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HomeMy WebLinkAbout0123 SHELL LANE - Health 123 SHELL LANE, COTUIT A= 019128 } i I CO'M\i0\7WEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF E:N'VIRONME\TAL: AFFAIRS r— r DEPARTMENT OF ENVIRONMENTAU PROTECTION ONE NVINTER STREET. BOSTON TL40210S (614) 292.550ki TRUDY CONE. u Secretarc ARGEO PAUL CELLUCCI DAVID B. STP,':HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 123 Shell Lane , Cotuit , M4k me of Owner Jim Lombardi Address of Owner:same Date of Inspection: 6 —/Ll F Name of Inspector:(Please Print)WM. E . Robinson Sr . I am a DEP approved systerrl inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) ' Company Name: Wm. E . Robinson Septic Service MalingAddress: PO Box 10 9. Centerville . MA Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se"ge disposal systems. The system: _V Passes Conditionally Passes _ Needs Further Evaluation By the local Approving Authority Fails Inspector's Signature: � p- Date: ��� • , The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority: NOTES AND COMMENTS k _, • �ECENEO - �� J'O N 1 8 1999 TOWN OF BARNSTAKE HEALTH DEPT. 'V revised 9/2/98 Page Iof11 �� ✓r:.^ted on Recyclyd Paper ;, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o PART A CERTIFICATION (continued) 'rop"Address: 123 Shell Lane , . Cotuit , MA Jurr.mr: Jim Lombardi Date of Inspection: 4 19- 9 17 INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. C ENTS: c B. SY TEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate y s, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal,_is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:123 Shell Lane , C of uit , MA Owner: Jim Lombardi Date of Inspection: k C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 6 T' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. ' 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool.or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS CTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil.r absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . I _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet.of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) 0 THER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (eoftnued) Property Address: 1�3 Shell Lane , Cbtuit , MA Owner: Jim Lombardi Date of Inspection: ���� D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: hhave determined that one or more of the-foliowing failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should.be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an 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. _ 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. RGE SYSTEM FAILS: You m st indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 11 of a public water supply well) The ow r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of he Department for further information. revised 9/2/98 Page 4ofII i I a� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address: 1�3 Shell Lane , 'Cotuit ,' MA Owner: Jim Lombardi '', Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye;/ No �/ _ Pumping information was provided by the owner, occupant, or Board of Health. - - ✓ _ None of the system components have been pumped for at least two weeks and•the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.' s - t , 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. _ The system does not receive non-sanitary or industrial waste flow. 4A _ The site was inspected for signs of breakout l! _ All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / (15.302(3)(b)) The facility owner (and occupants,if differera from owner) were provided with information on the proper:maintenance I SubSurface Disposal Systems. revised 9/2/98 Page 5of11. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 123 Shell Lane , Cotuit , MA Owner. Jim Lombardi Date of Inspection: L11 Q 1 FLOW CONDITIONS RESIDENTIAL: Design flow:160_g.p.d.lbedroom. Number of bedrooms(design): Number of bedrooms (actual),: Total DESIGN flow Number of current residents: Garbage grinder(yes or no):�4,® Laundry(separate system) (yes or no)otO; If yes, separate inspection required , Laundry system inspected (yes or no) Seasonal use (yes or no):A- 0 Water meter readings, if available (last two year's usage(gpd): 1998 173 , 000 gal. Sump Pump(yes or no): a 1997 105, 000 gal. Last date of occupancy: b' CO MERCIAL/INDUSTRIAL: Type f establishment: Desig flow: gpd ( Based on 15.203) Basis f design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings,if available: Last d e of occupancy: OTH :(Describe) Last to of occupancy: GENERAL INFORMATION PUMPING RECORDS and s urce of information: System puwflped as part of inspection: (yes or no)_0 If yes, volume pumped: gallons Reason for pumping: TYPE O YSTEM 9. 