laundry connected to system, yes or no No seasonal use, yes or no If nonresidential, calculated flow: c J9ri3 aq�o G/t� Water meter readings, if available: F,41& 012- /may Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System pumped as part of inspection, yes or no if yes, volume pumped G.9z -Reason for pumping: Type of system rlSeptic tank/distribution box/soil absorption system .Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: �f/�H/T /fi�i�G/Gfi %/�.✓y 410aKvvCO Id/`3/,3 A6 Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (/ (locate on site plan) depth. below grade: materihl of construction: concrete metal FRP other(explain) dimensions: �'F X V"? 33'' O.CO� � Tl�,r�N 4isfs L i�,�G 9`I sludge depth %a" distance from top of sludge to bottom of outlet tee or baffle y" scum thickness 96-1 distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) T-E.€S G ool�,e p � o T/��/� was .dyi�i/✓G/J itz� G✓L',�� fE" p�G ti DISTRIBUTION BOX:.'/ (locate on site plan) �— depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) 13o?r PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If n6t determined to be present, explain: Type leaching pits and number leaching chambers and. number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note -condition of soil, signs of hydraulic failure, level of ponding, condition of ve etation, recommendations for maintenance or repairs,etc. ) P/T wi95 Di�� fG.�iiy.� b1/�' /S ii' i' G�PcYiUo c�w.tit c�.�cs �� S,P�UIG.E, CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition -of soil, signs of hydraulic failure, level• of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ). �I 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL- SYSTEM: Q4�tO.SXv2e-7- iPa'l� cvT��T> �iig include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' . C 5 s n u � � DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: 7-11Z Th f 7.9'� � t��£P. TN,� d/�St%IU/lD G/1Ly✓.�ifJ l��T.�/I �.r/.� /c3`3� �iPi9ari/,vf iy r '2 )�;L ,d3 - 3-G 12.�IV, 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) A42 Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? /VW Liquid depth in cesspool <6" below .invert or available volume< 1/2 day flow? ,W Required pumping 4 times or more in the last year? number of times pumped AA9 Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is .any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? k-0 within. 100 feet of a surface water supply or tributary to a surface water supply? A,*_ within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? kX2 within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private g p water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, vol.atile organic compounds, ammonia nitrogen and nitrate nitrogen. I ' �-�---`------ — TOWN OF ,(3/��?y5�4LF ,�'� BOARD OF HEALTH- '--`----.----: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION J- -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS /oF lex,4 ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME 11/f7,--/.E4,0 y"�o�,Y/L97,E S L1.