HomeMy WebLinkAbout1519 SANTUIT-NEWTOWN ROAD - Health l5'�� cc.r►�'��-f/UeLJ4o Ada s`
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� / !!// TOWN OF BARNSTABLE
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,WATION 2+1101 14 —/VP4lp^ SEWAGE 0
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PI)LLAO]E ��� � 0' .�,_._ASSESSOR'S MM & LOT
NSTALI-ER:S NAhM&PHONE NO.
;EI9T'IC TANK CAPA►Crry 5�1127
.EACHNG FACILITY: (type) hers (size) S
IO,OF BEDROOMS..._.sa �..._ .
WILDER OR OWNER
'EIMITDATE: COMPLIANCE DATE:
separation distance Between(lice:
4aximurn Adjusted,Groundwater Table to the Bottom of Leaching Facility eet
xivate Water Supply Well acid Leaching Facility (If any wells exist
on site or within 200 feat of leaching facility) __
,Age of Wetland and Leaching Facility(If any wetlands e ' -
within 300 fact of IQ Ching facility) _Feet 1
'urnished by�W2�a w�, GCS
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/'TOWN OF BARNSTABLE G�
LOCATION � 3 /Y£�4,11-1 SEWAGE #
VIL,.AGE Ca �7� ASSESSOR'S MAP& LOT 1
'} INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (h'P 13OT 6*tLoN
NO.OF BEDROOMS —3 e /
BUILDER OR OWNER
PERMIT DATE:_ /T Z 9 9 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility B1- Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) �f Feet
Edge of Wetland and Leaching Facility(If any wetlands exist o2/p Feet
within 300 feet of leaching facility)
Furnished by 7;yyAw-1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
page. City(rown 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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Service
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
Cityrrown State Zip Code
17508-495-0905 S13971
Telephone Number License Number
B. Certification - '
L
I certify that I have personally inspected the sewage disposal system at this address and th'�t the '1
information reported below is true, accurate and complete as of the time of the`inspection.the inspectlont
was performed based on my training and experience in the,proper,function and maintenance of onlsite
sewage disposal systems. I am a DEP approved system inspector pursuant to SectiorR5.34.O of i
Title 5 (310 CM 15.000).The system:.'
® Passes ❑ Conditionally Passes ❑ Fails - r n
❑ Needs Further Evaluation by the Local Approving Authority
t
6-20-11'
Inspector's Signature w Date-
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
J 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-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disp I System•Page
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
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 is in good working order with no sign of failure.
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):
1
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
e
Commonwealth of Massachusetts . ,,,, , -,.
Title 5 Official Inspection . Forrh
Subsurface Sewage Disposal System form -Not forVoluntary.Assessments,
1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name •,,
information is Cotuit ;' MA 02635 6-20-11..
required for every -
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): ;
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health): ;
broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced M ❑ Y,." ❑ N'. ❑ ND (Explain below):
❑ obstruction is removed El ❑ N ❑ ND(Explain below):
C) Further Evaluation is'Required,by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment. `
1. System will pass unless.Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: `
❑ Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
p o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No' ,.
Backup of sewage into facility or system component due to overloaded or
®+ ..clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
❑ " ® due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Formj-Not,for,Voluntary..Assessments� ,
1434 Santuit-Newtown Rd '
M y
Property Address
Kay Shute ;.
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
page. Cityfrown 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:
r'"0 '`' ® e. "Any'portion oftAe`SAsl cesspool or"rivy'is below high'ground water elevation.
El ® 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 bactena'indicates absent and the presence
of ammonia nitrogen and'•nitrate`nitrogen:is'equal to or less than 5`ppm,
' X t ' provided'that no'other failure criteria'are triggered.A copy of the analysis
and chain of custody must be.attach'ed to'this form:j
The system is a cesspool serving a facility with a design flow of 2000gpd-
❑ Z' 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 ,. .:
❑ E]:. the sY stem 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
s>: ❑ s.'❑ ...the system,is located in,a nitrogen,sensitive area (Interim Wellhead Protection
Area—IWPA) or?,mapped,Zoney11-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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
,M 1434 Santuit-Newtown Rd
Property Address
Kay Shute `
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
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-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official , nspection- Form
- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
_ h
M 1434 Santuit-Newtown Rd .w +
Property Address
Kay Shute
Owner Owner's Name r
information is required for every Cotuit MA 02635 6-20-11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a'separate sewage system?-[if-yes separate inspection required] ❑ Yes ® No
Laundry system inspected?:, El Yes,® No
,f
Seasonal uses K, � , : > , ❑ Yes ® No
Water meter:readings,,if available.(last 2.years usage (gpd))
Detail:.
