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HomeMy WebLinkAbout0023 TROUT BROOK ROAD - Health /3 Trout Brook Road. Cotuit - -- A= 022-077 - - - - - -- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Trout Brook Rd i4nM Property Address Petzold Owner's Name Cotuit MA 02635 6117/14 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: J� p � 31 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address .East Falmouth MA 02536 Citylrown State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this add d.§s and th the Q information reported below is true, accurate and complete as of the time-of the In pection. TFe insp%tion was performed based on my training and experience in the proper function and maintenance of on;Me sewage disposal systems. I am a DEP approved system inspector pursuant to ection 0340 a Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/17/14 Inspector g tur 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. 23 Trout Brook Road•03/08 Title 5 Official InspectionFubsurface Sewage isposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced 4 I ❑ obstruction is removed 23 Trout Brook Road•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: n/a C Further Evaluation is b Required Board q y the e oa d of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 23 Trout Brook Road•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 CityrFown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: Thi's 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. 3. Other: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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 SAS, cesspool or privy is below high ground water elevation. ❑l ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 23 Trout Brook Road•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. r ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El Elthe system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large 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. 23 Trout Brook Road-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: [] Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] 23 Trout Brook Road•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 23 Trout Brook Road•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 1 month ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known) and source of information: System is original per age of home but a 2nd leach pit was added in 1996. Depicted as"D" in this report Were sewage odors detected when arriving at the site? ❑ Yes ® No 23 Trout Brook Road•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Steel cover to grade at inlet If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >12" Distance from bottom of scum to bottom of outlet tee or baffle >12 How were dimensions determined? measured 23 Trout Brook Road•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date-of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a 23 Trout Brook Road-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17114 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level_: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 23 Trout Brook Road•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach Pit"C" is dry at this time, leach pit"D" is about 2/3 full, no indication of past backup 23 Trout Brook Road•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM , 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a I 23 Trout Brook Road•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments n " 23 Trout Brook Rd - - Property Address . �; ..Retzold Owner's Name IIM Cotuit MA 02635 Cityrrown state Zip Code Date of,Inspection D. System Information (cant.) ` - Sketch Of Sewage Disposal-System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.-i Locate where public water supply ente the building. s �0)y F 3L • 8 . .F 3 r -�� 37 �f i • Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Petzold Owner's Name Cotuit MA 02635 6/17/14 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1989 NGW 12' Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above 23 Trout Brook Road•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector. Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 City/Town State Zip Code 508.272.6433 Telephone 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the.Local Approving Authority 11/3/09 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. I � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 Citylrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure'criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist..Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than Y2 day flow El ® 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. Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy.is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 1.5.304. The system owner should contact the appropriate regional office of the Department. r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M rY 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): unk DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): e Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3109 Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: System pumped post inspection Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. El Other(describe): Approximate age of all components, date installed (f known)and source of information: 1989 per BOH file Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 23 Trout Brook Rd Property Address Cabral-Petzold Owners Name Cotuit MA 02635 11/3/09 CitylTown State Zip Code Date of inspection D. System Information. (cont.) Building Sewer(locate on site plan): Depth below grade: 1, feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >10' Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic.Tank(locate on site plan): Depth below grade: 6„feet' Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) Riser to grade at inlet w/steel ring and cover If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000g Dimensions: -- Sludge depth 0 Distance from top of sludge to bottom of outlet tee or baffle n/a Scum thickness 0 Distance.from top of scum to top of outlet tee or baffle n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 Cityrrown state Zip Code, Date•of tnspedion D. System Information (cunt.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current.pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipe Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box is 18" below grade it is of H-10 construction and under a paved driveway. No adverse conditions at this time Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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' it Type: ® leaching pits. number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit"C" is the original Pit it is 1'6" below grade, dry at this time, and has a riser to 6"of grade. Pit"D" was installed in 1996 and is 2/3 full at this time. It was video inspected due to it being under the paved driveway. It is approximately 76"below grade. The D-Box serves both Pits Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,• f 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3109 Cityrrown State Zip Code Date of inspection D. System Information. (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells witliin 100 feet. Locate where public water supply,enter the building. l a�- cYo l � � aG �33 V Sots Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�' 23 Trout Brook Rd Property Address Cabral-Petzold Owner's Name Cotuit MA 02635 11/3/09 City/rown State Zip Code Date of Inspection D. System. Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: NGW 12' per BOH file Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above 508-420-57" 01:53:59a.m. 11-22-2009 1/1 Capewide Enterprises,LLC Invoice J.P.Macomber&Son P.O. Box 763 Date. Invoice No. Centerville,MA 02632 11/11/2009 9568 Name Joanna Cabtul-Petzold 21 Trout Brook Rd Coluil,MA 02635 Job No. Terms 15246 Due on nxcipt Quantity - Description Rate Amount I Septic pumping,1000 gallon tank 210.00 210,00 Thank you for your business. Total S210.00 A fmancr charge of 1.5%per month.will be charged to any outstanding balances that are not Fa mentslCredlts paid in full according thepayment terms above. $-210.00 Balance Due so.00 Phone# Fax# E-mail Web Site 1-508-4284029 I-508.428-3929 Janine©CapewideEnterprises con wivw.CapewideEnterprises.com TOWN OF BARNSTAB E ..:..,.; a 7 Z 47 %[err �) � LUCA70` SEWAGE # VII 'r.. , ASSESSOR'S MAP &LOT - ,LA;C� INSTALLER'S NAME&PHONE NO. 2.eo SEPTIC TANK CAPACITY LEACHING FACELI TY: (type) ��� (size) , o - NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: —COMPLIANCE DATE: 24 e .G 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 CID No. /6 76, Fee y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for )Di5po5al *p5tem Con.5truction