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) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: /6 Jy2-cep Sewage odors detected when arriving at the site: (yes or no) revised 9/2/9E Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) �Foperty Address: 123 Shell. Lane , C o t u it , MA r , Owrwr: Jim Lombardi Date of Inspection: B DING SEWER: (Lo to on site plan) Dep h below grade:_ Mat rial of construction: cast iron_40 PVC_other(explain) \ Di ante from private water supply well or suction line D meter Co ments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction: +!concrete_metal Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance (Yes/No) Dimensions: l ''G L ' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: 3 t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or affle: PLy► How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and o let teM§,or baffles, depth of liquid level in relations to outlet invert, structural integrity, evidee a of leakage,etc.) 1a 8?—�� l ��.�/� ��f` /�a. 1�✓A� L� GREA E TRAP: (locate o site plan) Depth belo grade:_ Material of onstruction:_concrete_metal_Fiberglass _Polyethylene—other(explain) Dimensions. Scum thick ass: Distance fr top of scum to top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee,orbaffle: Date of las pumping: r Common (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden a of leakage,etc.) revised 9/2/98 page 7orli SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -Iroperty Address: 123 Shell Lane , C otuit , MA s e Owner: Jim Lombardi Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) ilocat on site plan) Depth b low grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensio s: Capacity: gallons Design fl w: gallons/day Alarm pr sent Alarm I el: Alarm in working order: Yes_ No_ Date o previous pumping: Com nts: (con tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of) epds carryover, evidence of leakage into or out of box, etc.) - PUMP C AMBER:_ (locate o site plan) Pumps in orking order: (Yes or No) Alarms in ovorking order(Yes or No) Comment : (note con ition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of1.1 I �! Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 123 Shell Lane , C otuit, lviA x Owner: Jim Lombardi Date of Inspection: C'_AIL 91 9 , SOIL ABSORPTION SYSTEM(SAS): y (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type leaching pits, number: ` leaching chambers,number:_ leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number._ Alternative system: Name of Technology:" Comments: (note condition of soil, signs of hydraulic failure, level of_ponding, damp soil, pond! ion of vegetatio et 1 A- CES, OOLS:_ (locate on site plan) - ��: w•-+�_ -�- W" k Number nd configuration: Depth-to of liquid to inlet invert: " Depth of olids layer: i If )epth of cum layer: f•,�• " Dimensio s of cesspool <, " Materials f construction: .t Indicatio of groundwater. inflow (cesspool must be pumped as part of inspection) Com ents: f (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)` PRIVY: (locate n site plan) ; Materi Is of construction: f' Dimensions: Com ents: Depth of solids: s .?f ' (note ndition of soil, signs of hydraulic failure, level of ponding, condition ofvegetation, etc.) revised 9/2!98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icon tined) Nope"Address: 123 Shell Lane , Cotuit, MA Jw,er; Jim Lombardi Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where.public.water supply comes into house) Y C A revised 9/2/98 Page 10of11 I 71 Ile - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) top"Address: 123 Shell Lane , Co:tuit, .MA Owner: Jim Lombardi Date of Inspection: �` g NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar S Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.). D termined from local conditions y Checked with local Board of health Checked FEMA Maps Checked pumping records - # Checked local excavators, installers Used USGS Data Describe how ou established the High Groundwater Elevation. (Must be completed) J revised 9/2/98 Page 11of11 CON111Q\NNT_A..TH OF MASSACHliSETTS r; EXECUTAT OFFICE OF EIN'vIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION. O\E R'ITER STREE . BOSTQN ALA 0210F (61 r i 292•55(K! TRUDY COXF r ..Secre:ar+• ARGEO PAt L.CELLUCCI D_AN'ID'B. STRUHS Governor - - _ Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A.' ... .< CERTIFICATION 123 Shell Lane , Cotuit , . Mkame of Owner Jim Lombardi ` 1 + p Address of Owner:same I. Date of Inspection: G•—� f Nameeof,'Inspector:(Plaaae Prirrt)Wm.r"'E'. Robinson Sr. am a;DEP approved s erp inspector suer A to-Section 15.340 of Title-5(310 CMR 15.000) c«rrpartr,N.me:`Wm. E robinson lmic Service e MaNnaAddress PO Box 0 9". Centervllae . rNLA Tileplwne Number,: 2,2� =f j='�7 r " CERTIFICATION�STATEMENT f �• I certify.thgt 1,have personally inspected the sewage,?disposel'system at this address and that the information reported below is true, accurate I ; and complete as of the time of inspection. .The inspection was performed based on my training end experience in the proper function,and maintenance of on-site se ge disposal systems. The system: _ Passes r -,•tt,� _-Conditional!y;Passesr Needs'FurtKer Evaluation Byrthe Local Appro%(Ipg,Author'ty lilt Fails lnspecta's SignaOire Date; I The System,Inspector shall submit a copy of this inspection.report to the Approving Authority(Board of Health or DEP)within thirty (301days of j completing this-inspection. If the system is a sharedrsystem'or has a design flow oflo.000 gpd'or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of.EnvironmentaLProtection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 �i ✓,:^ied o�Req¢;rd Pape, ..