Sump pump? - ❑ Yes ® No
6-2011
Last date of.occupancy: ` Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): : Gallons 'erda " d
P Y�9P )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap presents A El Yes El No
�,. -. , . ...
Industrial waste holding;tank present? 4 rr r _.,„ ,� , ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11110 - Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection, Form
Subsurface Sewage Disposal System Form -Noffor Voluntary Assessments
�M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
r- 4
General Information
Pumping Records:
Source of information: Owner--pumped 2yrs ago
Was system pumped as part of the inspection? -t"` ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (f 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
El Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface,Sewage.Disposal System Form Notfor.Vol untary.Assessments ,�, i;
1434 Santuit-Newtown Rd
Property Address j
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (con'.)
Approximate age of ail components, date installed (f known) and source,of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron M 40 PVC ❑ other(explain): ,
Distance from"private_water supply well or suction line: , . -
feef +'
F >,, Comments(on condition of joints,venting,=,evidence of:leakage etc:),, .•
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑,polyethylene ❑ other(explain)
41
If tankas metal, list-ago; Y , years
Is age confirmed by a CerBfcate of Compliance? (attach a copy-of certificate)-- ❑ Yes ❑ No
Dimensions:
1500 gal
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
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"
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection- Form
Subsurface.Sewage Disposal System Form-Not•for Voluntary,Assessments
M 1434 Santuit-Newtown Rd
Property Address -
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
page. CityTrown 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.):
Z
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
• gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
{ I
e
4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
M 1434 Santuit-Newtown Rd �} f
Property Address
Kay Shute
Owner Owner's Name
information is Cotuit MA 02635 6-20-11
required for every
page. CityrTown 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 0
Comments (note if,box is level and distribution to outlets_ equal., any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up.
-r.r•.;
Pump Chamber(locate on site plan):
Pumps in workingorder: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts ,s
Title 5 Official Inspection Form
a
Subsurface.Sewage Disposal System Form -Not'for.Voluntary Assessments
M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA' 02635 6-20-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) z
Type: r
❑ leaching pits number:
t_. a ., 1 2-500's
` ® 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 pondi.ng, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition with no sign of back-up into d-box or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth-of scum,layer _.-.
Dimensions of cesspool .
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form =
Subsurface Sewage Disposal System Form -Not for Voluritary Assessments '
M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
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.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts t
Title 5 Official Inspection. Form x
Subsurface Sewage Disposal System Form Not for.Voluntary,Assessments_
M 1434 Santuit-Newtown Rd
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11 -
page. Cityrrown State Zip Code Date of Inspection t
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
t _ . {
46
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t5ins•11/10 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.forVoluntary Assessments
1434 Santuit-Newtown Rd t<<•M
Property Address
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
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
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed- Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form {
a Subsurface Sewage Disposal System Form Not,for Vol untary_Assessments-, .
^M 1434 Santuit-Newtown Rd
Property Address ?
Kay Shute
Owner Owner's Name
information is required for every Cotuit MA 02635 6-20-11
page. CitylTown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
/TOWN OF BARNSTABLE 0
47
LOCATION � �7 /y� 0✓� SEWAGE # ( t
VILLAGE CO ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. %c a vel /moo�e�•v 7 7 S-- �-
SEPTIC TANK CAPACITY Jed
LEACHING FACILITY: (tywe� 7/4, ze�Y •�li'9 G.P. i) .
NO.OF BEDROOMS —3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
JS/�/+ Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
OF �/�J,s�!✓oiTf�l�j
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct O) Repair ( ) Upgrade ( ) Abandon
e( ) - ❑Complete System ❑Individual Components
Ap 7- ?1�/ r- r:�,W_Aj &/--
Location �Owner's Name
M /Parcel# Address
^� Telephone#
Installer's Name Designers Name
Joe �s f'3 s ;✓ S
_ Address Address
elephone#ff Telephone#
Type of Building: Lot Size 6 t3'.� O Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other Type of Building r No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min:required) �I�I s gpd Calculated design flow 31® gpd Design flow provided j±f-gpd
Plan: Date /Iov r )- / !�16 C Number of sheets Revision Date �/ •�
Title �jm t J Ai,'n 3
Description of Soil(s) i
Soil Evaluator Form No. �� Name of Soil Evaluator ' L��2i�/&x0ate of Evaluation /.7
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi agrees to install the above described Individual Sewage Disposal System in accordance with.the provisions of
TITLE 5 and fu r grees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
F.