�iiTEa PAST D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME COMPANY ADDRESS 100 61tnX /i14 Street Town or City State ZIP COMPANY TELEPHONE (S-eFr ) 720 FAX .CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa-1 system at. this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has-' not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature % /!� Date ? 17f -9 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc l- ff r a 1 1 _ I F 13 12 11 l0 474 Ir i \�nl F CO N G[2.. S L A3 - 1._E V GL- I I fIJ ORl;SGGNT, I { I � �iJUEIL 1•b EL/G 11 II V _. - - - HT �G-N C r7-Sl_A 3 E AV -=7 '•F. .__$L1 E z c l._n _ A Ft32E G S - J2ETAL lLpl I>ol I 0 tD AO- V I � I I _ I AnmEt1aF coNja SI-AD, PITGH_'L" To 40025; i CO/l\PACI G2n4E-t_ F,111. '' I — - - ------ - N • - I I t_ CT 'G C3 E-NE 2rS e 21 C P t—J h h -8..x 4'_-_0.. cQNcrc 1JP;LL,S-�----- --- ( I - % Imo`---�rvu xT.D•.__ F'00_Tl�� ------- I I o I o.H. DoorL 9X rJPo R 8' ' _ hl Q tt „ — • t) \IN t7♦ N 1 _jQ =SOU hl OAZ'10 N _F�tL3T...1-L00 rL PLAL 1 5�6 F.C. g w EET.zoc-- _ III-FIBRE G_LAS _r'9p TY . -PT:S-I.toE ' •-CCS$ f225d5EV1ELT IaVC. C07L31� _S E/SLA t�T -- SCALE: t/Q''_1�_O APPROVED n DRAWN BY DATE.AIq r? Z � RFYSED _L-91 tzENE7 SLAM- UWO%r- rOEAli._fh,l W,&LL• -. � }}4 G/�2A�� .5!40a - - ---- ,. . DRAWING NUMBER 4 • 4. _ ' ` tz a �� F� \ 45 r2 II `AIL_I FTT-1 D • i - -- SZEA2 ( •. . =P;SPf�A LT_ ROOK to !2 / --' f/ Z(W4Z. �\ :S/4 T Gd Pr_! Et tT i tzC; 9�Qc -rx s .past n El E-71 2" G9X SNE^_-rw+r-1G �� � � •,Zk w'y 2y na TYJEc \v fL.n P•to C�Do2-�5'.ilr.I C,LcS � -_J �� _�I � I { I � I � � - `.. a Z As I SHp_P:. &r�A r_t4 pt32Ei ti•S T I C U r _ it H:z S_H EET,ioCK \Vat_}5-- --CETLt ri& IF L• 2d1_O _ r.8� p•. CONGfL -,,jA. _ -- -:F:IZONT-ECEVYiTtidIJ --- � r 1YA�T_Tt7-4 - --o -- ' ''- -. .- -- -.-• 9GI.C• t/G7• APPROVED RV: - -- -- � �a 1•-O DRAWNti1• • --- DATE:APR 2°O4 REyr�ED �LL_�VD_O�:_IN- Ct7t=+Ti:C-rZ•FtTEI__Co!�+�.E:�E." - fi =�rs2-LaG��= 5.u'a(? SSY�-P� C�SZE9S_pR=c�.T�cGAT�-t7---- - - _- -S'F-f`TLON--___------.-_- DRAWWMMUMDER -SC-AT l•a H-�- _-___-_ -- 2 of J w I I =Lh9?N ALT 200F StlI-,,IGL.a I IA __ ; ® i64-z I I i t• � 4 � t I G IC i j I 1 0 FF IT v I I I j i- 94oP T _ 2'��-O-_= G4rLaG6 SStaY_N E-�_SA�PyArtA_ PKIPPS sl �07-5 zr N)G LT /o,) G c;>'-v r j SCALE: rI.}Pc r•-O APPROVED BT• DRAWN BT ET L 2 (?L p o-J 2x t o Ca l tc•+ o,G.----- - DATE- ApR 21- REvsED- -1 q-�__t;.VEVAT_LOJ`s_- DRAWING NUMHFJi or 3 .j i i j #66 roDs� Desi n Calculations N V C0' a SITE PLAN 039-134 r'OAD Number of Bedrooms: 3 Existing $ SCALE: 1"=20' Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN Devo BENCH MARKON TOP OF #189 Septic Tank Capacity Required: 330 gpd X 200%_ = 660 gpd d FOUNDATION ELEV.-96.00' (ASSUMED) e eNH Septic Tank Provided: 1,000 gallon 03,,12 Dwell D� Leaching Capacity Required: 330 Gal./Day �o�y 12 Leaching Area Required: 330 Gal./(0.74 Gal./Sq.Ft.)