�W.'.w M.W�b'..a4+ ..:1!..nl'a.. a. .. r.x. •. d w. - r-. ... ... x r•. ._ . ..r. � •.nwkWk SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM h PART A r CERTIFICATION(eorttiinued) `roper,YAddress: 123 Shell ,Lane , Cot,uit., MA Jwr,a► Jim Lombardia, f Dsteoi lnshecton: G ��/6 .� / . INSPECTIOWSUMMARY: Check-A,. B, C, or•D: 'k A:'hM*SYSTEM PASSES.: w I'heve not found any information:which indicates that any of the failure conditions described in 310 CMR 15.303 exist. 'Anyfail uie criteria not evaluated are indicated'below EY. "' C ENTS I: B.. SY TEEM CONDITIONALLY PASSES: . ..: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon T ompletion of the replacement or repair.as;approved by the Board•of Health;will.;pass. Indicate y s, no, or not determined (Y, N,or ND). Describe basis of determination in all instances, If "not determined explain why'w6t.. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificawof Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfltration; or tank,; failure is imminent. The system vrill.pass;inspection if thwaxisting septic tank is replaced with a,complying.septic,tar*as- approved by,the Board of-Health, 1« _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The,syst _m will.poss inspectiowif(with approval of the Board of Healthl, ff `" broken pipe(s.);;are replaced ` obstruction is ►emoved-" distribution box is levelled or replaced The system required pumping more than.fourtimes•a year due to broken,or obstructed pipe(s). The system.will pass is inspection if(with.approval of the,Board of Health): (' broken pipe(s).are replaced ` obstruction is removed r- gym; ;revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM {y CERTIFICATION leontinued) G Pr 123 Shell Lane , Cotu t , MA - ' - owner: Jim Lombardi t Date of Inspection: i C. FURTHER EVALUATION IS REOUIRED•BY THE BOARD OF HEALTH: Conditions exist which require,further evaluation by the Board of Health in order to determine if the system is failing to protect the u public health, safety end the environment:' - . 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT- I Cesspool or privy is within 50 feet of surface water, i Cesspool or'privy is'within 50""feetof a borde►ing vegetated wetland or a salt marsh. - } , . t � I s `e SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF YI DETERMINES THAT THE SYSTEM IS +_s CTIONING IN'A MANNER�THAT PROTECTS.THE PUBLIC HEALTH ANC`SAFETY AND E ENVIRONMENT t Ji_ , 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. ff _ The system has a septic tank and-soil:absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well:, The system has a septic tank and soil 46sorption system and the SAS is less than 100 feet but 50 feet or mote from a private water supply well, unless a well water analysis'for coliform bacteria and volatile'organic compounds indicates that the well is free from.poliution from'that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) 0 HER t -...-... - .e revised 9/2/98 Pagc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " a �; . PART A r CERTIFICATION Icontinued) Pro pertYAddress: 123 Shell Lane , C ot"uit , MA } Owner: Jim Lombardi d w.•. w Date of Inspection7`� D. SYSTEM FAILS • , You;_must indicate either ,,as or."No to each of the following:, t.have determined'that one or more of t4ii;illowing failure conditions exist as described:in 310.CMR 15.303. The.ba,sis'for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes 'No Backup of sewage into facility-or;system co.,mponent due to an overloaded or clogged SAS or cesspool. l _ Discharge or ponding.of,effluent to the.surface of the ground or surface waters.due to an.overloaded or clogged SAS or cesspool. 1 Static liquid level in the distribution box above-outlet invert due to an overloaded or clogged SAS or cesspool. 1 _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). i Number of times pumped IAny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of.a cesspool or pnyy.,is within 100,feet of a surface water supply or tributary to a surface water supply. 1 '.• Any,portion of a cesspool or privy;rs,within,a Zone,I of a public well. — , . - Any portion of a cesspool or privy rs within 50 feet of a private water.supplywell. Any portion of a cesspool of privy IS less-than 100 feet but greater than 50,feet from a private water supply well with no F acceptable water.quality,,analysis. If the well has been analyzed to be acceptable, attach copy of well,water analysis for " colrform bacteria, volatile organic compounds, ammonia,nitrogen and nitrate,nitrogen. d . E. RGE,SYSTEM FAILS: -. You m st indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: 1, .. _. l• The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes N_o 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 t _ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply well) S I The