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HomeMy WebLinkAbout0029 SCHOONER DRIVE - Health 29 SCHOONER DRIVE Cotuit A= 009-.011 - 002 �' I --_------ 1 . _ -- - -- - - / a \ r/��F (,� ti \� I''_' — f � � - � � � �� � � Pic. as 00q- 011 - 002— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner s--4 Owner Owner's Name W61 information is M. required for every Cotuit ✓ Ma 02635 3/12/19„^ page. City/Town State Zip Code Date of I''681pection 00 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. Inspector Information 614 l � v 3 3Q on the computer, use only the tab Michael D'IBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Company Address Cotuit Ma 02635 City/Town State Zip Code reaan 508-364-9587 - SI 13522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally-Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority, 4. ❑ Fails - i - '3/13/19 Inspector's Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required for every COtUIt Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 contains a 1500 Gallon septic tank as well as a concrete distribution box and two concrete leacvh pits 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is Cotuit Ma 02635 3/12/19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes.(cont.): Pump Chamber um s/alarms not operational. System will ass with Board of Health approval if ❑ P PP P P P P Y pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due` to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed • ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: I ` ❑ -.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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official fnspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts 9 IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required for every COtult Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. ° c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Fora Subsurface Sewage DisposaUSystem Form - Not for Voluntary Assessments V 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required Cotuit Ma 02635 3/12/19 page. City/Town State Zip Code Date of Inspection ' C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No -. A . El ® 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 El ®' than Y day flow El ® Required pumping more than 4 times in the last yearaNOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z 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 water supply 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 nitrogenand.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 wi6a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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 r necessary to correct the failure. 5) 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 CA. Yes No x ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 a Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�.� 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is COtUIt required for every Ma 02635 3/12/19 page. Cltyrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c� Commonwealth of Massachusetts Title 5 Official ~Inspection Form~ Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is Cotuit Ma 02635 3/12/19 required for every " page. Cityrrown State _ Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#,•of bedrooms): 440 Description: ° .. it Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection,-*, El Yes ❑ No information in this report.) 1. Laundry system inspected? ® Yes ❑ No Seasonal used ❑ Yes ® No Water meter readings, if available last 2 ears usage Approximated 96 ( Y 9 (gpd)) 239 Gpd Detail: Sump pump? ❑ Yes ❑ No; - Last date of occupancy: Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 7 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is reg uired for every COtUIt Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped after inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site glass on truck Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is Cotuit Ma 02635 3/12/19 required for every - ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool s ❑ 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 DFP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 3/23/1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3.5 feet Material of construction: ' ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,,evidence of leakage, etc.