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HomeMy WebLinkAbout0125 SHELL LANE - Health 125 Shell Lane Cotuit ,e n 'I !I commonwealth of Massachusetts r tTitle o Subsurface Sewage Disposal System Forts Not for Voluntary Assessments 125 SHELL LN ' Property Address FLORENCE BACA$ Owner Owner's Name information is MA . 02635 JULY 29 2011 required for every _COTUIT page, City/Town State Zip Code Bate of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way,Please see completeness checklist at the end of the form. Important_when A. General Information filling out forms 4 ! \ on the computer, �Jp n Uy� � use only the tab " �y key to move your 1. inspector: cursor-do not MARK WHITE ........... use the return . .-....,__F. key. Name of Inspector A B CANCC? x_ Company Name 350 MAIN ST ROUTE 28 --- Company Address W YARMOUTH _- MA - 02673 City/Town State Zip Code -W 508-775-2820 -- S-13381 Telephone Number — License Number B. Certification I certify that i have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000).The system: z Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority fi qa,/jb0U,'� �4/ JULY29201 Inspector's Signature T Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit,the report to the appropriate regional office of the DEP The.original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under, the same or different conditions of use. e Title 5 Official inspection Form:Subsurface sewage Disposal System•Page 1 of 19 II Commonwealth of Massachusetts. Title 5 Official t r 95 Subsurface Sewage Disposal System Form a Not for Voluntary.Assessments b 125 SHELL LN Prop"Address W FLORENCE SACAS _....: .... _. - Owner Owner's Name information is C©Tt;IT MA 02635 JULY 29 2011 required for every - — State Zip Code Date of Inspection page City/Town w B. Certification (coat.) inspection Summary: Check A,B,C;D or E/aly�ays complete ail of Section D A) system Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303,or in 310-CMR 15.304 exist. Any failure criteria not evaluated,are indicated below. Comments: 13) 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 exfiltratien 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 121 N ❑ ND (Explain below): TO 5 Qitidal Inspection Form:suosur6aca Save e Disposv)SY,4*m 2 o/19 t5ins•09/08 Commonwealth o Massachusetts - TitleicyInspection Subsurface Sewage Disposal System Form -Not for voluntary Assessments 125 SHELL LN Property Address FLORENCE BACAS Owner Owners Name information is CC?TUIT ILIA 02635 JULY 29 2011� —__ required for every --- , Page. City/Town Sate Zip Code Date of inspection III ification coat. . . Cert t ) B) System Conditionally Passes(cunt.):. D 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): 0 broken pipes)are replaced ❑ Y ❑ N d NO (Explain below): Q obstruction{is removed ❑ Y Q N Q NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y d N Q NO (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 pipes)are replaced El .Y ❑ N 0 NO (Explain below): ❑ obstruction is removed ❑ Y 0 N 0 NO (Explain below): 14fe 5 6ffieial Inspection i-omi:Subsurface Sewage Dispo"ai.SWOm•Page a Df 19 t5ins•09MB Commonwealth of Massachusetts , - Title i i r _ Subsurface Sewage Disposal System Formm Not for Voluntary Assessments 125 SHELL LN Property Address FLORENCE SACAS Owner Owner's Flame information is COTU{T MA 02635 JULY 29 2011 required for every .. ._. _-_— Zip Code Date of Inspection page Cityfrown Stag C9 Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 C R 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment 11 Cesspool or privyyits within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh B. Certification (cons.) 2. System will fail unless the Board of Health (and Public dater Supplier, if an 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. lfl The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 0 The system hasa septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private eater supply well**. Method used to determine _ ---- distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. To-le 5 ornoat inspection Fo—subsurface sewage Disposal System•Page 4 of 19 t5ins-09108 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Fora a Not for Voluntary Assessments �..... 125 SHELL LN _.w. ...... _ Property Address FLORENCE BACAS Owner owner's Name information is COTUIT MA 02635 JULY 29 2011 required for every - page City/Town State Zip Code Cate of inspection 3. Other: D) System Failure Criteria Applicable to All Systems: You Must indicate"Yes," or"No"to each of the following for all inspections. Yes No © ❑X 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 ❑ Q 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/z day flow B. Certification (cone.) Yes No ❑ Required`pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or prig is within a Zone 1 of a public well. ❑ [Xj- Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins°09108 TAle 5 i7fficfoj lnspvctjon Form:Subsurface Smage Disposal System°Page 5 of 19 Commonwealth of Massachusetts -- _-_ Title 5 Official sInspection Form Subsurface Sewage[disposal System Form -Not for Voluntary Assessments _ 125 SHELL LN __. _._......