ow, r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional 4 ,offce of he Department for further information. r t • Vi 1 4 1 revised 9/2/98 Page 4 of,II '77 b ! - SUBSURFACE"AGE'DISPOSAV-SYSTEM INSPECTION FORM l PART B 1 '`CHECKLIST' Property Address: 123 Shell Lane , Cotuit , MA ' owner: Jim Lombardi Date of Inspection.: ` Check if the following have been done: You must indicate either "Yes' or ^No"" as•to'each•of the'following: }�. ' YeV No Pumping information,was provided by the owner, occupant, or,Board of Health. None of the system components.;have been pumped for:at least two weeks and-the eystem hes been-receiving formal flow rates during that.ppriod, {Large.volumes•of water have.not been introduced into the system recently or as'part of`this^ ' r inspection. r As built plans have been obtamed-and.examined. Note.if they are not available with NIA. The facility or dwelling was inspected for signs,of sewage back-up. The.system does not receive non-sanitary or,industrial waste flow. m j The site was inspected for.signs of breakout: J� All system components, excluding the Soil Absorption System, 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. y). The size and location of the Soil,Absorption System on the:site has,been determinedbased on: r '_ --'" _ Existing information. For example, Plan at B:D:H. r Determined in the field.,(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) The facility owner (and occupants,if different from owner) were provided with information on the propermw in tanaac"f SubSurface Disposal.Systems. , S revised Page 5 of 11 9 2 98 f �. , - F '-f SUBSURFACE SEWAGE DISPOSALSYST-EM,INSPECTION.,FORM �. . . PART C T, SYSTEM;INFORMATION 123 '-Shell Lane , Gotuit , MA ^ 'oMrner narim Lombardi , �Date of•Inspection:.�'/Lj^Q 'g . t •e�Ma. FLOW CONDITIONS }` '1RESIDENTIAL a Design flow g p d.!bedroom. v r 'Number of!bedrooms(design): ., Number of bedrooms tactual). a Total DESIGN flow34 o f - Number of currant residents: Gerbage grinder(yes or no):" * Laundry separate system), lyes or no) o' If yeS"separate inspection required Laundry system inspected (yes or no) �- Seasonal use IYesVor not. 0 f,r,, , • , Water meter readings,if available (last two years usage(gPd): r 1998 173,000 gal. . j Sump Pump(yes or no) 1997 105, OQO gal. Lest date.of occupancy: 9 y• ,¢; CO MERCIAUINDUSTRIAL: s •Type f establishment: Desig flow: qpd ( Based on 15.203)- Basis f design flow . _. Grease rap present: (yes or no)_ I Industri 1'Waste Holding Tank present (yes or no) Non se itery waste discharged,to the jitle 5system.(yes or no)., ,,,,,Water' eter readings,if available: Last.d a of,occupancy •-• f , r OT•li :(Describe) _.._ "Lest to of occupancy: GENERAL'INFORMATION <w: PUMPING RECORDS ands urce of.information: " System pu pad as part of inspection (yes`or no) - If,yes volume pumped gallons: Reason or pumping. ' .TYPE O Y$7EM Septic tank/distribution box/soil absorption system k Single.cesspool - Overflow cesspool Privy Sharedisystem(yes or no) (if yes, attach previous inspection records,,if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval t Other APRROXIM,TE AGE of all components, date installed lif known)and source of information: A& f2-c"i Sewage odors detected when ar►iving at the site: (.yes or no)� Q t z _ lrevised-"91/'2/9� Page 6nrll - I — , i$UBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM -- - PART.CK i-rSYSTEIM'INFORMATION:1Fondr uad) IropertyAddress: 123 Shell Lane , Cotuit, MA Owner: Jim Lombardi Date of Inspection: B ING SEWER: I llo to on site plan) Pep h below grade:_ j Mat nal of.construction._cast iron_40 PVC_other(explain) ] -Di ancerfrom private.water.supplywell or,s4Ftion line ' D' meter Co_ ments.: (condition of joints, venting, evidence of,leakage,-etc.) t SEPTIC-TANK_ - e . (locate on site plan) -: �I* Depth below grader 'Material of construction:_concrete_metal_Fiberglass _Polyethylene,_otherlexplain) ,_,+ If.tank is metal,list age,__Is.age confirmed bysCertificate of Compliance (Yes/No1 ~ Dimensions: z ''C L Sludge depth .y,0/ ' Distance from top of sludge to bottom of outlet tee or baffle: 0 i Scum thickness: . r l Distance from top of scum to top of outlet tee or'beffie:— ` Distance from bottom of scum to bottom of outlet tee or affle:/fir i Mow dimensions were determined: /3<� f ;omments: j _(recommendation for pumping, condition of inlet and.o let ear baff( s,depth of liquid level in relstio to outlet.invert, structure rntegnty ,.- ,;evlde a ofaeak•age, etc.