=446 Sq.Ft. c1Q Sao' Existing Leaching Structure: TO BE REMOVED S° ti �' o 60.00, Proposed Leaching Area Provided: 31.5' X 13' X 2' = 384 gpd. R fs Total Leaching Capacity: 384 gpd > 330 gpd. req'd. �ooe eco a Me ERV e AREA S I T E �g ay x 9373' COTUIT" GENERAL NOTES PROPOSED SAS LOCUS 1. ADDRESS: #108 ROOSEVELT ROAD 31.5'L X 13'W X 2.0' D x 16' 2. ASSESSORS NUMBER: 039-135 NO SCALE O leaching trench using 3 H-10 3. DEVELOPERS LOT: LOT 33 O O 500 gal. chambers with 3' of 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN stone on sides & ends. ON THE GROUND INSTRUMENT SURVEY. 5. TOWN WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES. 6. REFERENCE PLAN: L.C. PLAN 36608C SHEET 4 OF 4 + r1 x 94.87' REFERENCE PLAN: MORTGAGE INSPECTION PREPARED FC)R Hl4TFIELD PROPERETIES LTD., TN 92 PREPARED BY YANKEE SURVEY CONSULTANTS, SCALE 1 =30. 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS. O EXISTINg 93.13' 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. 9. THIS PLAN WAS PREPARED FOR THE SEPTIC INSTALLATION ONLY. i o X 94M' 10. ZONING COMPLIANCE IS THE RESPONSIBILITY OF THE OWNER & BUILDER. $��P EXISTING S,T. 94.54' _ =` ck` _ lob SHE be' CONSTRUCTION NOTES 9 0 1. Contractor is responsible for Digsafe notification x 92.42' ` �o a and protection of all underground utilities and pipes. Ej(I 2. The septic tank a l distribution box shall be set ST/ level on 6 of 3�4 -11/2 stone. AREA L02 625t SQ.FT. �WE N O 3. Backfill should be clean sand or gravel with no TOE i G =. stones over 3 1n size. FL +e+•00, 4. This system is subject to inspection during installation tv by Glen E. Harrington, R.S. 8 o� 5. The contractor shall install this system in accordance '�� N with Title V of the Massachusetts Environmental Code _ and the Regulations of the Town of Barnstable. ,�� 94,79•'.. '.'.• ''.'. 6. Provide an Acme Precast H-10, 500 gal. chamber or equal. 1-20'aAw.ACCESS wA,e+aE v ; •'.; '•'.: ;;:'. 7. No vehicle or heavy machinery-shall drive over the septic system unless noted as H-20 septic components. a I• Lo X 9 .43' e`er, 8. Install gas baffle or equal on septic tank outlet tee end. -'t 9. All existing inverts and site conditions shall be verified by contractor. § STEEI.REINFORCED PRECAST CONCRETE PLAN VIEW -�.-. 5' PERK TEST & OBSERVATION PITS '' :;';::'. :; •'.'. Date of Perc: Test: March 2, 1983 f0 O C3 34" R 0 Test Performed By.HOS Engineering Associates, Inc. (W.P. Oldham) �T24- WITNESSED BY: Barnstable Board of Health Agent 0,3C PERK NO.: P1648 VE PERK RATE: LESS THAN 2 MPI (ASSUMED) 3 H-10 500 gal. chambers Test Hole Test Hole END—SECTION Ro No. 1 No. 2 H-10 500 GALLON CHAMBER DDEPTH SOILS ELEV. DEP SOILS ELEV. NOT TO SCALE D D Vt1O f L/OY USE ACME PRECAST OR.EQUAL "Zou t .a 12" 12• OFMA S,q PROPOSED SEPTIC SYSTEM UPGRADE coarse `we el Q �'yG PREPARED FOR �• 9 48• LE RIN WAYNE PHIPPS ET UX oto°n o 0 EXISTING 1000 GAL A co AT H-10 SEPTIC TANK 10 0 o xIkW en #108 ROOSEVELT ROAD X 104.46 DENOTES EXISTING 9� Q`�� 1. • 81.5 SPOT GRADE S • NO GROUNDWATER ENCOU,ATERED qN/TpR\P BARNSTABLE (COTUIT), MA 10' min. from *NOTE: ALL PIPES ARE TO BE 4• DIA. SCHEDULE 40 P.V.C. 95 EXISTING CONTOUR house to septic tank Existing House Finished grade ovenss em DEEP TEST HOLE 2% slope away PREPARED BY: TOF ELEV.