_...._.-_ —._.__.......-.---.___-- `J Property Address FLORENCE RACAS Owner Owner's Fume information is COTUIT M,4 02635 JULY 29 2011 required for every ----- -- - ___ ----- page. Cityrrown State Zip Code Date of Inspection ❑ O Any portion of a cesspool or privy is less than 100 feet but greater than 50 fleet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this fors.] ® The system is a cesspool serving a.facility with a design flow,of 2000gpd- 10,000gpd. ❑ ❑y ;The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the'Following, in addition to the questions in-Section D. Yes No ❑ (� the system is within 400 feet of a surface drinking water supply Cl ❑ 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)oe a mapped Zone 11 of a public water supply well If you have answered_ "yes"to any question in Section E the system is considered'a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall,,upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No El L1 PPumping 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? ® 0 Have large volumes of water been introduced to the system recently or as part of this inspection? t5ins•09108 Title S Official Inspection Form:Subsurf,-c—a sewage Disposal system-Page 6 of 19 f Commonwealth of Massachusetts w-- - Its 5 Official10 VA Subsurface Sewage Disposal System Foie Not for`Joluntary Assessments 125 SHELL LN Property Address f=LORENCE SACAS Owner owner's Name information is MA 02635 JULY 29 2011 - required for every .. CC3TtJlT ------ ----— ...._page. Cttylrown State Zip Code Dale of inspection Were as built plans of the system obtained and examined? (If they were not 01 available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? n ❑ Was the site inspected for signs of break out? {� ❑ Were all system components, including the SAS, located on site? ❑x ❑ 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 Sofa Absorption System (SAS)on the site.has been determined based on: ❑ ❑X 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 ❑ Q approximation of distance is unacceptable) [310 CIV1R 15.302(5)) D. System Information Residential Flow Conditions: unknown Number of bedrooms actual Number of.bedrooms(design): - -------- (actual)' DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): unknown 4 D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? Oyes 9 No t5ins•09108 'title 5 Official inaoection dorm:Subsurface sewage Dispose;System•P e;1- 19 Commonwealth of Massachusetts , Title 5 Official ct r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . a 125 SHELL LN N ham• - _..-.-_..........-.-__Property Address Address FLORENCE BACA5 - - ...- --- - -- Owner Owner's Name information is MA 02635 JULY 29 2011 COTUIT _.-- ---. required for every ____ _..__ page. City/Town State Zip Code Date of inspection Is laundry on a separate sewage system?[if yes separate inspection required] ®Yes O No Laundry system inspected? DYes C No Seasonal use? L iYes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: y Sump pump? ' Yes Z No UNKNOWN Last date of occupancy: Rate Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Y Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? DYes ❑ No Industrial waste holding tank.present? Oyes 0 No Non-sanitary waste discharged to the Title 5 system? 0Yes 0 No Water meter readings, if available: D. System Information ;coat.} UNKNOWN.__... _._..._ Last date of occupancy/use: Date Other(describe below): Title 5 tfcial Inspection Form:Subsur(acO sewage Disposal System-Page 8 of 19 t5ins•09/06 Commonwealth of Massachusetts usetts - -- Title Subsurface Sewage Disposal System Form Not for Voluntary Assessments — 125 SHELL LN Property Address _ FLORENCE BAC.A ---- Owner Owner's Name information is MA 02535 �' JULY 20 2011 COTUIT required for every state page Cltylrown State Zip Cade hate of tr spectton. - _ ' F ` General information Pumping Records: Source of information: was system pumped as part of the inspectionZ ryes ❑ No . If yes,volume pumped' 1000 ----- _- ___.