( _.: l - GREA _TRAP: _hocpte o site plan) Depth belo; grade:_ 'Material of oristruction: concrete_metal._Fiberglass _Polyethylene•_other(explain) Dimensions. Seum thick;ass: r ,r Distance fr top of scum to top of outlet tee or baffle: }y. Distance fr m bottom of scum to bottom of outlet tee or baffle: �.a (` w Date of las pumping, . . . m. Common Irecom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, n --- eviden.e.of leakage,etc.) revised 9/2/98 Page 7of11 M r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION fcontinued) 'roperty Address: 123 Shell Lane , Cotuit , MA Owner: Jim Lombardi Date of Inspection:6 /41^ 9 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locat on site plan) Depth b low grade:_ Material f construction: _concrete _metal _Fiberglass_Polyethylene_other explain) — Dimensi0 s: Capacity: gallons Design fl w: gallons!da, Alarm pr sent Alarm I el: Alarm in working order: Yes ` No_ Date o previous pumping: Com nts: Icon tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION'BOX:-Ae,/**"/ (locate on site plan) �r Depth of liquid level above outlet invert: (� Comments: (note if level and distribution is equal, evidence f�}ids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate o site plan) Pumps in orking order: (Yes or No) Alarms in orking order (Yes or No) Comment : (note con ition of pump chamber, condition of pumps and appurtenances, etc.) -i revise6 9/21 98 Page SofII SUBSURFACE SEWAGE•:DISPOSAL SYSTEM INSPECTION'FORM PART `. '-,SYSTEM INFORMATION(continued) ropwtyAddress: 123 Shell Lane , Cotuit, VIA { 0VOW: Jim Lombardi • Date of•Inapeeoon: G.�IG�L q:7 ' / r - _, �, '-�-.�i� -;s. SOIL ABSORPTION SYSTEM(SAS):v (locate'on•site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) i VzR_ilf.not located, explain: i Type leaching pits, number: I leaching chambers,number:_ leaching.galleries,number:, ^^* j teaching trenches,number,length: s .; leaching fields, number;dimensions: overflow cesspool,number. y A.lilpmative system: ; Name of Technology., ' Comments: (note condition o oil;signs of hydraulic failure, level o Ionding, damp soi�l/, condi;on of v getatio o trA aJ' IQAG ICc: n 6 .► dlr.. CES .00LS: . (locat . n site plan) _ __ . ......� _. - `l Number, nd configuration: Depth-to, of liquid to inlet invert`. Depth of olids layer: ,z )epth of;,cum layer. f Dimensio s of cesspool: , ,mot ,.� � ,. ! �•,. Materials- ►-;construction: Indicatio of groyndwater. inflow (cesspool must be pumped as part of inspection) Com ents: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ,PRIVY: (locate n site plan) Materi Is of construction: Dimensions: Depth f solids: _. Com nts: (note' ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9 Or. 11- a I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) NopertyAddress: 123 Shell Lane , Cotuit , MA Jwner: Jim Lombardi .)ate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 pagE 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contnued) ropertyAddress: 123 Shell Lane , Cotuit , NIA Owner: Jim Lombardi Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM ' Slope Surface water Check Cellar Shallow wells — Estimated Depth to Groundwater "Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how ou established the High Groundwater Elevation. (Must be completed) l3� " revised 9/2./96 Page lfuf11 fo . 019 A Q � BORTOLOTTI CONSTRUCTION,INC. m ""ECEIVE 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 MAY -2 3 1997 509-771-9399 508-428-8926 FAX: 508428-9399. t~ � TOWH.�F4DEPTABLE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A A CERTIFICATION E pd+ Property Address: 3 Date of Inspection: Ins ctor's Name: q-'s Name Ad Address: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informs- tion repoited below is true;accurate and complete as of the time of inspection. The inspection was per- formed based on my.training and experience in the proper function and maintenance of on-site sewage disposal ms. The System: Passes Conditionally Passes Needs Further luatio y t e Local Aproving Authority Fails I r' i o s S afore• nspect D� ate: � 7 The'System Inspector shall submit a copy of this inspection report to the Approving`authority within thir- ty(30),days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd orireater,the inspector and the system own er shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner . and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY* A)SYSII 4PASSES: 44 'I have not found anv information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes;nor,or not determined(Y,N,OR ND). Describe basis of determination in instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed .�' Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health). ; Broken pipe(s)are replaced r Obstruction-is-removed ...... C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions.exist which require further evaluation by The Board of Health in order to determine,if the system is failing to protect the public health,safety and the environment. 1),SYSTEM,WILL.PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE y SYSTEM IS NOT,FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS.FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC.HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface .water supply or tributary to a surface water supply: The system has a septic tank and soil absorption system and is with a Zone I of a public i f,'.. water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private,, water supply well. The system has a septic tank and soil absorption system and is less-than 100 Feet but 50.