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form 6-P Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr V Property Address Denise Larner Owner Owner's Name information is required for every Cotuit Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure 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 pumped at time of inspection I ti 5 nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owners r' Name information is required for every Cotuit Ma 02635 3/12/19 page. City/Town # State Zip Code - Date of Inspection D. System Information (cont.) p 7. Grease Trap (locate on site plan): .; Depth below grade: feet Material of construction:_,; El 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 , Comments (on pumping recommendations, inlet and outlet.tee'or baffle'condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,'etc): 8. Tight or Holding Tank tank must be um ed°at time of Ins ecti n (locate on site plan):,Depth below grade: .4 . r Material of construction: y n k ❑ concrete ❑ metal ❑:fiberglass ❑ polyethylene ❑ other(explain): . Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page 11 of 18 , Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required for every Cotuit Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level with no sign of levels higher than normal. 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.): Camera inspection to distribution box showed no signs of failure t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts s. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required for every Cotuit Ma 02635 3/12/19 page. City/Town State Zip Code Date of Inspection D. System Information 10. 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.): "If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: , 2 ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr v Property Address Denise Larner Owner Owner's Name information is required for every Cotuit Ma 02635 3/12/19 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Two leach pits. Camera inspection to distribution box showed no sign of failure. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr • 'u Property Address Denise Larner Owner Owner's Name information is required for every Cotuit Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) = 13. 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.): ' F ° I' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form _ (/ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' V � 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required for every COtUIt Ma 02635 3/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 II I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 it Commonwealth of Massachusetts Title 5 Official Inspection Form - M o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is Cotuit Ma 02635 3/12/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope " ❑ Surface water ' ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 13+feet d 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: ' 1/3/93 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Schooner Dr Property Address Denise Larner Owner Owner's Name information is required for every COtUIt Ma 02635 3/12/19 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 AsBuilt Page 1 of 1 A wy L�TOWN OF BARNSTABLE Sc 4v 0.•/r Dr/v6 LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 00 INSTALLER'S NAME & PHONE NO. J04- SEPTIC TANK CAPACITY /5'00 .1 LEACHING FACILITYArype) 2� Aguo L Ps (size) �')e W NO. OF BEDROOMS PRIVATE WELL OR PU�BLl_ ATER BUILDER OR OWNER L� �� �tio✓t ��f��o DATE PERMIT ISSUED: Y DATE CO MPLIANCE,ISSUED: VARIANCE GRANTED: Yes No t a ' ••. .:,', � �' � •s3,, 'tip http://issgl2/intranet/propdata/prebuilt.aspx?mappar=009011002&seq=1 3/8/2019 THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH ASSESSoIIs MAP o: PARCEL NO: OF............................... ............................. Applira#inn for Disposal Works Tonstrurtinn pantit Application is hereby made for a Permit to Construct (o/) or Repair ( ) an Individual Sewage Disposal System at: ......... � _ ..��L! o©,.s ..�I ,�=------------ .... .. .' - -._..................................................... Location-A dress or Lot No �_ a.. --..:: -& c .... ...�9...W1. .: 1a.. _.�....Co- .> i1MA.... ?U�05 Owner jAddress W Ins'aiier Address 00 ' U Type of Building ,1 Size Lot____ lct!.....Sq. fee Dwelling—No. of Bedrooms... ..........................Expansion Attic ( 1.1b Garbage Grinder ( O '� Other—T e of Building k.......... No. of persons............................ Showers — Cafeteria a YP g ••• -- P ( ) ( ) Otherfixtures ---------- - ---------•-•--•------------------------------------------ W Design Flow.......:..... glu�v ..._.. allons per person per day. Total daily flow__..._.5 ...•.... ..........._gallonsR; Septic Tank—Liquid capac .. allons Length___D.O... Width..!;;-.'o.. Diameter__N . II. . dDisposal Trencli—No. .... ...... idth.................... Total Length.......-`._....�`.. Total leaching, area._____._______.....sq. ft. Seepage Pit No.....___.2......... Diameter...1.0.......... Depth below inlet..�r.' ..... Total leaching area'.. ..sq. ft. z Other Distribution box ( ) . Dosing ta}tk ( ) '-' Percolation Test Results Performed by........ ..�_. . ,tea Test Pit No. 1...... .....minutes per inch Depth of Test Pit...... Depth to ground water._�ol:?.