- gallons TANK SIZE AND TRUCK LEVEL How was quantity pumped determined - — - Reason for pumping: _W__.._w._.._._.. _... Type of System: ❑x Septic tank, distribution box, soil absorption system ❑ Cesspool ❑ Overflow cesspool ❑ Privy ❑ Snared system (yes or no} (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology:Attach a copy of the current operation and , maintenance contract(to be obtained from system owner)and a copy of latest inspection'of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): ; D. s stem information (cont.) Approximate age of all components, date installed (if known)and source of information: t5ins•09/98 Title 5 Official Insp Lion Form:Subsurface S o.V DiSPaSN SySt"•Aage 9 Of19 Commonwealth of Massachusetts Title r i Not for Voluntary Assessments Subsurface Sewage Disposal System Form- s` 125 SHELL LN - ---<Property Address Address FLORENCE BACAS ---.._...._..-......_-__ Owner Owner's Name information is COTUIT _ MA 02635 JULY 29 2011 required for every - - — page Cityrrown State Zip Code Date of inspection JULY 27 1987 - --- .:-.. , Were sewage odors detected when arriving at the site? [:]yes No Building Sewer(locate on site plan): 19 INCHES Depth below grade: feet -.-_-- Material of construction: 11 cast iron O 40 PVC 0 other(explain): iv well or suction line: Distance from private water supply feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): , Depth below grade: feet Material of construction: M concrete ❑ metal ❑fiberglass 0 polyethylene ❑other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a cony of certificate) OYes C1 No Dimensions: 12INCHES .......... ... -- Sludge depth: - D. System Information (coat) File 5 miiciai Inspection Form-Subsurface Sewage Disposal System,•Page 10 of 19 t5ins-Moe Commonwealth of Massachusetts Subsurface Sewage Disposal System Fora Not for Voluntary Assessments 125 SHELL LN Property Address FLORENCE BACAS Owner Owner's Name information is COTUIT MA 02635 JULY 29 2011 required for every -- -- page. City/Town State Zip Code Date of Inspection Septic Tank(cant.) Distance from tap of sludge to bottom of outlet tee or baffle 4 FEET---- - _._:.__--- 4 INCHES__ -_-_ Scum thickness 8 INCHES -- Distance from top of scum to top of outlet tee or baffle -- 16 INCHES _ Distance from bottom of scum'to bottom of outlet tee or baffle --- --------- SLUDGE JUDGE, TAPE How were dimensions determined? -- --- ---..__----._......_. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: C1 concrete 0 metal _ ' L1 fiberglass U polyethylene L!other(explain): Dimensions: _._---_,.._.w_...._._.n..._......._.._._-.� Scum thickness Distance from top of scumto top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date tSirls•09/08 Tft 5 Official inspsctjor,form:Sul surface Sewage Disposal System•Page 91 of 19 Commonwealth of Massachusetts -- 01 Title l Inspection J I Subsurface Sewage Disposal System Form Not for Voluntary Assessments • 125 SHELL LN _._ Property Address FLORENCE BACAS ---...._...... ..-- Owner Owner's Name information is co,rulT MA 02635 JULY 29 2011 required for every page City/Town state Zip C de Hate of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: - ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: - e Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: El Yes ❑ No Date of last pumping: gate Comments(condition of alarm and float switches;etc.): *Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No t5irts•091CR Title 5 Official inspedion Form:Subsurface 59*aGe Disposal syst0mm•Page 12 of 19 Commonwealth of Massachusetts Title4c Inspection subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 125 SHELL LN _,.._.. �_.._...._ Property Address FLORENCE BACAS....._..._..------ ---- Owner Owner's Name information is MA 02635 DULY 2g�01! __._.. .. -... ..-_ required for every COTUIT --........._.---- page city/TownState Zip Code Date of tnspectian - D. System Information (cent.) Distribution BOX(i€present must be opened) (locate on site plan): 4 AT INVERT ---- Depth of liquid level above outlet invert 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.): NO EVIDENCE OF SOLMS CARRYOVER AND NO SIGNS OF LEAKAGE� Pump Chamber(locate on site plan): Pumps in working order: ElYes ❑ No Alarms in working order: [ Yes , ® No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Trtte 5 ofuciai inspaCtion Form:$ubsurfaOe SOWWO Dispcsai System•page 13 of 19 t5ins•09108 Com monweafth ofMassa-chuse Title Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 SHELL LN -- ---,_..__..._.............._.-_- Property Address FLORENCE SACAS Owner Owner's Name ------ information is COTUIT MA 02635 JULY 29 2011 required for every __----_.