-96.0' EXIS77W GRADE DIST. BOX Existing Grade Elev.-94.W* Approx. location GLEN E. HARRINGTON, R.S. 1+1n.z•-,/a•-,/s• :,min. 9 LEDA ROSE LANE s-O,pZ' dwitde-waeh stone _ Max. existing water line f u �, 1000 GAL. 2a r S 91.59' Approx. location MARSTON S MILLS, MA 02648 c e o r SEPTIc rANK - , &Mt. Fl.elw.-ee.a3' e, H-10 ' 21 09 existing gas service TEL: 508-428-3862 GAS B m o o O O o s4• • OR EQUAL , a+s' rent ev.= 09' FAX: 508-428-3862 , y 9' * (S'min. req'd.) s e LEACH TRENCH E•OF 3/4•-11/2•STONE 3: yRottom of T.H. #1 elev.=6 .5' ' 3/4',to 1 1/2•auahed SCALE: 1 =20 DRAWN BY: GEH JULY 28, 2004 SYSTEM PROFILE a' OF 3/4•-11/2•STONE doable-waeh.d stone Not to Scale DATUM: ASSUMED FILE: breenphipps SHEET 1 OF 1 c j I -73-54-42 w /ODO C-JALL0/V �5.00 ! �o.00 /�6 41?ECAS7' LEACHING PIT PRECAST SEPTIC TANK (NOT TO SCALE) 01jT TO 5CA,10 j LOT 33 III 00 o o ' _ o a CJC�AN510 hl ��s �Il 2 AASHEv 2"K 45HEL ARILA 0 ❑ 1] O O L7 O ❑ 0 Ill Si-'JNE• jg„T,9 „ STONE• iB„T 7 % „ / r \ PROP. ro L.-AGHING PIT 'a ❑ C3 a ❑ 0` r — — Poop. v1s-r. box ll/ rtiASHEU IV.45NED 4 o ❑ o 0 0 0 0 ❑ a. 0 //I 00 a o a o ❑ 0 0 PRoP 1000 &AL- - N U` �E?T I TAN K �9 / — _-� •' Grp¢ 'L'-O' -- }�- (o-lo' ►11 - 2'-O' -. +. \\ Wtu I P�A,'v ✓ _ Y✓ fA -- - 10 - r' Lp - — / p ,P'ROPdSE t7 �-- ➢ s o1 L L O C s �- 4 T-- j -t----z- TP " I TP" 2 3" � - - --- ---- - - 1 104.3_ 104.0 �} LOAM Ar.1D l-OAM AND 103 S S 5UP�:oI L svc3So1 L i - - _ GRAYEL ( C- RAYEL a 4-G 4 , 4 0. Io2 102� - MEL7IUM MEt71UM BP1. EL-&V 100.0 7S4"aE?: NUT - TG�-� • a osG3cv�c.e` o HY�7WA"-r _ i 73-s4-42 \ I CROSS SECT/ON ✓iEkv --H W �^'� " 12S.00 99 1 go.o \ c 1 PERCOLATION /GAT-E OF z M/N,JTES /NCl/ �O � � v/L. l�T ��PRIVwTE 4c' w�c� �� ROAD ' ' / _ ---- - .. PRESENT DURING TESTS BA�CNST"AE�L_F BOAL7 CB \ OF HEALTH AGENT. /EkFO QMEO B Hv S En/GQ, ' �' 4S5C►G. /n/C. (11V•G? OLL7H.41-f) 2-25-83 -CT N Th'R U L (;V 7- TO 5 c a,E) 2„ " ' _ -"-"'=ujr - • _ EL icy¢ '-` _ -- j - 4°casT s _ - -5S SF A C' _ t - io� 73 I e051.�;9 ' 97.84 I D/.S T 3 9AC PRECAST C'/47R/841T/O1V BOX SEPT/L TANIr LEA�tiINU N/r -a 5, _ I 95.69EL i I P A.v t • DESl; /V CRITERIA • PROPOSED FLOW L//VE GRADES (� --- 3 cE„rr ��•l u.✓El,/ti� AT 110 :,P� = �Sj�o PL' PIPE lhv AT B/l,0/NS 103.0o r R� Po s E r ��E P'T1 _ IN I — -----7- -- - REQUI1ZLty GAV-AGITY ssc=0 31ac> PIPE /N� AT SEPTIC TANK ,INLLcF l02_15 - ----- - pIOE lN BA � N STA � ' - v., M A . '.SI�EWAL•L ArZEA /47�2 SPx2.Sc-.�a�=���5'��, ✓ AT .;EPTIC TAN/t OJI�E J i o 2.5o I DoTrdt>m AICEA Sa.054 SF x I_0 G__A.l-- CiA.L P/PE IN A T GIST d�,e ////-ET 10 2.oo 1 DES►GNEC7 G.ApAGITY _ I,Qq <.AL /PAY PIPE /N` AT G/5T tsoX 9JTLE7- 101.E VIESIGNEUP AS PEIZ TMLcr P/PE //VP AT LEACH/N(i OPWr J1[W ` e VTOM OF �EALN/NG P,/T 9569 a', � 1 A N ta WA T ER TA 8L E �ww �jo.oo d�``� �/>E C n � d)' L"e 4 PPRO v co e r C K BENCH NUT ON /-/ ,k'AA/T A '✓