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Home My WebLink About0471 SAMPSONS MILL ROAD - Health FA471 SAMPSONS MILL ROAD, COTUIT = 039 149 r U. sf- ti Apo R.d7 I .a 18� _ V' . Y - : . 1 9 0 yy y ; a I No. Fee ��y E COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Migpogaf bpgtem Congtruction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.411 Lf, Assessor's Map/Parcel l 1 CN 03 q-v 49 v staile EO e,Address,and Tel.No. �g � Designer's Name,Address and Tel.No. 0 Sl 145 k1115 1W 02W Type of Building: Dwelling No.of Bedrooms Lot Size (A@�,q,ff 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 1000 Type of S A.S. e Description of Soil Nature o ep 'rs o terati ns(A swer when appl'cabl �D W' 14 MW Q I 'J Date last inspected: Q �' .}:... Agreement: ` The undestgnediagrees to ensure the construction and maintenanct Ye of the afore described on-'site sewage disposal system ! in accordance with the`provisions of Title 5 of the Environmental Code and not place the system in operation until a Ce 'fi- Cate of Compliance has been iss Bo d of p Signe _ - Date ' �l J Application Approved by OL ' Date Application Disapproved for the following reasons jPermit No. Date Issued �i No, : Fee E COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for ;Di.5pozar ip terry COTY!ftrUcti0n Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components 4 ?-- Y'Location Address or Lot Own s Name,Adndr`e�ss ad,TeQ li l'� Ada ' Assessor's Map/Parcel D�, (� _ W I 1 �l ��7 n,, r `\ ` 1 ( il..lJ��K I stalleIs tame,Address,and Tel.No. �� a �Q' Designer's Name,Address and Tel.No. 0 ► 0K Type of Building: k, Dwelling No.,of Bedrooms-_ � Lot Size �q..,K Garbage Grinder( ) -Other Type of Building KMIll #Ah dNo..of Persons Showers( ) Cafeteria( ) • Other Fixtures Design Flow f gallons per day Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1000 Type of S.A.S. A D D r Description of Soil; ' Nature of ep 'rs r tera' ns(A swer when appli ab e) r ol°� air on�'fy o r M Date last inspected: u/1u 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-this Bo .d of ea Signed2. F : , x F -'—Application-Approved-by,v. . __.._ r ate - Application Disapproved for the following reasons Permit No. a7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS '' { F Certificate of Compliance .. THIS IS TO CERj ,that the On-site Sewage Disposal System Constructed( )Repaired( ` )Upgraded Abandoned M� , tat \\ � � +., �- as Men structed in accordance With the provisions of Title 5 and-the for Dis�osal System Construction Permit No. "�Installer`-. V: Designer 43 ---�-�T v tssuan:;v Lug pe.u..�s al�l res,t be�cnsuued as a=gaarartee ttia�ti�e�yjtdiffl r 11c for o.desigile Date- ' i' r 3 Inspector _ -- w No. 91 Fees ��••/'` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS / tg �ogaYpterr� ongtrutttonernttt Permission is hereby t Co ct f e air )U' rad//e(� )Ab do ( ) ' System located at In 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. r Provided:Construction m r1ete7dithin�t be three years of the date of this pe ",.. t '� Date: ✓` Approved by � Cif z 6 t.� i r I UNITED STATES POSTAL SERVICE First ass Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division 200 Main Street I Hyannis, MA 02601 I i I i I f; ■ Complete items 1,2,and 3.Also.complete 7A. ignatureitem 4 if Restricted Delivery is',desired„+ �gent ® Print your name and address othe reverse ssee so that we can return the card to you. i s B.Received by( rinted Name) C. D to of Del e.. ■ Attach this card to the back of the mailpiece. I or on the front if space permits. �1e n e L /�Co " SO I D. Is delivery address different from item 1? Yes Article Addressed to: If YES,enter delivery address below:- ❑No i _ I Luke4P""Le.caishensky 471 Sampsons Mill Road 3. Service Type I I Cot4jA-;``MA 02635 k ZArtified Mail ❑Express Mail 41A + ❑Registered ❑Return Receipt for Merchandise x� i ❑Insured Mail ❑C.O.D._ I 4. Restricted Delivery?