- ._....... .. .........._. page City/Town -- ---- -— State Zip Code Date of Inspection D. System Information (cont.) , Type: Q leaching pits number:l 6x6 PRr<cAsr [� leaching chambers number: Q leaching galleries number: Q leaching trenches number, length L leaching fields, number,'dimensions: —--------_ ® overflow cesspool number: Q innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition:of vegetation, etc.): LEACH PIT IS DRY Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth--top of liquid to inlet invert t5ins•09M Title 5 Official Insect or,Form:subsur!sce Sage Gispo el system-Page 14 of 19 Commonwealth of!Massachusetts Title 5 Official Inspection Form M Subsurface sewage Disposal System Form Not for Voluntary Assessments ;1 r _125 SHELL LN _ — _--- Property FLORENCE BACAs ----- Owner Owner's Name information is COTUIT MA 02635: JULY 29 2--011-..... required for every --- — -- ---- — State Zip Code Date of tnspe inn page. Cityfrown Depth of solids layer -_— Depth of scum layer ----- -- - Dimensions of cesspool -------._.. . ....._._._._-- Materials of construction -------- --- Indication of groundwater inflow i-]Yes a No D. System Information (coat.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of paneling, condition of vegetation, etc.): t5ins•09/08 Title 5 official Inspection Form:Subsurface$ewage D,Sposal System•Page 15 of 19 Commonwealth of Massachusetts Title 5 Official Inspection subsurface Sewage Disposal System Eon Not for Voluntary Assessments 125 SHELL_LN FLORENCE BACA Owner Owner's Name 02635 DULY 29 2011 information is COTUIT MA -----_.._.__. .......... ._ required for every ---___._.-............_......___-- Ccty/Town State Zip Code Date of Inspection page. • D. System lnformaW®- (cone.) Sketch Of Sewage Disposal System'. Provide a view of the sewage disposal system, i;ciuding ties to at feast two permanent reference landmarks or benchmarks. Locate all wells within 10"feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below M drawing attached separately Tdfe 5 offic al Inspecbm Form:Subsurface SeWage Dsp7"i S,stem•page 16 of 19 t5m•09108 Commonwealth of Massachusetts Titleicy Inspection _._ Subsurface Sewage Disposal System Form µ Not for Voluntary Assessments 125 SHELL LN _T Property Address FLORENCE BACAS Owner Owner's Name information is COTUIT MA 02635 JULY 29 20 1 required for every _..... page. City(fown State Zip Code Date of#nsP action f t i a I � 1 I .aRJ i D. System Information (cone.) Site Exam: Q Check Slope iJ Surface water t5ins 09/06 Tdle 5 Off+c:af Insp?Lion Farm:Subsurface Sewage,Disposal System•Page 17 of 19 r Commonwealth of Massachusetts 14- Title 5 Official Inspection r IGl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - - 125 SHELL LN Property Address FLORENCE BACAS Owner Owner's Name _. .... ........-- -_._.... ..._. .. ... ._. ----- information is COTUIT -MA '02635 JUL`�29 2011 required for every ..............- --------'...-.......-...,. page. City/Town state Zip Code Date of Inspection ® Check cellar Q Shallow wells Estimated depth to no ground water: _------ feet Please indicate all methods used to determine the high around water elevation: ❑ Obtained from system design plans on record' If checked, date of design plan reviewed: Date" --- t - CCJ Observed site(abutting property/observation hale 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: AUGERED THROUGH THE DRY LEACH PIT 7 FEET DOWN r Before feting this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist EXI Inspection Summary: A, 13, C, D, or E checked l❑X Inspection Summary.D(System Failure Criteria Applicable to All Systems) completed tsins•MOB - Title-5 Official inspection Form:Subsurface S&xage Disposai System Page 18 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form sj Subsurface Sewage Disposal Systems Farm -Not for Voluntary Assessments g - 125 SHELL Property Address FLORENCE BACAS Owner Owner's Name information is COTUIT MA 0 535 _ JU_LY 29 2011 required for every _._ _.. _; -- ___-.- page. Cityrrown .State Zip Code Date of Inspection Fx1 System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn.on page 15 or attached in separate file t5ins•M-08 Title 5 Official Inspection Forth;Subsurface Sewage Oisposat System-page 19 of 19 Ar NST ABLE �' 6 C�-► L� CATION Lo"� �J_ c��'�l� < SEWAGE # \... VI'LL.AGE_ ASSEtiSOR'S MAP Sz LOT_ ►4K f C AApCD -S-r _ Seru INSTALLER'S NAME & PHONE NO. 0c.k \ A: Acc. ���,�zr SEPTIC TANK CAPACITY - + (size) �� LEACHING FACILITYAtYPe) NO. OF BEDROOMS �s PRIVATE WELT. OR UBLIC ATER___ BUILDER OR OWNER sa ����- xr�� 14,c� 41b", Z� tCd�r. � - -- I DATE PERMIT ISSUED: + -- — DATE COMPLIANCE VARIANCE GRANTED: Yes_.: i + 0 1 ay 0 � � J • J t No.. ....... Fics��... 8....... THE COMMONWEALTH OF MASSACHUSETTS ��✓�" BOAR® OF HEALTH 1....._......OF...: a cn. :fa_.b.Le ---------------------------...... Allp iration for 11hipos al Work/ Tonstriir#iun 1hrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal ,System at: . :r.2. ..._ - ........ ...-•----..•--••--------•......._. ....................................•---• .,n n� �Jca/�ton ddress Ci ��, or Lot No. Owner Address W � Installer Address Type of Building ISize Lott._2 3D_:.....Sq. feet Dwelling—No. of Bedrooms..........-13..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ._..... No. of persons -................ Showers YP g ---------------•----- P ( ) — Cafeteria ( ) Otherfi.Uures --------------------------•------•-------------------....•---------•------•------------..-------•--•-------....----._........----------............... Design Flow.........._ gallons per erso per day. Total it flow.. s ....................... W g ------------•..............g P P � u �� y � _... ��� ions. 04 Septic Tank—Liquid capacity_1,64v gallons Length ...�c!__..__ Width.__ -__�®... Diameter________________ Depth. .._. ..... xDisposal Trench—No. .................... WA�h_................. Total Length................. Total leaching area....................sq. ft. Seepage Pit No--------------- _____Diameter..`-. ._0_.......... Depth below inlet._�12_.Q_ .... Total leaching area.a .O....sq. ft. Z Other Distribution box ( V Dosing tank ( 1) P (0S_qZ Percolation Test Results Performed b _._b da c�_ .__. _ `: Date..ij.o_e-� �_�� -____. Test Pit No. 1... per inch epth of Test Pit w.._.___._ epth to ground water_.___'.__.._.__" (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------------- ---.------ .................................................................................................................. 0 Description of Soil``___-_ '._..._. ? ...... � -1ES _I�NAIhIEEEt.MUST.SUP.ER�/4U... <31�i— -1��:." 1ar.�� - !------•---•-----JWTALLATM-MO.IrMIFY.lu.WSITINC... W Nature o Repairs or Alterations—Answer when applicable _����SYS?E(M__YYAS..IIVSI'ALLE�.1[1L_�TALC.T... U f Rep pp RDANGE.Tg-P.[M.-....................................... ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------••••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ued�, and of lh Signed...... ��-90 ..... . ....... D e Application Approved By.................. ........1's� - = Z .... ate Application Disapproved for the following reasons--------------------------------------------------------•---------------------•-•-------------------------....... -•--------------•--•.....-••---•-••------.....----------•---•------------•••-•-------•-•---•-----...-------------•------------------------------....................................................... Permit No............. .. .—.?.�....... Issued_.•••-----..._.....Z l f--- a-------- THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH lr✓.!�).. ............0F....,,,u J.�,. Y,-).L»................................ Appliration for Disposal Works Tonstrndion Prrutit Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal . System at: �s:?:�:2 ..» - .a % .................. .....................................••-•--r Lot No. ......... ... o-catiton- o ...................................................................... Owner Address af d r7�.``""" Installer Address , Type of Building Size Lot3�_i 7»�a......Sq. feet Dwelling—No. of Bedrooms___________ _____________________________Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons......-, ---------------- Showers — Cafeteria dOther fixtures -----------------------------------------------••-----.--------....._..._..---•----...------------------------------------..._.._.....------•---•----• WDesign Flow...........�- .....................gallons per person per day. Total daily flow_.-._-..3,50......................gallons. WSeptic Tank—Liquid capacity_1_L),gallons Length .In,___. Width_Lt__ 0___ Diameter________________ Depth_'7__... x Disposal Trench—No..................... Width.................... Total Length.-______i._..__.,.. Total leaching area....................sq. ft. Seepage Pit No___________________„ Diameter__`1�,--�____..._- Depth below inlet-_��__(�...___. Total leaching area.�:?6j.�....sq. ft. Z Other Distribution box ( f Dosing tank '-' Percolation Test Results Performed b gc_k___ lGt tt.� LiAUtL lE Gu:_C©'. Date__ 1 0 � c�Test Pit No. I.__,__�._,_.__.minutes per inchepth of TestDepth to ground water......:_.......... fT4 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ O �, .................................-------- ................ ---------------........................................-...._._._.........•-••-----..._......................... Description of Soi1Q.- - -�?? acl ..................................................... -•---- v 421^_.-...I�fy ` ?,C1.E_L)n�__�11Lrt J�ESI(aNING.ENGINEE UST_ SUt�EIVISE W INSTALLATION AND Ci 'q`i1=Y IN il1fR1T11V '' •-•----------------------------------------------------------------------------------------------------------------------------------••--------- UNature of Repairs or Alterations—Answer when applicable._-_._.