�.. Test Pit No. 2.._...a......._nunutes per inch Depth of Test Pit..._._.._-``....... Depth to ground water........................ R+' ••---- . . . x l Ot- ..... 0 � •Oo Description of Soil ® _.._1'B •- 4. . - L -. a v -••-•-•-••..............•••... ............................................................---------------- •......................................... W ----••••••••----------------••---•••-•---••---•-•-••••••••••-------•••--•-•-••-•-••••••••-••••••••••••••••••••-•-•••••-------•••-••••••-••••--•••........••....•••••••-••••......-----•-•-......._•••••- VNature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------:-`-•�•••--••••••••-•••-•-•••-••-•••••••-••••-•--•-•--...........-•-••-.........•••....•--••-•••••--••••-•--••--•--.....••--•--•---•. Agreement: ��'fF `r4r_ �C`S 1'� �i l(�u FOR- - ?�IMDP�5 The undersigned agrees to in tail the aforedescribed Individual sewage Disposal System in accordance with the provisions of L 51 of the State Sanitary Code—The undersigned 'further agrees not to place the system in operation until a Certificate of Compliance has been iss ' by thetborld of health. Signed......... ----•---- --•------------------------•--•••--....-- ............•--••.....�Date Application Approved By '`�"' -•--• - - •- -•------------------ --- ✓`�- " Date Application Disapproved for the following reasons-------------------------- ----------------------------------•---------------------------..Da e-------------- Cr THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN ..................OF .�vpfiratinn for Disposal Works Tonstrnrtinn rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: SCHOONER DRIVE LOT 2 PL BK 495/57 ASS.MAP 9/11 Location-Address or Lot No.. .................... IIrI,-?E o -•-�,A•R ER------__-_---------•----•-- -•9.9---W.J.&B---WArY f...CGATR 'f-r... Ar-:•--•E 2633--------- W Owner A dress ......- PQ Installer Address vType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............a 5:__._.__...----------------Expansion Attic (Nd Garbage Grinder (NO)Other—Type of Building ......N./A.............. No. of persons Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow.........55................ .. gallons per person per day. Total daily flow.__....330*.....•__..........__._._..gallons. WSeptic Tank—Liquid capacitig lons Length.l0.:'__-,0"Width.,5.!.-Q.". Diameter-----N./.A__ Depth-_ 4_-'_-p x Disposal Trench—No.-U/-A.......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......2............ Diameter.....1.0-'_....... Depth below inlet....... .!.-Q".Total leaching area....5.3.4......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......JACK.-LAUaERSmCAUL-EY.............. Date......_II9../28_/.93---------- Test Pit No. I.....2.........minutes per inch Depth of Test Pit.....13-_0.... Depth to ground water------N.ONF....ENC. fT4 Test Pit No. 2....._'_'_._..._..minutes per inch Depth of Test Pit.._.....!'.......... Depth to ground water.............!.......... 9 .-•---•----•-•------••--------------•---••-•---•----•-----...................-•-...----...----------......................................................... 0 Description of Soil....D...Il----_.1__0.......W.ODll---ISO.AN.;....l.._Q--3__fl...S.UBSLOIL_......3._Q_-13_.0-'____MELLIZJ24...SAND x W U Nature of Repairs or Alterations—Answer when applicable....................................... .............::......................................... ---------------------------------- •------------------- •............... . ......... ---------------------------------- •----------------------------------------- -------------------•----- 1 Agreement: * THE SYSTEM p�s,,S 'EE£1 D.ESI NED FO FOB (4 BEDROOMS 4` The undersigned agrees to installHthe a ore escri ed In ividual ewage Disposa System in accordance with the provisions of TITIS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. jo Signed --___.... Date ..... Application Approved BY ..... . L/// ..................... ------ r'� -" Date Application Disapproved for the following reasons:........................... ••---•-•---••••-•----------------• --•--------____........._.. ._.........._... --------------•--------------------------•----------•-------------------•-....---•-----.......--------•--..........---------------•---------------•--------_-------------------------....•--•----•-•----- Permit No........ �� - ......................- Issued-....... ®Date e •--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN BARNSTABLE ..........................................OF..................................................................................... Qrrtifiratr of fauntplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( e01r Repaired ( ) by---------------- ---------------------------- =-----------------------------.........._..._._..----------....-----...-------....---------------- J Installer ��•�+ � �"�.