Signed Date
� I
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
t
;0� T1i COMMONWEALTH OF MASStACH'USETTS ��k FEE lac2
BOARD` 01F HEALTH
OF B/4"/5'Tie 15 t-� r`
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIONP,ERMIT
Application for a Permit`'to Construct ()()`epair ( ) Upgrade ( ) Abandon ( ) ❑Complete System ❑Lndi,lRlual ComporIents
A /%to
*' Location ~ M�^ Owner's Name
MJ' /Parcel# Address
H + Telephone#
.S 1A.1<-�-
`�Installer's Name ,! Designer's Name
Address �� Address
Ayf
elephone# Telephone#
k Type`of Buildi ng: Lot Size tv 1 O Sq.feet ,
Dwelling—No.of Bedrooms v7 f Garbage Grinder ( ) #
Other Type of Building No.of persons Showers ( ), Cafeteria ( )f)
Other fixtures
Design Flow(min.required) !�!o gpd Calculated'desig�flow 33d gpd Design flow provided gpd
Plan: Date 641a ) Number of sheets Revision Date
Title /7 7E f sx-;W44-, 10kA.,d IV F A07 ....A✓�!-IllbA o
�lW Description of Soil(s) ��/ �i4,.-� `
Soil Evaluator Form No. /I Name of Soil Evaluator A. La`�2i�✓mate of Evaluation
ti 01 SCRIPTION OF REPAIRS OR ALTERATIONS
The undersigpo agrees to install the above described Individual Sewage Disposal System in accordance with the provisions-of
TITLE S and fur" grass not to place the system.in opemtign unfil a_Certificate-of'Comphance has been issued by the Board of Health. i
A /
r'
yS,igneed F'"1 'a 'DateI /2 let 4
Insnezlmns• .� '4, i ' f/
FORM t - APPL-1'CATION FOR DSCP DEP APPROVED FORM 5/96 ,:s
NO. � THE COM ON vEALTH OF MASSACHUSETTS 'I?l FEE '
�I BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
"ANCE
` Description of Work: ❑ Individual Component(s) ❑Complete System
o # The undersi ne ereby certify that the Sewage Disposal System'' onstructed�( ),Repaired(. ),Upgraded( ),Abandoned( )
A'C(,2 � � ?by: ,
at
has been..mstalled in accordanc with the rovisions of 310''CMR 15.60 (Title 5) an the approved design plans/as-built
plans relating to application No. dated 1 Approved Design Flow (gPd)
Installer s
rtAM A
Designer: \ Inspector - ! �yOU ate
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF,COMPLIANCE DEP APPROVED FORM 5/96
t
r
No. THE COMMONWEALTH OF MASSACHU`ETTS FEE /V
BOARD OF HEALTH �.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gra d 10 Con truct �e air/( ) grade ( bandooj ( ap&ndividual sewage
disposal system at s �N�/ l ' as described
in the application for Disposal System Construction Permit No. dated
Provided: Const uction hall be completed within three years of the date of thi er it.All local conditiolas mu be
met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
J
FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS- BOSTON
SEPTIC PROFILE- TEST HOLE LOGS
T.O.F. AT EL. 63:.5'
ACCESS COVER TO WITHIN 8" OF FIN. GRADE (NOT TO SCALE)
ACCESS COVER (WATERTIGHT) TO ENGINEER. RICHARD LEARNED
63.0' MINIMUM .75' OF COVER OVER PRECASTIr WITHIN 6" OF FIN. GRADE JERRY DUNNING
2% SLOPE REQUIRED OVER SYSTEM 63.10' WITNESS:
" DATE: 4/17/97 o Pond
• RUN PIPE LEVEL 2" DOUBLE WASHED PEAST0�3�t
60.5' 1500 �,
FOR FIRST 2' PERC. RATE = < 5 MIN/INCH
PROPOSED 3 MAX.
rp
SLLl1J GALLON SEPTIC _
8928 Y
9.95 60.10' CLASS- I ..SOILS P#
r
TANK (H- 1 O ) GAS ,
BAFFLE 8,., 59.3859.55 :\ L7000 C7E7QC)
59.27' C] 00m m ooao P 4' 0SIDES ?