(Extra Fee) ❑.Yes 2r;Article Number -- I rrisir from service label) 7 012 1010 0000 2851 2583 I _ PS Form 3811. February 200d Domestic Return Receipt ?02595-02-MA540 m . co Ln fv ICE A L U S E Ln co Postage $ rLi 41 Certified Fee 0 M Q' Postma O Retum.Recelpt Fee Here p (Endorsement Required) O C3 ,Restricted Delivery Fee JUL 2 92014, —' 0 (Endorsement Required) r=1 p Total Postage&Fees s - LISP S Luke P. Lecashensky 471 Sampsons Mill Road Cotuit, MA 02635 I Certified Mail Providgs: >W a A mailing receipt a A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: ,a Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. a Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. r a For an additional fee; delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry.- PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 r � r Town of Barnstable Barnstable AFMwwacft Regulatory Services Department 1 3ARNSTABM • I, 6yq. Public Health Division 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 2583 July 25, 2014 Luke P. Lecashensky 471 Sampsons Mill Road Cotuit, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at 471 Sampsons Mill Road, Cotuit, MA was last inspected on 6/25/2014 by John P Graci Sr, a certified septic inspector for the State of Massachusetts-. The inspection of your septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • At time of inspection pit was empty. The pit has (2) two feet of leaching left. • Recommend pumping now and every two years there after. • Distribution box is deteriorating and has roots in it. It needs to be replaced. You are ordered.to repair or replace the septic system within sixty (60) days from the date you receive this notification. Q:\SEPTIC\Conditionally Passes Ltr\471 Sampsons Mill Rd,Cot Jul 2014.doc r r Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH �n?m . HO Agent of the Board of Health TM/sc Q:\SEPTIC\Conditionally Passes Ltr\471 Sampson Mill Rd Cot Jul 2014.doc f z c httC.;Assgl2 irhar ttPrnF'i tryh �r t.,il pr ID-25�2 I��rl :V,Search. 'i p • �i% Aj http--www.town.barnstable... ®Application center S ggested Sites dieb.SlirN CA lery Favorites 0°0 Official Website of The To... Parcel Detail X f = 17 X Fmd I @Y.e r+pu '•Jea'Y. Options of nE 7C�.'�n-•r-'�!4 ,,-^---- wort ! (t t s� 5➢tRt�4TA13I F'•I Mom" ... . T .. yi t 1 }� Parcel Info Parcel 039-149------ __. ____..._.__.�._-- _.....f Developer ID t Lot Location 471 SAMPSOtVS MILL ROAD I Frontage y369 Sec'- - - ------.. - —� Sec' Road Frontage _ --- -- _ __—_----- Fire C_____ _ ----.-. ......_.--- __._ . .... - Village COTUIT OTUIT Districtyi Town sewer exists at this address To ...._... __...._- Road Indexi1415I Asbuilt Septic Scan: Interactive j 039149_1 ma aew - y LA t Owner Info ` } Owner LUCASHENSKY,LUKE P Co-Owner's — -� - Str CityiCOTUTMPSONSStstate tv1A Zip j02635 Country Locallntra [j's7aa } Monday ..,.,�...�. ..,,...„...... _U.�...._ r, ��°,� �J �6�y5 �� r . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not JOHN P GRACI SR 1V1 use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC Company Name PO BOX 2119 Company Address fewA� TEATICKET MA 02536 City/Town State Zip Code 508-641-6694 S1468 Telephone Number License Number Z B. Certification 1 i y 01 I certify that I have personally inspected the sewage disposal system at this address and thabthe information reported below is true, accurate and complete as of the time of the inspection. The insction was performed based on my training and experience in the proper function and rriaintenance'of of ite sewage disposal systems. I am a DEP approved system inspector pursuant to Section 45.340;9f Title 5(310 CMR 1 .000).The system: I ❑ Passes ® Conditionally Passes ❑ Fails El Needs Needs F I her Evaluation by the Local Approving Authority I y- 06-25-2014 Inspector's Sign' a Date The system i Spector shall submit a copy of this inspection report to the Approving Authority(Board of Health or i,P)within 30 days of completing this inspection. If the system is a shared system or has a design low 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•3/13 Title 5 Official Inspection Form:S u ce Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts ti L; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 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: NA B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): NA , t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts k W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 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): DISTRIBUTION BOX IS BROKEN AND NEEDS TO BE REPLACED. ❑ 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): NA 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 471 SAMPSONS MILL ROAD Property Address LUKE LECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: NA 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 'h day flow t5ins•3/13 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 ;M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection. B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water'supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a, design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large i 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 W Title Z Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M s 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name - information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK. DISTRIBUTION BOX . 1000 GALLON LEACH PIT Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? El Yes ❑ No Seasonal use? ❑- .Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gP )): Detail: - 2012-21,000 2013- 10,000 Sump pump? ❑ Yes ® No Last date of occupancy: JUNE 2014Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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: NA t5ins•3/13 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 °M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate'on site plan): Depth below grade: (5) FIVE FEET feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: (10)TEN PLUS FEET feet Comments(on condition of joints, venting, evidence of leakage, etc.): NA Septic Tank (locate on site plan): Depth below grade: (4) FOUR FEET(6). SIX INCHES feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) NA If tank is metal, list age: NAyears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: (1000)THOUSAND GALLON Sludge depth: (10) TEN INCHES t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle (24)TWENTY-FOUR INCHES Scum thickness (7) SEVEN INCHES Distance from top of scum to top of outlet tee or baffle, (6) SIX INCHES Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK AT TIME OF INSPECTION APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY . RECOMMEND PUMPING NOW AND EVERY TWO YEARS. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins-3/13 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 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.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NAgallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping:, NA Date Comments(condition of alarm and float switches, etc.): I NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert LIQUID LEVEL WITH BOTTOM OF PIPE 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.): DISTRIBUTION BOX IS DETERIORATING AND HAS ROOTS IN IT. 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: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. Cityrrown State Zip Code Date of Inspection, D. System Information (cont.) Type: ® leaching pits number: (1) ONE ❑ 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.): (1) ONE-(1000)THOUSAND GALLON LEACH PIT. AT TIME OF INSPECTION LEACH PIT APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY. AT TIME OF INSEPCTION PIT WAS EMPTY. THE PIT HAS (2) TWO FEET OF LEACHING LEFT. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins-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 M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): . NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is COTUIT MA 02635 06-25-2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately $HED F 6 FRowT A COVERED wMUN - o SE'Pn C. A c>-WA 3 AA 133 f}-t3 3b ,+c 4(o S O G 1000 r► L W-14 BA 52 �tr e13 s$9 SAMPSONS MILL ROAD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: (12+) TWELVE PLUS FEETfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record - If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation.hole within 150 feet of$AS) ❑ 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: AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 471 SAMPSONS MILL ROAD Property Address LUKELECASHENSKY Owner Owner's Name information is required for every COTUIT MA 02635 06-25-2014 page. Cityfrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 y7� TOWN OF BARNSTABLE LOCATION �� t ��, �� SEWAGE # VILLAGE ASSESSOR'S MAP Cz LOT bNSTAL' LER'S NAME & PHONE NO.�'ctr( tee Iti��.; tells c%PTIC TANK CAPACITY E� ♦o LEACHING FACILITY:(type) - (size) ''-'NO. OF BEDROOMS PRIVATE WEL ,OR PUBLIC WATER BUILDER OR OWNE - -e-u DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L/ 13' 1000 a yb 10 too -� FIZ$.......... COMMONWEALTH 4y�1 THEBOARD OF FHEALTH TS %G .............OF.......... 5�/ .........------------.....----- 3 Appliration for Disposal Works Tonstrnr#iun fermi# Application i ereby made for a Permit to Construct (--301"Or Repair ( ) an Individual Sewage Disposal System at: P ................_.... -- - .._ ..... . - -- - Location Address or Lot W Owner i. Address ------- .....---- �..... . . ................................................ ........... Installer Address Type of Building Size Lot...... .., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g -------------•----••-------- P (--->--- Cafeteria.(..._>.. Otherfixtures .................................-•---•---•----------.----......_.:---•------------------------------------- W Design Flow.............. Jt_- ............................. per person per day. Total flaily flow............. Q...............--... lon s. W Septic Tank—Liquid capacityV0.0 _._.gallons Length _.-_ "._ Width ..-.14�.._ Diameter................ Depth ._-. .. J- --- . x Disposal Trench—No..................... Width P................... Length..................Total Total leaching area___.._..___........sq. ft. Seepage Pit No......./........... Diameter.._f�e..-U.__._. Depth below inlet.... O. __ Total leaching area:i ...s/. Z Other Distribution box ( ) Dosing tank. aPercolation Test Results Performed Performed by. �/41-1�11�Q�✓_F_�` -?_ __ :...... Date.... _:. Test Pit No. 1._Gt---------minutes per inch Depth of Test Pit---/,V;.... Depth to ground water.YVVI C....__. f3, Test Pit No. 2................minutes per inch Depth of Test Pit....14.......... Depth to ground water........................ ---• --- ------ ----------- --••- ..... --•------_ ----- ----- ------•----- -------•-•----•--.-----•--•----------•- O x De4cription of Soil----/.' Q��---' �PP ulG:[ ._.__./....�'SIAsa✓L�'./.. '� �`G�.,�=�/✓E-/1!/E�/U /✓!� -------------- x ----------------------------•--------------------•-----------•------------•---••-•----•---------------•------••-•-••-------•------------------•---••-------------------------------........--------•--- U Nature of Repairs or Alterations—Answer when applicable............................:.................................................................. ---------------------------•-------------------•-•--------•------------.......---••--•---------•------.......-------------------------•----•--...-----------•--............................0.-----..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of J ITLI4 5 of the State Sanita ode—The undersigned further agrees of to place the system in operation until a Certificate of Compliance ha be issued b the board if ealth. Date Application Approved By............... --•----• -------------�- r- - ----- ............. ........-........... ........................................ Date Application Disapproved for the following reasons-----------------------•------------------------------------•-•----------------------------------.............._ ...................•--------•--.....----••----•----------•-••---•---------...-•----............