Perron Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I O�w,nner's Name,Address and Tel.No. .3 %teaU i 8;Z-e0J4 , Ce,7V/T TiH JO�V�S Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 'P. o. fir 4J ' v M4 Type of Building: Dwelling No.of Bedrooms —3 Lot Size.3 .Xywsq.ft. Garbage Grinder(M� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow gallons per day. Calculated daily flow. gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �nl&se Nature of Repairs or Alterations(Answer when applicable) OqZD /o!)tb el z-. k —I JF? --jr /6 x4 ' -' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ Code and not to place the system in operation until a Ce ifi- cate of Compliance has been is oard• t�. Signed Date Application Approved by Date Application Disapproved for the ollowin reasons Permit No. to Date Issued No. �[? 7 Fee Ves THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTHDIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPYication for Miopo!6at *pgtem Con!5tructiou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No.. a,3 7-A&OuT 6;iZvOX , C'urt,i T //,,�. -ter.jo_tb=s • . Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J Type of Building: , Dwelling No.of Bedrooms ,✓ Lot Size;?$T U sq.ft. Garbage Grinder(n-?9) Other Type of Building: No..of PeiWns-. Showers( ) .Cafeteria Other Fixtures A Design Flow gallons per day. Calculated daily flow � ,�S-Zb gallons. p Plan Date Number of sheets Revision Date i Title Size of Septic Tank Type of S.A.S. Description of Soil i r Nature of Repairs or Alterations(Answer when applicable) Z L' Date last inspected: - { Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on`site sewage disposal system in accordance with the provisions of Title 5 of the,Environmental Code and not to place A system in operation until a Certifi- cate of Compliance has been issued y ]%i-s':Board f- Signe f'~ Date % L3 Application Approved by 1 Date r Application Disapproved for the ollowi reasons . I Permit No. Date Issued, —————— —— - ——————— -—� = ————— ———— THE COMMONWEALTH OF,MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(�)Repaired (Upgraded ( ) Abandoned( )by '"1¢ (I at Q~ �-. _ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector --------------------- ---- --------------- No....... 1A74 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoml *p6tem Cow5truction'Vermit Permission is hereby granted to Construct( )Repair(\e,)Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction,must be completed within three years of the date of this permit. Date: Approved by V CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CUNS'I"KUC'I"ION PEI+�11"f (WITHOUT ]DESIGNED PLANSI hereby certify that the application for disposal works construction permit signed by me dated �-Z coming the property located at ,�� i �v7 ti .eo®� meets all of the following criteria: There are no wetlands within 300 feet or the proposed septic system There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase in now and/or change in use proposed There are no variances requested or needed. DATE: I z .23 C SldNEUQ� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTA13LE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer pose§ses a certified plot plan, this plan should be submitted).. .` � '--.) �(" '\ p• r� `T I TOWN OF BARNSTABL,E L0�iv_.__ 3 `i c� �2�r1�� SEWAGE # 5�F-&7 VILLAGE G.C-U-i7- ASSESSOR'S .MAP LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(tyPe) �7�� �'�'IriT (size) ,31 t 7� NO. OF BEDROOMS PRIVATE WELL OR BLIC WAT R ' BUILDER OR OWNER �t� `® DATE PERMIT.ISSUED: -�-�— ' DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes Now f ,� •-�. t I � � 25 -t /� �„ d. � -� � �I �i fr. d �z� s � R z � �� 'C � �. jC �u.S v v \ e ✓. i ' Y i�� r, iat THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH T ..W.N.............OF.... .A RN��' 'f1B1, ,,.......--------------------------- ApplirFa#ion for Disposal Works Tonstrurtion ranfit Application ' hereby ma a for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: cruse o� -64 _ _ V......... COLW� 1 ,� Location- d r ss f - •- 6.1 --...or Lot o. ,ry ,� Ow er 4 es a ( - •------------ --------- Installer Address Type of Building Size Lot. 8,_Q.1.Q----Sq. feet U Dwelling—No. of Bedrooms...__._.__._____________________________Expansion Attic ( ) Garbage Grinder ("Q Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................ . W Design Flow.........551. ..........................gallons per person per day. Total daily<<flow____-_3.30........................ �� lon s WSeptic Tank—Liquid capacity=.Q.gallons Length.a_"_�Q..._ Width5."4_-.-_. Diameter................ Depth.5."6.... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......1..--------- Diameter......17........ Depth below inlet... _A 67... Total leaching area.Z.5.1......sq. ft. z Other Distribution box ( ) Dosing tank ( ) , aPercolation Test Results Performed by.7 _ .N...__ L.QB._1 ... Date........................................ a Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water..IJl��f._. Test Pit No. 2................minutes per inch Depth o Test Pit._�...._______�___ Depth to ground water_.,�,IO o T P-_1........_.Q__-_1�.-5_-...._.'I"VI-N33-, LIS0-r--1_�'r..._-.1 Mob SA��.. --------------------------- Description of Soil'.*Pn?....--••Q"�'Jr--.. •- -'--I - �0.- -ME.b-.---5 )....................... W --------------------------------------------------------------------------------------•----•-•-------------------.._...--------...-----------------•-----------------------------------•---•----•-•---- 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 hjDn issued by e b and of 1 th. SigneG�!!!_At----- ----------•- Da e Application Approved By..... -`c`c-�-`} =-•............................ 1- 4...---- < Date Application Disapproved for the following reasons:-----•-------------------------------------------------•---------------------------------------------.....------ I ...............................---••--•----------------.._....•---•---•-•-----•-----_...-----_.....-----•--------------••---••-•-•-•---•--•----•-•••---•-••••--•--•-•-•--••-----------•----•......----- t c� Date PermitNo. .__ :.7.1.. ............................ Issued....................................................... Date No.. .:..T.. .7 o FE13.....7..s....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1....®. t.. ..............OF..... - 6...5TL . Applira#ion for Disposal Works Toustrurttnn Frrmit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: -' Location 3..#1 . d rt -L . :t L or . e , reOw � a,.06 ... .... { '�-... .............................. Installer Address d Type of Building Size Lot_a`ln ..()A_�2....Sq. feet U Dwelling—No. of Bedrooms.............. ..............Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures . ---------------------------------------------.---•-.....-•-•-----• ---•--------•-----• w Design Flow......... .............. gallons per person der day. Total daily flow........ ........................gallons WSeptic Tank—Liquid capacitylOOO.gallons Length_8: .G._.. Width ..4'_.__.. Diameter................ Depth.__.5.-.. x Disposal Trench—No..................... Width..................... Total Length..................:. Total leaching area....................sq. ft. Seepage Pit No.......L......... Diameter'.-A.Z........ Depth below in1et.....(0 .(... Total leaching area.Z 1......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by_lb_� t 4._.. :_.s.. Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_.J0A_-.5.t__. 44 Test Pit No. 2................minutes per inch .De th of Test Pit.................... Depth to ground water..KQC_d�_ . rx T P l ._ ! '-- T �. S, _r�S-. .a_V........................... 0 Description of Soil--i.p--2-- -- Z.-.. ------ � ). t �a�. � .a �...... ................. x w 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 TITLL 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 ------....-••--••-•-•--• a .. Application Approved By-•--• ................... --•------------------------------------- Date Application Disapproved for the following reasons-----------------------•-----------------------•------------------------------------...----................... ------------------------------------•---•-..... .......................-----•-----•----------•-------....------•••.........•------------•-•------•--•--•--------------•-•--------•---------••-----••----- 51/�( / / / Date PermitNo.........................•---•--•----•-••-------••---•-. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... al.,vt....,........OF.............. ........................................................... (9rdifirate of ToutpliFanrr THIS.IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( r Repaired ( ) 1 ---•............... ------------------- ----------------- •----- ------ 1-0 3 /� at-----•--------•-------•--- -------------•-•-----•---•-•...•-----•---•---•--....