__THE SYSTEM WAS �NSTALCEI) IN STRiC ACCORDANCE T(S PL.AW--------------------------------•-------- -------------------------------------------•----•----------------------------._..,_......•-•....--•---------•----------------------------------------------------------------._...__.._..------•---•---- 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 by the board of lth. Signed ..." -------------•----- tv Dat Application Approved By.................... ;;<..: - `.......................................................... ........ D --� Application Disapproved for the following reasons:....................•-•----•---•----•-----------------------.....---------•--------------------------._..._.... .._.._..•-•----•..................•••-------------------------.......---••-------•-•--•-•••-••------•••••---•---------•-•--•-.._._----_.._..----...-------•-----•-------------------•------------------- . Permit No............... .» Issued...............•-•- 2 / J� L._..__...». D ................. ate .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _7710.�. .................oF......�,�.��'/�. .T.'9���C. .......................... Trdif iratr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k) or Repaired ( ) by..........oA?.'PO...... 2-^f----------------------------------------------------------- ........................................................... i Inst ller at.........Z-4z�.-- -Q�.t1rv-�----- --------------------CQ.1.0.4-,�•---•--........................................----•----•---- has been installed in accordance with the provisions of TIT _ Th e Sanitary Cole .de ied in the application for Disposal Works Construction Permit No....... _:! dated_....._.._...�w/_."._._-_...._.___..... , THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... • ........................................ DESIGNING ENGINEER MUS S CJFPERVISE THE COMMONWEALTH OF MASSACHUIS�'P,�i LATION AND CERTIFY IN WRITING THE SYSTEM WAS INSTALLED IN STRICT BOARD OF HEALTH ACCORDANCE TO PLAN. No......................... FEE........................ i5 Works Cron #rnnr an rr i t ' j J Permission is hereby granted__,__,,7_z4eP ............ P.t ...............•-------..._.........._._......_...::..._._.. to Construct ( p e) or Repair ( ) an Individual Sewage Disposal System at ; .......01.911_..Lfk..C2/0_.....5'- ..........L'•la-Z U� ---------------------------- .............................. Street L/ 1 / as shown on the application for Disposal Works Construction Per No_„" __Dated........... .- elf _. --------------------`-- ••--•-•-•-•---._ DATE- ----- �-0................................... Board of Health FORM 125S H_" BS & WARREN,^;W.`C.. PUBLISHERS ` 4.�\ f OWN OF BARNSTABLE LOCATI SEW GE #Py 'VILLAGE07�;7L ASSESSOR'S MAP & LOT. INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY /a�G LEACHING FACILITY:(type) /Uda q„l (size) 6 XT NO, OF BEDROOMS. 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ZI VARIANCE GRANTED: Yes r. No { i 1 . i sY +1 S ! 0W N ARI P L6 Cep LtOCATzoN L.®� �� C�a �.�car c � ,^iSEWAGE # 9-7'L4q( VILLAGE_ �OTc3 ? � ASSESSOR'S MAP LOT_— _ INSTAL ER S NAME & I.HONE NO. SEPTIC TANK CAPACITY— 160(D_�ca��® "_ '�k '(size) LEACHING FACILITYAtype) . k _ NO. OF BEDROOMS_ !S PRIVATE;WELT. OR UBLIC ATER BUILDER OR OWNER DATE PERMIT ISSUED: .'. . -7' DATE COtiPLIANCE ISSUED_ VARIANCE GRANTED: Yes i • i 4 1 CA R - a 0 -- Fmc THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH w!'J....................0F..... !3�7!'n.ST�x..4�.��....------------..................... Allp ira#ion for UiipngFal Works Tonotrnrtiun ramit Application is hereby made for a Permit to Construct (X) or Repair ) an Individual Sewage Disposal System at: Re-ow-m goo 2enA-%A- o 1> ,_ G — / ....Lo f L c.......... V a Sam' o T..7 ........... - ................... .. Local Addres or Lot No. ...fYl.�.. �?r N ....... i✓mi l U K.............. ..........................•-----......---••---................---^............................... Owner / ,address Wc /..�--a....�.P-.a •..w. S 1, 3// ............................1-•1 ............... .......... ................................... ............................. ...... ..... ................_.._.. Installer Address Type of Building Size Lot... -------Sq. feet Dwelling—No. of Bedrooms..................... Attic ( ) Garbage Grinder ( ) '4 Other—T e of BuildingNo. of persons............................ Showers — Cafeteria a' Other fixtures ............................... . . W Design Flow...........................-5_5------gallons per person per day. Total daily flow._._._._....._3.3... ....._.._._.