-----------------------------------------------------•---••-------------------------•---••--•------------ Date PermitNo......F7......3-7-5------------------------- Issued....................................................... Date 1401 No...3-•7'-„22.! Fxs,.....,,,! � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `` - t A.Ppliration for Disposal Works Tonstrurtion rrrmft Application ishereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: fy �, -.....:.`................A 4+--=•=.... !'1 Y'--. .;SP.... �' .............................. '--- ! Location Address .• Lot A ! r-�•- mil, k9!! 5eritC............ �=' ..._ � r .� �: _ :::�4�` �E.. -� �%ram-•••_VF3 .............. W Owner _ )_ c. Address ------------••• .:max' - -t.1f'�-tr Pl S ........................... ...---. ..--•---- ,-� ------------------ Installer Address - d Type of Building Size Lot..... .:: _ U Dwelling No. of Bedrooms........................ .Ex Expansion Attic� g— ------------------ p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person,.per day. Total daily flow...........C ------ --- - ......_.... ._._...._..ga-1 lo-ns. WSeptic Tank—Liquid ca acit ua(Q._ allons Len th�� Width -_--P - Diameter---------------- Depth-- -'--/ °-- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------ ------------ Diameter..... `....... Depth below;inlet__t:._.:..:__.__. Total leaching areal. °_./f.....sq�t.!{'� Z Other Distribution box ( ) Dosin tank ) Percolation Test Results Performed by. Z.`�.................. ..�..... -". 5. _" �..� • - a ••---•--......_._ Date.-- ------'' ---- ,..a Test Pit No. 1_. '......minutes per inch Depth of Test Pit Oc.�._ .: Depth to ground water /k&/ /�........ PL( Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------- --. Description of Soil - .ti 's%7L, � a 1� Q> '_ ,f t > A� -- -----••-- ....--- { / '" I�',is4 z./ ,• > >Y/ i f! ' ./j�v w 1= �' � . . T . .. _......, - • -----• ................................................ ......................... V Nature of Repairs or Alterations—Answer when applicable............................•................................................................. ......................-............................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanita ode— The undersigned further agrees of to place the system in operation until a Certificate of Compliance ha be issued b he board of ealth. G Q 77 Signed `'`' " •.............. _r ..C..P.. '�'�: Date .._......... Application Approved By.......:'.:: ._ Date Application Disapproved for the following reasons:-------•-------•---------------•-------•----•--....----------------------------------------------...._._......_ ..---•---------------------•-•------------------••-•-----•-•-----•------•-------------------...-----...--•--•-•-•---•-••-•----••----••••-•-•----•-•-•-••---•••---•--------••-------------••-••.....--••- Date Permit No.....�� ......3.%...`3........................ issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ........................................................ uprrtifiratr of Tomplianrr THIS IS_ TO CERTIFY,, That the Individual Sewage Disposal System constructed (k) or Repaired ( ) by----" �," - i .3 ..... ` U�.;r ��1 --...--•---•----------•-------•.................•-- -- ....-•---........-..------.....----......-•-------..... C ,..----_—� Installer ,_. . ---------------- has �.:. been installed in accordance with the provisions o TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..-,5?7.::...J 2_5, ........ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 4 DATE................. �_..� ........................... Inspector.... V G2.. THE COMMONWEALTH OF MASSACHUSETTS -- BOARD F_.HEALTH r ...✓R! OF Jft �c ..............................— �............. --� No...Y.2'.,,7- .`.) FEE..,7.�. �i��tt1 urko �un�#rnrtion rrmit Permission is hereby granted..:____._.. �.f.��.••. .:.u►n• ................. ........................................................ to Construct ( ) or Repair ( ) an I dividual,Sewage Disposal System ( -. at No 4 - Street as shown on the application for Disposal Works Construction Permit No.i?7.