`#v,,' Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from`pollutlon from the facility,and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less �. than 5 ppm• D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health- should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to aw overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. .Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool,or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for col iform.bacteria,volatile organic compounds;ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant' threat to public health and safety and the environment because one or more of the following conditions exist: 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. ., ._ The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check`if the following have been done: ' V—Pumping information was requested of the owner,occupant, and Board of Health. _/None of the system components have been pumped for atleast 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: P"' As-built plans have been obtained and examined. Note if they are'not available with N/A. facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. i/All system components,excluding the Soil Absorption System, have been located on site. �LThe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- s spected for condition of baffles or tees, material of construction,dimensions;depth of.liquid, depth of sludge,depth of scum. e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods: -3- . ,. ,.. .. ♦ -{..--'.tt+,i•• � S-PrI � S w 1.y4, r!� „f}9 ,} 3".. M .. . - '? � dot.s��f,1• �$g��}' Y ;t�f uq"" ; 1 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION FLOW CONDITIONS RES ENTL4,LI Design Flow: 3 gallons Number of Bedrooms: Number of Current Residents: zjze�-� Garbage Grinder: Laundry Connected To Systern�� Seasonal U WaterMeter Readings, 'f pailable. Last Date of Occupan COMMERCIATANDUSTRIAL: /W Type of Establishment: Design Flow: „Q gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of mforma on: System Pumped as part of inspection:_ If yes,volum roped: gallons;' Reason for pumping: TYPE OPSYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): P OXIMATE AGE of all compone ts,dilte installed(if known)and source of information: ewage odors detect when arriving At the Me: -4- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: IV Material of Construction: i--concrete metal FRP Other (explain) — Dimisions: . Y ' Sludge Depth:__ " Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bade: /®a e Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level i01 n anon to tlet invert, stru�egrity,evidence of leakage,etc.) �i. . GREASE TRAP: �O Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — . Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: r ' Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles;depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:/`N0 Depth Below Grade: Material of Construction:_concrete metal_FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments:.(condition of inlet tee,condition of alarm apd float switches;etc.) ' DISTRIBUTION BOX: Depth of liquid level above outlet inve cam, Comments: (note if 1 1 and distribution is equal, vi bde of solids carryover,evidence of leakage i o or out o box,Aetc.) PUMP CHAMBER. ' Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,-etc.) ' 5 L ,Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site plan, if possible;excavation not required,but maybe approximated by non-intrusive methods) If not determined to be present,explain: ,hype: Leaching pits,number: 1 Leaching chambers, number: Leaching galleries,number: Ieaching trenches, number,length: M Leaching fields,number,dimensions: Overflow cesspool,number: Comments:.(note condition of soil, signs of hydrauli failur evel of po ing,co di ` n of vegetation etc. ii CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: y Materials of construction: . Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc:) E -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. t ' DEPTH TO GROUNDWATER: + Depth to groundwater: /g Feet , Method of Determination or A proximation: /�rf'//�l4 �7�� •5OJ� 4 TOWN OF BARNSTABLE LCQXTION SEWAGE IMLAGE ASSESSOR'S &LO dl DgsPE�_C I NAME&PHONE NO. SEPTIC TANK CAPACITY 1600 LEACHING FACILITY: (type) / (size) 10 00 _ NO.OF BEDROOM�3 BUILDER OR WNER ) PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I _ _ r � 3i1p r O 5r ���rr L ( C-AT ION ' - SEWAGE PERMIT NO. VILLAGE Coty f fi INSTA_LLER'S NAME a ADDRESS nn `).a A h A, Aa 16c 414 /hvl Y ; ArS-/Ores AWS S U I L D E R OR OWNER /14c 7c Co in S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED J \ ;- �~. S� {� .. � _ , i. �� �' � � 1 r ' i . � ,_ ,�, fir,�i e � . i . __ ►� �� i � � ,• � l l - y � ,yy' V` +�, � � � 1 'x. ti * � 'ti"�Y t 's�„ � :. t * t A , THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH T'.. . �9�n. 6/<m .....-.....oF........................................ Appliratinn for Disposal Works Gaimtrnrtiun Urrmit Application is her eby made for a Permit to Const�u�c ��� or i an Individual Sewage Disposal System at: , )L.3 ve'F4 e�Q, CJl'r' ( ) g P t ,:JA; ress C ' or Lot No. ..... - .......................................ram. I................ --------•--------._......