___gallons. WSeptic Tank—Liquid capacityAd.�?P.gallons Length..iffG."Width..M',na"Diameter---------------- Depths`.7.:' x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....___.�_._______.. Diameter... Depth below inlet..._G`"G`"_.. Total leaching area..Z.G 7...sq. ft. Z Other Distribution box ( x) Dosing tank ( ) P aPercolation Test Results Performed ...... . Date..�YQ.....� ........... ,.a Test Pit No. 1.......?--__minutes per inch Depth of Test Pit---- .... Depth to ground water....l li Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x �" moo.,Z....... sdsfo,.. 0 Description of Soil...........24. _ ........... ......... s`-`-w--•---------------------•--•-------------------------......---..._.. x •----•----------------------------••---------------------------••-•------ -•-----••• - W Repairs or Alterations—Answer when-------------------------------------------------------------------------------------•--.._.._..-----•--•--...--- U Nature of Re P applicable............................................................................................... •-------•--------------------------•-------•----------------------------------------.......------------------------------------------------------------•--------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en 'sued by t board of health. Signed------ - 9' --•-----------------------------------------------•--------•---•-••...---- .......................... Date Application Approved By •--•-•--------•-- ------------------- .----•-------------------------••------ Date Application Disapproved for the following reasons----------------------------••--•----•------------...---•---------------------=-••-----••---••-••---------••... ...................................•----......_..-•....•----...---------------•-----•------....-------------•----•-•--...------------------•-----•--••-•----•••------.....-----•--'- -----••••..... Date PermitNo......13... ................... Issued....................................................... Date r � Fizz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r OF.......'✓ 1-7 - 7'r ...-.. ......................... ................................................... Appliratilan for Disposal Warks Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct ( x) or Repair ( ) an Individual Sewage Disposal System at: ev, ....::r Location-Addres1s. / or Lot No. ...................... -/1c ----- - - ............................. ---- ------- Owner g W / Installer Address _ Q Type of Building Size Lo ':-.!:_.� �}`_-____- - feet t_-- aDwelling—No. of Bedrooms.....................:%...................Expansion Attic ( ) Garbage Gr.-in_&T ( ) 04 Other—Type of Building ............................ No. of persons.....--..................... Showers ( ) — Cafeteria ( ) Q' Other fixtures •-------•--•......-----•---•-•-• - W Design Flow............................:5:.41 .......gallons per person per day. Total daily flow............... ....................gallons. WSeptic Tank—Liquid*capacityZ. L L.gallons Length.. ._..1=..` Width_-` :.! Diameter................ Depth_%. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.................... Diameter...r°.!�%...... .:: Depth below inlet..... ...... Total leaching area... .IL2...sq. ft. Z Other Distribution box ( r) Dosing tank ( ) Percolation Test Results Performed by C.%.-a--.,.../::......:: :......:::Y.... _.._....%..... Date..—:....=. %r 7 Test Pit No.,1.......t:.....minutes per inch Depth of Test Pit..../<f e =__ Depth to ground water..-..<.` Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ T._:y::........... ........................................ -•-------- ----•------...._......................................................... Description of Soil............zZ`--- ... .. .. .......................................................r: .l ....._./.. .. ......................................... A� w "t. ............................................... ................................................................................................I........................................_....._......... 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 TITTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n" sued b t board of health. Signed---- .. 7_ 0t G� ---------------•---•----------------- -.--------- ------ Application Approved By......... `" —� "'�►------•.............................•-- ....................Date.............. Date Application Disapproved for the following reasons:............................................................................................................. -•--------•-------------------------------•-----......---------------•------•----•--------•-•-------...