---••-------•---- -------------------------------------------------•----------------------------••-•---•------•- has been installed in accordance with the provisions of TITI o_f T t e Sanitary Code as described in the application for Disposal Works Construction Permit No..__._.....� ��. dated............................................... THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ .............................. Inspector---------..... -- -------.-..-._--.--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 OF..................................................................................... 7 No.... _ _...._........ FEE........................ Disposal Works Tnntritrtion rrntit Permission is hereby grant d - to Construck ( 1} o>; %p ' ) a�ndivil S �a Disposal Systemat No.--- -- ---- ..L.-------- . - Street as shown on the application for Disposal Works Construction Permit No_________ Dated------------------------------------------ ...................................... -i ---- DATE................................................................................ oard of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS d o d �' Z � mb (� Q CP mya, z 'at m o o 0-47 1 1 IS w Zo- D rr- �. IV i ,ro . j t t t t � t t t ' t ' � �t 't ar T �i 1 »... »r-,,,::s°-' ...t v rt�l �•,'�� .Y°w�:�r. :v,.x<.�-�,'',,�2�.y�k-��.r� .;,.,;r .r,+, '�,c;�;. ,., �M�\ � �� �,�. ;� ,. ,,.. S�fr.W .--.� __ , o ,. �, a� `` � � `� � � � `4 � 1 N !4 �� - _ �.: �,. 1e[,,._ ._ _ .. `* r it i ZONE.' RF � SOIL TEST PIT DATA: sETBACKs• p_ 69wS P- 09� 5 FRONT 30 ' SIDE 15' T.P. -1 T.P. -2 REAR 15' GRAD. ELEV. 99. 40 GRND. ELEV. 99. 50 G. W. ELEV. NONE G. W. ELEV. /TONE of ROGERT/L/S r�� sv� DESIGN CRITERIA: PAUL N 1.5 MICHN EWICZ No.30420 •S EL DESIGN FL Ok p CIVIC 3 BEDROOM DWELLI EDt uNG @ 110 GAL/DA Y PER BEDROOM 5 A�D M r^ EQUALS 3 30 GALS PER DAY. 8 /9 88 � SAt�D !VO G�lR�iAGE• G1Z.INDEtZ SEPTIC TANK REQUIRED., -DA TE PROFESSIONAL ENGINEER Cl VIL INDICA TES PERC. 33OGPD X 15OX =455 GAL . TEST N of ,;,�r^ SEPTIC TANK PROVIDED.' _ l000 GAL . PAUL yG a` 6LF�9 �� SIZE OF LEACHING FA OIL I TY REQUIRED.' RY« y ti INDICA TES � No. 32448 oe cg qE� Ea�o OBSERVED DESIGN PERC. RA TE =<Z. MINUTES/INCH s�oN fST ND S� GROUNDWA TER 3 3o GAL L ONS PER DA Y SIZE OF LEACHING FACILITY PROVIDED., A TE PR FE S�ONAL LAND EYOR 4-"PIT WITH 3' STONE DA TE, DA TE, SIDEWAL L 13 0 S 1' X 2.5' 3 4 C-rP v JUNE 1, 1988 DUNE 1, 1988 TEST BY* TEST BY.• BOTTOM 113 S� x �. O = 11 3 G p y JOHN JAC09 R. S. 458 GPb �23g• A�� 9 JOHN JACOBI, R. S. TOTALS 2 51 S.F. Py • h. \�� WITNESSED BY.• WITNESSED L :' 1 _ 91 3 PERC. RATE BREAKOUT CAL CUL A TIONS.' .A < 2 MIN/IN SLOPE ¢' X 150 a_ '.0� 40. 00 ' WIDE N �, Q • (a o Ss. �� . .,. ® / — TOP OF r-aU EL- 10k.00 B0 100-00 OF c.1o0• 0 Dr ELE SUMEp) ' . . . . Et_ 97^00 EL 9 6�.40(AS z q�. J- EMEN / ACCESS COVERS MUST BE WI THIN 12" OF FINISH GRADE. z ,• ✓ � � 2 h EL96-ZZ t� L I NE B•M• # YpIN. 2" OF 1/8"-1/2" DIA. .o� SED 3�R IpE ON ,N gg. BS �/' 3� - �r.�r. _ Q EL')ro.8 �r - 'Y EL.96.F WASHED STONE t1 - ✓t:.LL 1 tJG n-1 t, ,cH p , Ell r ; ,, A T. 1 o.� p �' , - I _ o 0 MIN. I , DEP H \ W -�-- 3/4'"-1 19 DIA. 0 P t . WASHED STONE l A G .���00 GAL . • °th w SEPTIC M TANK W LOT 34 co ir EL 1�sL4-0 oM _ WIRES - -- _ INVERT EL /A TIONS.' INVERT AT BUILDING INVERT IN A T SEPTIC TANK • 81 REVISIONS.' INVERT OUT A T SEPTIC TANK 5 Co NO. DA TE REVISION INVERT IN AT DIST. BOX 9 G •4 O INVERT OUT A T DIST. BOX 5 G 2 3 INVERT IN.A T LEACH PIT BOTTOM OF LEACH PIT 2. 40 z GENERAL NOTES. 1. THIS PLAN Is FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE DISPOSAL FLAN SHOWING THE DESIGN OF A PROPOSED - FACILITY ONL Y. 2. AL L CONSTRUCTION METHODS AND MA TERIAL S SUBSURFACE SEPTIC DISPOSAL SYSTEM FOR THE __.._ SEPTIC SYSTEM SHALL CONFORM TO MASS. D. E. 0. E. TITLE 5 LOT 34 AND L OCAL BOARD OF HEAL TH REGULA TIONS. Q 3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO TROUTBROOK ROAD, BARNS TABL E, MA . VEHICL E L OADING (I. E. UNDER DRI VEWA YS, ETC.) 00 SHALL BE DESIGNED TO WITHSTAND H-20 LOADING. PREPARED FOR R' 4. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR o APPROVED EouaL . HOL IDA Y HOMES 5. BEFORE STARTING CONSTRUCTION. CALL DIG SAFE SCALE, 1 " = 30 ' AUGUST 18, 1988 1-800-322-4844 FOR LOCATION OF UNDERGROUND UTIL I TIES. EA GL E SURVEYING AND ENGINEERING, INC. 6. DATUM IS ASSUMED. 441 ROUTE 130 1 INCH = 30 FEET 30 0 30 60 so 120 SANDWICH, MA . 02563 (617) 888-0559 PROJECT NUMBER 88-050