-----____............ Owner Address a ............................. -------•--- ....... --•-------- ------------------------------------•------ staller Address PQ Q Type of Building Size Lot...Z!f_7 ----Sq. feet aDwelling—No. of Bedrooms....................._..___.___.________Expansion Attic ( ) Garbage Grinder ( ) a., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow.............. ...s......._.......•__gallons per person per day. Total daily flow__...............13.3.0_.._.._......gallons. WSeptic Tank—Liquid capacity/o 0 o_gallons Length.e7.G y. Width..`. ! O V Diameter................ Depths`-7 Y. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-•-__�_......_.... Diameter../o.c".... Depth below inlet..G °_4 Total leaching area..ZA.7...sq. ft. Z Other Distribution box ( -K) ' Dosingtank ( ) Al d5-Vo Percolation Test Results Performed by._C�V- /----- ' �'.S""' ! -.__..... ��Date__ Test Pit No. 1......z-.....minutes per inch Depth of Test Pit..... Depth to ground water...... � G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Sd6 6- TQ J O Description of Soil 3 6 "...........................x U .................. .................................................................---------..... --------•---•-----------. --------------------------•---------------- ------------.--------------- W ----/y0-----�1_�-o-.�mac/ . ti c v ,.7Lc r c ....................... U 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 TIT L- 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. Signed....... Z*� Z— ........................................................ a3`$S .. . Date ........... Application Approved By...... ,,c.�-�....�: . . . ......... .................................. Date Application Disapproved for the following reasons-----------------------------------------•---------------...---------------•-••-•--- ............................ ..........................................................................................................--.......---......•.---............---................------.......__.._.__............� Permit No....... _. _ �'.. ------�-- �--•---•------------ Issued...................................................... - Date - THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) 1 N. I . M 1���C&L DATA i No--- ............- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH OF:......................................................................................... Appliratiaan for llispaa aal Workii Taanstruriivit rruti# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ........................ ..............................._._.............------------------------------------.---------•---- Location-Address or Lot No. r r _ ... . C c � /... f Owner Address W �„� •.........................^................---.....•...•-............._.....-----...._.........._ ............---..__.........._..--•--........^.^.-...... � ......4^G.._...------•--- Installer Address dType of Building Size Lot......:.../... .:.........Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----------•------------•-----------•.......................--•-•-----------------------------------------•----------------•-•--•------......--------- d W Design Flow................ ____.___.....____...gallons per person per day. Total daily flow__._..................3_ �.............gallons. _. - W Septic Tank—Liquid capacityl"-c.gallons Length_f.'!.'... Width..-.`�_�'!-:..' Diameter................ Depth._ ............ ` x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... ........... Diameter...Lj:..�i_...... Depth below inlet... Total leaching area._ .f......sq. ft. Z Other Distribution box O Dosing tank ( ) `" Percolation Test Results Performed by...... _� ..........................................� :.f.- _:____` r`Date._.�Z'r�jF_. .....f.......% . ... I a Test Pit No. 1...... ..:......minutes per inch Depth of Test Pit.._._..'.v_/._._.. Depth to ground water......4"'t...... .__. Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ aJ c 3........................ r 2:7,,,.. ./ -5—-6 ` ..... ............................. _.._....__.....------•----...............---_............................- Descriptionof Soil-----------=-•------••-•---------------.........--•--------•----•-•----••------- --------=----------------------.....----•--...-•---•--......__...........--•---._.. M V .....•-•-••----.....--•-•--•----••---•--•-•----------•-----•--•...................................•-------••---•-------...... _ W v �� cv /w - �c cc41' IS c --------------------------------------------------------------------------- .------------------------ ••-----•-••----•-•------ -------------•--- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ......................................-..........................................................................--•------•-------------•-•-----------•-•--........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued 1Iy the board of health. ' r Signed..... --------•------------ --=�'--�3......`. Date Application Approved By......��.