----•---••----•-•-••------•-•---•-•••---••••-•-•-----------••-----••--••------•-•--••....._------ Date PermitNo........ ..2_:... 7e....................... Issued................................................•-•----- Date 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 04 ...............O F.. ....................... .................. Tntifirtttr of Tlamplianrr THIS TO CERTIFY, That the Individual Sewage Disposal System constructed (k or Repaired ( ) by------------- - - --- -----------------•-_-••. ...._••--...--- ....-------•---••--•---•-•--------------..........-----•-•------.._..-•---- - at.......4�`.---•• -----. .._ S ...Install-- ------------•.....................•--------........----------------- has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......t�..:n...Y.?4� ...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM L FU TION S�A...T. ITACTORY. Inspector.................................................................................... ..� 7DATE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QQ {{,� ;Z'�_ . OF....... L.. . ... No....�1.�...yl.� FEE.. :......... Mops 1 nrks Tunstrnrtilan "permit Permission is hereby granted....... ---qA. (..ray—if ---------------------------------------------•-------.....---.........-----..._.. to Construct 01?-Por Repair ( ) ar' Individun S wa e Disepe1salPst atNo...... f-..Z. ey - -•----•••.....--------- -• -- --------•-•.............................. Street as shown on the application for Disposal Works Construction Permit . _1' � D ..... ................. ....e_.... .----•--•----.tom..... <..._ j: ..s... _ DATE........ �1716� d and of ealth FORM I 5 HOBB & WARREN, INC., PUBLISHERS -SYSTEM PROFILE NOT TO SCALE j TOP FDN. FINISH GRADE -' �-�'� c� - - e;',; FINISH GRADE OVER FINISH GRADE- OVER EL . o.:: e DIST. BOX FINISH GRADE OVER o , " SEPTIC TANK ..:o-.•e LEACHING PIT � °.:o°• VARIES l o•b .O• �. '.�0.'i: :C.�'.4;.�.0:�..Ot�.,.e.p;4.•.0•�.,0.'.d.e,,P.:o••. B:d 'O,f°:ea.0p 12 TX ° ASHED PEA STONE PRECAST CONC. OR G'. p .d :e ter BRICK 6 MORTAR 3 I! OUTLET PIPE LEVEL TO 12" BELOW GRADE FOR 2 FT. MIN. to•-. .o• �. ® O •:p•o4;.:ofo�'i� :o;o:e:a°:.oe.:•- .:o Q 0•. :: 0'. b.: -a "0:::!. O'- ..' ...e 'O.'p..C.'•O•.•0.p.°: .� ..O" Q,e °• �.° °. . • o F6 6. C. I. OR PVC TEES \E= 4 BSMT. FLR. C) GALLON ;' DIS TRIBUTION BOX INSTALL ON LEVEL BASE 3/4 " TO 1-1/2" a 6 ' o ck PRECAST CONCRETE a PRECAST H— 0 I ..�: .4"..''..'�•..e:'°: .� REINFORCED •.: WASHED I .o e'."�.'•o .'0'•:0`••: 0. CRUSHED CONCRETE 't : ; :®:o-o..o:..e:p:::a`:o.p'•o.e a:.'Q::°:a'Q.4::.::.s': d. 'o' o:o:a: STONE s •°. °. o.°:•:a Q H— 0 REINF. D, SEPTIC TANK a':a::a °; ; �.o• INSTALL ON LEVEL BASE � NO EXCA VA TE TO EL EV V. - . - OR �'• : P:•_ _ _i . I LOWER TO REMOVE ALL IMPERVIOUS — MA TERIAL BENEA TH THE L EA CHING AREA REPL A CE EXCA VA TED MA TERIA L WI TH ` a CL EAN, CL A Y FREE SAND too EFFECTI VE DIAMETER i GENER NOTES LEACHING PIT 1. ALL EL EV 4 Tl ARE BASED ON A INSTALL ON LEVEL BASE 2. ALL PIOF' MUST BE CAST IRON OP' scr.. OBSER VA TION PIT 3. THE BOARD JS T BE NOTIFIED WHEN CONS TRL 3 ,'OMPL E TE PRIOR � �o r ,PRECAST CONCRETE TO BA CKFIL L Ih►,� PERCOL A TION RATE: �.�L�EA CHING PI T 4. ANY CHANGES Ill 'IIS PLAN MUST BE APPROVED IMIN./IN. BY THE BOARD C .SEAL TH AND CAPE 6 ISLANDS WITNESSED BY.' Lit z 7 Wit . SURVEYING CO., . IC. := 5. MATERIALS AND ..NSTALLA TION SHALL BE IN \ COMPL IANCE WI TH THE STA TE SA NI TARP "". BRD. OF HEALTH DESIGN DA TA �•2 CODE — TITLE V — AND LOCAL APPLICABLE DA TE.' ` \ RULES AND REGUL A TIONS `� NUMBER OF BEDROOMS •. 6 9` -��' 6. NORTH ARROW IS FROM RECORD PLANS AND T"Q p s ,t �, GA RBA GE DISPOSAL �"► • IS NOT TO BE USED FOR SOLAR PURPOSES _s�, �; � � � r:. 7. FLOOD HAZARD ZONE � DAILY FLOW . GA L . y ,RAC • J tYF V _ _ _ _ _a._ _._ ._ SEPTIC TANK REO 'D. GA L . 8. WA TER SUPPLY � • �'• �� � � 1000 GALLON ` -, GAL . PRECAST CONCRETE SEPTIC TANK PROVIDED TANK ' � GPD.SEPTIC b X c r✓ ....-...-.,..,,� S sq SIDEWAL L AREA �U _ S. F 1'aJr Z7 S. F. X G/S.F. _ f GPD 9 BOTTOM AREA = S. F. LEGEND _ 4 ' S. F. X . � G/S. F. "° GPD �. C)T_ —'_ i 41O ^ L EA CHING PRO VIDED = GPD s AV wo f r } aF_q_ rags ' \ o � PROPOSED ELEVA TION ` EXISTING CONTOUR --------- / ?� p 2 Q "' SINGL E FA MIL Y RESIDENCE OBSERVA TION PIT ❑ DISTRIBUTION BOX ` PROPOSED SEWAGE DISPOSAL S YS TEM JAMES -- --- L t A CHING PIT E PREPARED FOR 0 o SEPTIC TANK ►,►, .__at. "=' MC SHA NE CONSTRUCTION —N - ' 7 x lRP► RESERVE .. LOT 25 OAKWOOD STREET CO TUI T — BA RNS TA BL E — MASS . PIPE IN EL TION x `� ' Ct AR `S DA TE.' 'kSAP CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN 2 7_6T ,3� SCA L E: 1 "_ % SCALE A S NOTED P. 0. BOX 334 MAP SEC PCL L 0T HSE PL AN NO. TEA TICKET, MASS.