( 2 % SLOPE) =ErCRUSHED STONE OR MECHANICAL Cl 0 0 0 0 0 0 0 0 ELEV. ELEV. v �
4 COMPACTION. (15.221 [2]) 2' 0 0 0 0 C7 O I:) E7 E7 ; 0 57.27' Q Q'
DEPTH OF FLOW = ( 1 % SLOPE) ( 1 % SLOPE) $ #3�1 3/4" TO 1 1/2 0.. 66.1' 65.7'DOUBLE WASHED S°tONE
TEE SIZES: A A
INLET DEPTH = 10 9 LS
" �OFR, 1OYR 3 3 LS LOCATION MAP SCALE 1"
OUTLET DEPTH = 14 #4 %�Fc 1 4.57' 6 / 6 1 OYR 3/3
B B
FOUNDATION t5' SEPTIC TANK 40' D' BOX LS ASSESSORS MAP 25 PARCEL 11
LS
A •� 10YR 4 6 ZONING DISTRICT: RF
�{ 10YR 4/6 24 / 63.7 '
.4� �� ��� ".' � 52.7' 29 63.68
YARD SETBACKS:
FRONT = 30'
-41 EST. GROUNDWATER EL. 38't C C SIDE = 1 5'
.4
� \ REAR = 15'
5
MS MS PLAN REF. - 532/63
-
�:, A FLOOD ZONE: C
2.5Y 6/8 2.5Y 6/8
BENCHMARK - CTR OF CATCH
BASIN EL. = 67.85 (ASSMp -
BARN. G.I.S.) 4' Fc�\ F aE
r
may,
/6 T k��liti eip / s 1
SANTUIT - NEWTOWN ROAD .''6 �R \,�oRcs3s. / Oil? 144" 54.1 ' 156" 52.7'
\ y
j NO WATER ENCOUNTERED NOTES.
W SEPTIC DESIGN: (GARBAGE DISPOSER Is NOT ALLOWED ) 1 . DATUM IS ASSUMED
_
DESIGN FLOW: .3 BEDROOMS (1 10 GPD) 330 GPD 2. MUNICIPAL WATER IS AVAILABLE
F,r / USE A ;�.w 3PD DESIGN i=LJVU 3. 11AIiV�IVfv�� RIFE i=1Tc,�-' �v �� i�'u' �'�n
OWTH2 rH� SEPTIC TANK: 330 GPD ( 2 ) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10
/ 5. PIPE JOINTS TO BE MADE WATERTIGHT.
s / S� 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
�> LEACHING: ENVIRONMENTAL CODE TITLE V.
!2(25 + 12.83) 2 (.74) = 112 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
SIDES: USED FOR LOT LINE STAKING.
� E/ / BOTTOM: 25 x 12.83 (.74) = 237 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
/.oT Is i PP/EOM TOTAL: 472 S.F. 349 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
°Q USE (2) 500 GAL. LEACHING CHAMBERS WITH INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
FROM BOARD OF HEALTH.
OF STONE ALL AROUND
/ 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE
LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR
TO COMMENCEMENT OF WORK.
11 . SEPTIC SYSTEM IS NOT DESIGNED FOR VEHICLE LOADING
EXISTING
LEGEND SITE AND SEWAGE PLAN
BUILDING 100.0 PROPOSED SPOT ELEVATION OF
' or 4 LOT 4 SANTU,T NEWTOWN ROAD
��_ 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF:
(1.42t cc.)
100 PROPOSED CONTOUR COTU IT BARN STABLE
I / / 72- TOWN OF BARNSTABLE
/ 100 EXISTING CONTOUR PREPARED FOR:
JACQUES MORIN
II 40 O 40 80 120
rn
BOARD OF HEALTH
m G Y WIRE MA SCALE: 1" = 40' DATE: NOVEMBER 12, 1998
III APPROVED DATE
off 5W
fox 508 362-49880
UTILITY
I POLE
III ' down cape engineering, inc. Of
I off' ARNE H. ti� oe ARNE cJ
> CIVIL ENGINEERS V OJALA H.
CIVIL CA
LA
_ LAND SURVEYORS � No. 2 A o.2s3a13IST
e
.�• F � `� 11.E
Ir` 939 main st. yarmouth, ma 02676 H. .;ALA ---- �-
• - ., -..S. DATE
98-248L4 -