-_.) Dated.......................................:.. U ............................... Board of Health DATE ...... �I ....... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS t 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 1 S owner's name a,,,,P5�� sA /� 9d Go�i1� C� Date of Inspection 4 e e PART A j CHECKLIST d Check if the following have been done: Pumping information was requested of th e he owne Health. r, occupant, and Board of _..� None of the system components have been for at pumped 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. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of .sewage back-up. p t The site was inspected for signs of breakout. ` All system components, excluding 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.. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. f SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms _ number of current residents H& garbage grinder, yes or no , CS laundry connected to system, yes or no %Vo seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: lcl`� 3 ,� 1 3;� ovv : e-J, Last date of occupancy GENERAL INFORMATION Pumping records and source of information: `Vo// cL0— 1 G ✓-•, /0 c Y1 CU 7f// 4G G �j` .J '� h�uh i 6;��f[Ji C'1 �•tp+l S I T iN u � ✓J J t1r O-�� Lt✓J Or!J 3� �]L.v�'T � / / ,J ' / ff _ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Typ of system , V 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) ' Other (explain) Approximate age of all components. Date installed, if known. Source of information: �e�► i7 u 7g , s-4e rh N0 Sewage odors detected when arriving at the site, yes or no L 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:—Z (locate on site plan) depth below grade: /,-� 6 Q0 -'�/c 4. a " material of construction: —V—/concrete metal FRP other(explain) dimensions: .S X X CI /0 y s I 4M-1 {� sludge depth L(L distance from top of sludge to bottom of outlet tee or baffle 3 At scum thickness V' distance from top of scum to top of outlet tee or baffle 1 y 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. ) C�� C" . N S Li v r rJ rU .� r✓ �� C ✓I'C-`. In c �- rr� P s� DISTRIBUTION BOX: (locate on site plan) le-u� 1 u-k',411 depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of eakage into or out of box, recommendation for repairs, etc.) o n ✓ 2 Uh r 1 0vH � tau �, J CoJ .r 4 t C t o. 1 C.,rr sS.r a00, 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. ) I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK 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 not determined to be present, explain: Type. leaching pits and number ah e- X L 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 vegetation, recommendations for maintenance or repairs,etc. ) SZ1" " Sa•-,d c, u c /o a/-, CESSPOOLS (lb(cate 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. ) f • 11 ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least .two permanent references landmarks or benchmarks locate all wells within 1001 Fro � �- 5a 591 lye, �000yNi 6ok' e� �b 6 X 6 DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: , 44b At A y l v c' +y 1-3 ' w V1 a W cv 1� �J y01 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PECTION N 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) 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? Liquid depth in cesspool <6" below invert or available volumes 1/2 da} flow? Required pumping 4 times or more in the last year? number of times pumped �L Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: NV N below the high groundwater elevation? \/ within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? 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)? within 50 feet of a private water supply well? 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 ana1K .for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. L 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Jl r0 CA 01 Company Address !