� has been installed in accordance with the provisions of TITLE 5 of T e State Sanitary Code as described in the ,. application for Disposal Works Construction Permit No...._ _.3-�_ ___ dated.._. _ _. _:____ .._ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIC ORY. c`..�� �.- -- - Inspector_: DATE.--_.... ........... a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ^Oio/ ......OF...... .......... No...... .,_�.. FEE... Disoruual Workii Tuunutrnrtiun famit Permissioni hereby granted.............................................................................................................................................. to Construct,,( or Re it ( a Individual Sev�=ag sposal System .,, J r Street as shown on the application fpr Disposal Works Construction P No. .....M, Hearlt ted.__._ ._.71' `' o �;-•--•--•- 1 `) 9 ................_ Boh DATE...................... - 1........................ =' FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE Sc 4& Ake.- prJ�® LOCATION SEWAGE # �7 rs3� VILLAGE ASSESSOR'S MAP & LOT 110 7.N-0®/ INSTALLER'S NAME & PHONE NO. jo /9 Rc. I SEPTIC TANK CAPACITY ✓5-00 LEACHING FACILITY:(type) 2 v 16700 bf-s (size) �r X4a s NO. OF BEDROOMS PRIVATE WELL OR PUBLIC-WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: " ~" VARIANCE GRANTED: Yes No r woo 'D �� DRIVE' _ _ _ _ _ - - - - - = - - SC_H_0_ON_ R - _ _ _ - - proposed berm s� ' _ — — — -- — — — =50 utilities S86 45'00"yV — — wa ter ' � 175. 00' utilities El service S86 45 00 W o 196. 76' , 1st. —J °� —�` reserve Yarea 48 ® � le ching \� \� ~ ' \ 'ti pl� \ 46 Q septic \ i NOTES:co tank �., �- R __ TO WN WATER IS A VAILABLE Q ' �� / LOT IS NOT WITHIN A FLOOD HAZARD ZONE Af � fa=e s por. 42 W / 48.5 __ Proposed-_ O 105 house,; r` 4 % O -; y1 _boat 48.4p o i �i o' 4B..5p24 PROJECT LOCA T/ON.• L 0 T 2, SCHOONER DRIVE ASS. MAP 9, PARCEL 11 an d 12 LOT I COTU/T, MA LOT 3 APPLICANT � WILLIAM and DEN/SE LARNER 99 WILD WAY, COTU/T, MA 02635 YANKEE SURVEY CONSULTANTS P. O. BOX 265 LOT 2 UNI T 5, 408 INDUSTR Y ROAD i 32. 06 of MARSTONS MILLS, MA. 02648 43561 t sf - �y�hA��� �' PH. (508)428-0055 - FA X(508)420-5553 JOHN 162. `N OFy � � LANDERS-CAULEY S7916 2731 W o�'��`PAS No Ia5 y SCALE. 1"=30' DA TE. 10-03-93 MERITNEW A���Fs�o�sTERG\��`� RSV REV. y 4941 No. R2MA R N E JOB NO. 50390 SHEET I OF 2 49.2 PROPOSED TOP OF FOUNDATION 20' MIN. 10' min CONCRETE COVERS 2"LA YER OF 48.5 PROPOSED 46.5 PROPOSED 4 7.Of EXISTING CONCRETE CO VERS WASHED STONE 47.5E EXISING 4" CAST IRON OR SCHEDULE 40 4" SCHEDULE 40 P. V.C. P. V.C. PIPE 12„ DIST. M N. FLOW LINE S=O 02, D=L2.6' BOX INVERT S=0.02, D=32' 0" S=0. 05, D=19' PRECAST 1 M1IN. 19 LEACHING EL= 44_50 - 2, IT OR INVERT r� ` o EQUIVALENT INVERT EL.= 43.61 LEVELxx c q o0 EL.= 4_3.86 0. oc INVERT INVERT INVER ° 6 F 3/4"' TO 1-1/2"" 1250 __GALLONS ° �' o ASKED STONE EL.= 43.36 EL.=_43.19 EL.=_42.24 0 � oc SEPTIC TANK ---- -- - o W c` EL.= 36.3 LEACH PIT I z ----- z' 6' y PROFILE OF 10'DIAM.-- � SEWAGE DISPOSAL SYSTEM - - - - - - - - - - - - - - NOT TO SCALE BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL= 30.8 ALL ELEVATIONS ARE ASSIGNED BOTTOM OF TEST HOLE # 2 IS 13 FEET BELOW SURFACE. SOIL LOG - WITNESSED BY- J. LA NDERS-CA ULE Y, -PE 'a J. DUNNING GENERAL NOTES PERCOLATION RATE -2?-' MIN./ INCH 1. THIS PLAN IS FOR CONSTRUCTION OF A SEWERAGE DISPOSAL SYSTEM. Py# 8113 2. PLAN REFERENCE BOOK 495 PAGE 57, LOT 2, BARN. REG. DEEDS. DATE 09-_28-93 DATE 09_28-93 3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM TEST HOLE 1 TEST HOLE 2 AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. EL. = 43.8 EL-- DESIGN DA TA: 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.R _ 47.0 TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. NUMBER OF BEDROOMS THREE 5. ALL COVER TO SANITARY UNITS SHALL BE BRO tIGHT TO WITHIN TOP & SUBSOIL 40.8 .3.0' 2 5 TOP & SUBSOIL 12" OF FINISHED GRADE. GARBAGE DISPOSAL NONE 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY .THE SAME, UNLESS NOTED BY FINAL CONTOURS. TOTAL ESTIMATED FLOW 330 GPD 7 ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE ( 110 -_GAL./BR.IDA Y x _3- BR. OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SEPTIC TANK CAPACITY 1250-- SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING. MED. SAND MED. SAND UNLESS NOTED. LEACHING AREA REQUIREMENTS 8. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. 30.8. 13.0' 13.0' SIDEWALL AREA 188_5 GAL./S.F. 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM AREA _ 78.5 GAL.�S/F. DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO LEACHING CAPACITY (BOTTOM & SIDEWALL� 1098 GAL OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. NO WATER ENCOUNTERED - 10. THE EXCA VA TOR�CONTRACTOR SHALL VERIFY THE LOCATION OF ALL ( 3.14 X 6 X 10 X 2.5 f ( 3.14 X 52 X 1. 0 UNDERGROUND UTILITIES PRIOR TO ANY EXCA VATION. RESERVE LEACHING CAPACITY 1098 - GAL. SHEET 2 OF 2 * CAPACITY OF TWO PITS JOB NUMBER_- 50390