�--�-.... .................. ...._....... Date Application Disapproved for the following reasons----------------------------•------...------------------------....-----------:....---------............-----•---- ••----••------•--•••----•-------•...........-•---------•......................•--•--•--......._...-•-----'--------...._...._..•--•...----•-•-•-•---•-•------............................................ Daft Permit No......19.7 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........OF......... ....... 4J1 ' ............. -'aA. 4 wEn#ifiratr Tampliatta T IS TO _CERTIFY, That the Individual Sewage Disposal System constructed (Y—) or Repaired ( ) by ......... ...... ...•--•----------------------•----....------........................-•-----•---•-----•-------------•----..........._......-•---•-_.... Installer at........ ..... �- --�' - ------- %i- ..................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... ........ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM LL FUNCTION SATISFACTORY. DATE.----ye;.& . ---.�i .?......................... Inspector....._........_..-- ---..1,.,1:.............................................. THE COMMONWEALTH OF MASSACHUSETTS BOAR F HEA TH No...V 1.-�l-.Lj FEE....21 ...... Disposal Workii Tonstr ian rrutii Permissionis hereby granted............................................................................................................................................... to Construct ( ) or Repair ( ) an In vi ual Sewa Disposal,Sy tem atNo._4-mot•. ...3.....CT 012_ Ca��;...-_.....---'� .-•-----•----•----------••----------- --- -- - ----- treet �. {y as shown on the application for Disposal Works Construction it No..52—T __ Dat _ _ .� . /� _.... of Fealf DATE... . ..... .�� e � FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 I13 SMAL� LOCATION SEWAGE PERMIT NO. VILLAGE , fi � �q I N S T A LLER'S NAME i ADDRESS ------------------ Q Ih�7 St. W, AV/1- W4 0�26/1y8 IV Q U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 5 - ; j� /CV \ lei �.,fodoJel ��19 S YS TEM PROFILE NOT T,) SCALE TOP FDN. FINISH GRADE = FINISH GRADE OVER EL . .o:..ee:,: FINISH GRADE OVER DIST. BOX FINISH GRADE OVER &' ° SEPTIC TANK LEACHING PIT ca .e VARIES - o. .o.o. .•e . :e.. ..e.:..,: ; .;:' .o::..q.::a:' e•. •: •,. ..e• 3" OF 1/8" — 1/2" 12" MAX 4 01.6 O . . o•.'e: :0.•.'.e:: .0:..'.o::'.•.e. . •o. .o..a:e: ,�.:o:.'O:C•'O:n:e',�O ASHED PEA STONE Ni. ZPRECAST CONC. OR BRICK 6 MORTAR 3OUTLET PIPE LEVELTO 12" BELOW GRADE FOR 2 FT. MIN. c• :a:vo 'o•' o. �.'e ..e. r:• e ° 0 L6� r��-77�77� o•. o:0 6.: a e;::1. •'y.. e..,• ..0•'0:.0. .0..?•0.0: :o b: .. .p'- .o Q:;o'O :b a o:•,•o.v- p:•' a :b.0 .po; o. C. I. OR P VC TEES <s -,•p•.. a .a o'' �O:D.'�•' � ° �.'e.' p Al BSMT T. FLR. _� • GALLON D' ba rS TRIBU TION BOX e f: I EL . � e .. ° ° '� PRECAST CONCRETE INSTALL ON LEVEL BASE 3/4" TO 1-1/2" a ' 6 WASHED PRECA S T p H— i 0 REINFORCED CRUSHED I CONCRETE 't STONE y .b;:°: o, o..o.o o.o:o•p••o••o,o:.;o•_o•,o.. o:•.o,o o:o•e-. :,o:.. o:. o•b,;o: : • H— 0 REINF. SEPTIC TANK o:`o: a°: INSTALL ON LEVEL BASE - _ NOTE.' EXCA VA TE TO ELEV. <.:-'.c�' OR a .e.o. a a P,o: .. �. ,a,b, c•. ,o.p.r L OWER TO REMO VE AL L IMPERVIOUS _ — MA TERIA L BENEA TH THE L EA CHING AREA REPLACE EXCA VA TED MA TERIAL WI TH " CL EAN. CL A Y FREE SAND EFFECTI VE DIAMETER GENERAL NOTES LEACHING PIT ?. ALL ELEVATIONS SHOWN ARE BASED ON :- INSTALL ON LEVEL BASE 2. AL L PIPES IN T LiE S YS TEM MUS T BE CAS T IRON OR SCHEDULE 4Cs PVC. OBSER VA TION PIT 3. THE BOARD OF H=AL TH MUST BE NOTIFIED cw WHEN CONS TRUC T FON IS COMPLETE PRIOR F' TO BA CKFIL L ING PERCOLA TION RATE: 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED MIN./IN. Ar BY THE BOARD OC HEALTH AND CAPE 6 ISLANDS WI TNESSED BY.' SURVEYING CO., ;"'NC. 5. MATERIALS AND .'NSTALLA TION SHALL BE IN j '1eS COMPLIANCE WI Ttt THE STA TE SA NI TARP BRO. OF HEALTH DESIGN DA TA 30 -" o a CODE — TITLE V — AND LOCAL APPLICABLE DA TE.' RULES AND REGUi A TIONS NUMBER OF BEDROOMS = 6. NORTH ARROW IS FROM RECORD PLANS AND Tu �� W 4 ', IS NOT TO BE U.'ED FOR SOLAR PURPOSES GARBAGE DISPOSAL 7. FLOOD HAZARD ZONE t DA IL Y FLOW GAL . 6. WA TER SUPPL Y� 7"� �. ��� �a ._:.�'��, �" "'— _ —�. .�� '� -- SEPTIC TANK REO 'D. > �� f:� GAL . Get z a,,, t ; y1 L... �� c GAL . _ SEPTIC TANK PROVIDED �° zv M : • �` L EA CHING REGUIRED GPD. ti hl nl � o -� o ► � 1 Y t°�G d c ae tr. E Y Z ,e. ��• .S SIDEWALL AREA S. F. w S. F.X G/S.F. _ .- f; GPD P*CAST CONCRETE R D� a L EA CHING PIT \ LEGEND BOTTOM AREA S.F. \'� f S. F. X G/S. F. GPO LEACHING PROVIDED GPD ----•--._ ..�..._ ____..__________._ moo.,-, PRC 70SED ELEVA TION —— —— EX1 i TING CONTOUR 1000 SALLON OB5,=RVA TION PIT SINGLE FA MIL Y RES ENC G PRECAST CONCRETE SEPTIC TANK 0 DI3 r'RIBUTION BOX J '` �0 t �' ��' Go ;a�"^ 4 PROPOSED SEPIA GE DISPOSAL S YS TEM © LEA 'KING PIT y K No. 29894 PREPA RED FOR 0 o sEF'"IC TANK MC SHA NE CONSTRUCTION t RESl:R4E r . L O T 23 OAKWOOD STREET y 3, oo PIPF INVERT ELEVA TION COTUI T — BARNSTABLE — MASS . I CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN SCALE AS NOTED SCALE.• ? „_ -�c.� , f r� TEA TICF BOX .334 � _ PLAN NO. FT, MSS �'Al SEC PCL LOT H;� _ ____ _._.__