/ 15 5 S Certification Statement I certify that I have personally inspected the sewage disposal 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 manitenance of on-site sewage disposal systems. Che k one: I have 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. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature---- Date Original to system owner/ / Copies to: Buyer (if applicable) Approving authority i I a TEST PIT *1 TEST PIT *2 GENERAL .NOTES o, ELEV=46.6 0' ELEV.=47.9 1. ALL ELEVATIONS SHOWN ARE BASED UPON AN 6" HUMUS it HUMUS (- - - - - - - - - - - 1 ASSUMED DATUM. suesolL I, r1 2. PITCH ALLLINES A MINIMUM OF 1/8" /FT. UNLESS 1811 SUBSOIL 1 .�- �... ,, � � OTHERWISE SPECIFIED. 0000000000 4 24" i I Q � 000000000 0 0 0 000 3. ALL PIPES TO AND IN THE SYSTEM SHALL BE CAST _ DODO 0 0 0 0 00 IRON OR SCHEDULE 40 PVC. 0 00 0 0 0 O O O 000000 m 0 0 000000 M O 1 4. ALL SEPTIC TANKS, DISTRIBUTION BOXES, AND 00000 m m ® m 00 0000 ti - `�' � � 000 0 0 m O � 0 000000 LEACHING PITS SHALL BE DESIGNED FOR H 20 WHEEL FINE TO / 00000 O @ 0 000000 LOADINGS WHEN UNDER PAVING. MEDIUM FINE To 00 0 0 0 m m 0 0 0 000 5. REMOVE ALL UNSUITABLE MATERIAL BENEATH THE MEDIUM SAND i 00000 @ 0 O 000000 INVERT ELEVATIONS OF THE LEACHING PIT FOR SAND 3 _ TYPICAL DISTRIBUTION BOX 000 0 0 O O O 000000 A DISTANCE OF 1OFT. AND BACKFILL WITH CLAY- 41-0" '� FREE SAND 8 GRAVEL HAVING A PERCOLATION RATE LIQUID LEVEL it OF 2 MINUTES PER INCH OR LESS. NOT TO SCALE-6-o 121 14' NOTE' DISTRIBUTION BOX AND 1000 6. THE BARNSTABLE BOARD OF HEALTH MUST BE NOTIFIED WHEN THE SYSTEM IS NEAR COMPLETION NO WATER NO WATER GAL, REINFORCED SEPTIC TANK BY ACME PRECAST OR EQUAL. TYPICAL LEACHING PIT AND PRIOR TO BACKFILLING. OBSERVATION • PIT TYPICAL- 1000 GAL. SEPTIC TANK 7. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS NOT TO SCALE NOT TO SCALE SHALL BE INSTALLED IN ACCORDANCE WITH TITLE PERCOLATION RATE 2 MIN/INCH OF THE STATE SANITARY CODE AND ANY LOCAL I OBSERVATIONS BY, NOTE TANKS REINFORCED THROUGHOUT WITH RULES WHICH MAY APPLY. BARNSTABLE BOARD OF HEALTH ELECTRIC WELDED WIRE WITH 24-1/2 = 8. CONTRACTOR IS TO NOTIFY ENGINEER, PRIOR TO THE ENGINEER: McKINNON a KEESE ENGINEERING EMBEDDED STEEL RODS IN TOP a BOT- INSTALLATION OF SEPTIC SYSTEM, OF ANY DISCREP- DATE_ `APR I L 3, 1986 TOM, CONCRETE IS 41000 P.S.I. TEST. ANCIES BETWEEN TEST PIT RESULTS AND. FIELD 4TX2 p A � CONDITIONS. 9. ACCESS MANHOLES TO,SEPTIC TANKS AND LEACHING " PITS TO BE BUILT UP TO 12 INCHES BELOW, FINISH y GRADE. TOP OF Boxa FOUNDATION ELEV.=51+5 FINISH GRADE FINISH GRADE FINISH GRADE OVER LEACHING FINISH GRADE OVER TANK . OVER I'D" BOX AREA ELEV.= 47+0 4TX� rs� /-ELEV.=50+0 ELEV.= 47+e EXIST. GROUND ELEV.= 47+00 • • ux i'SuX`74 I INV s. WASHED STONE INV.= 1000 GAL. INV.=45+2,i 24��x�4x 1'%2,� ' REINFORCED DIST. BOX ,, ,� ..••••••• •••••••• (TO BE LEVEL WASHED STONE ......... . ....... ± Acres CONCRETE 81 STABLE) ..•::a ••• •••••... 47119 SEPTIC TANK ••••••••••••-•»• BOTTOM OF PIT I INV.= 44+60 _r (TO BE LEVEL a STABLE) ELEV.- 3e+60 a9' 43X4 UTILITY Box s: TYPICAL SEWAGE SYSTEM PROFILE PRECAST LEACHING PIT (TO BE LEVEL a STABLE) � NOT TO SCALE i / 49x, LEGEND MAP I SECTION I PARCEL I LOT A RESS EXIST. CONTOUR -- — — — 8 PROPOSED CONTOUR EXIST. SPOT ELEVATION 8 X O - ` PROPOSED SPOT ELEVATION 0 8+0 ZONING DISTRICT FLOOD HAZARD ZONE `' PERCOLATION TEST m RF C ,o ff �•�, / / 44xa 4axs I, / ` OBSERVATION PIT m 44 0MM, PROPOSED LOCATION OF DWELLING fi X, OpO DESIGN CRITERIA ►�'' & SEWAGE DISPOSAL SYSTEM 5 o sx / NUMBER OF BEDROOMS / I PERSON PER BEDROOM _ 2- ' �i�•MU,_ LOT 60, SAM PSONS MILL RD 4ex5 GALLONS PER PERSON PER DAY _55_ . LEACHING REQUIRED GRp ` � BARNSTABLE, MA f i46xss / LEACHING PROVIDED _GPI ` �` t DISPOSAL NOAPPLICANT : ENGINEER I 0 47XT —i .vy �r �%4 � THEO CONSTRUCTION ARROW ENGINEERING INC.' ' SEWER DESIGN 24 GREAT POND ROAD 10 CAPE DRIVE SUITE B• tgz A X9 � YARMOUTH, MA MASHPEE, MA 02649 ,' 2x?Tx5x6x2.5 _ 471 GPD. • y qI:rM;•'VL� E .. � .. SIDEWALL 78 GPD SCALE BOTTOM• `r"rx5tx 1.0 ; 19p)5`• N DATE= SHEET, �.'� r AS SHOWN MAY 20 1987 1 OF .1 4?x8 � TOTAL• 549 GPD DRAWN BY, CHECKED 8Y= APPD. BY= PLAN NO. ��PrjONS EE/SEM JTH RER 468 49X3 S Q`!,; PLAN SCALE 1" 30 S