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HomeMy WebLinkAbout0034 TROUT BROOK ROAD - Health L rout Brook RoadIC'ntl 022 070 — -- - -—- - - IV L Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal',System Form -Not for Voluntary Assessments 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is CO'TUIT MA 02635 4/3/07 required for every P9 a e. City/Town State Zip Code Date of Inspection n'this form. Ins ection forms may not be altered in an Inspection results must be submitted o p y Y / way. Important: General Information When filling out A. G � �Z o `7 D forms on the computer,use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not ' Name of Inspector i use the return - key. COMPASS REALTY DEV CORP ( _ Company Name I _73 =, r� P.O. BOX 2384J Company Address W'_rItL xX MASHPEE MA >i 02649 `'- Cityfrown State "�`j Zip Code 508-221-5003 II Telephone Number License Number CD 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: g-_'Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/3/07 Inspector's Sign atur6- Date The system in'spector'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. 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 TROUTBROOK RD r Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 - required for every page. City/Town State Zip Code Date of Inspection r B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Syste 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: B) System S Conditional) Passes: Y ❑ 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 1 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 281 OLD MEETINGHOUSE•08/06 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 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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: C) 'Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ 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. 281 OLD MEETINGHOUSE.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 required for State Zip Code Date of Inspection every page. City/Town 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 ❑ 9( Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded . or clogged SAS or cesspool ❑ E? Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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. El tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 261 OLD MEETINGHOUSE•08106 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 TROUTBROOK RD — Property Address SANDRA GAY Owner Owner's.Name information is COTUIT MA 02635 4/3/07 required for State Zip Code Date of Inspection every page. City/Town 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 P privy❑ An portion of a cesspool or riv 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 feca l 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 15.304. The system owner should contact,the appropriate regional office of the Department. 281OLD MEETINGHOUSE•08/06 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 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 required for State Zip Code Date of Inspection every page. City/Town C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes o ❑ 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? i 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)] I 281OLD MEETINGHOUSE•08/06 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 34 TROUTBROOK RD r Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 _ required for State Zip Code Date of Inspection City/Town a e. Y every page. !Town D. System Information Residential Flow Conditions: Number of bedrooms (design): 75 Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes eNo Is laundry on.a separate sewage system? [if yes separate inspection required) ❑ .Yes LK' No Laundry system inspected? ❑ Yes 2-**No Seasonal use? ❑ Yes EK"No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes 2 No Last date of occupancy: 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): 281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 I / Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA , 02635 4/3/07 required for every page. City/Town State Zip Code Date of Inspection D. System.Information (cost.) General Information Pumping Records: Source of information: —f— Was system pumped as part of the inspection? ❑ Yes 2/"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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: . Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 281 OLD MEETINGHOUSE-08/06 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 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is COTUIT' MA 02635 4/3/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): �If Depth below grade: feet Material of construction ❑ cast iron 240 PVC ❑ other(explain): Distance from private water supply well or suction line: feet���i� � Comments (on condition of joints, venting, evidence of leakage, etc.): �U Septic Tank (locate on site plan): Depth below grade: feet Material of construction: 2-C"O'ncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- o Dimensions: > � � Sludge depth: �I Distance from top of sludge to bottom of outlet tee or baffle r Scum thickness I v l Distance from top of scum to top of outlet tee or baffle — I � Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 TROUTBROOK RD ` Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 ' required for every page. City/Town 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.): )QA' 1W �6 i lei tA� Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass [],polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 281OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is COTUIT MA 02635 4/3/07 _ required for every page. City/Town 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.): *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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 TROUTBROOK RD Property Address SANDRA GAY Owner Owner's Name information is required for COTUIT MA 02635 4/3/07 every page. City/Town 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: - Type: ❑ leaching pits number: 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.): T 4 � Q6` - N ' �' Z ..�C10 pis'— NC`c ti o4,0 P—) t�1? ��� P G' .� C""✓ ¢ '�' I�"4'1vV—e 2810LD MEETINGHOUSE•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 TROUTBROOK RD — Property Address SANDRA GAY — Owner Owner's Name information is COTUIT MA 02635 4/3/07 required for every page. 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.): 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 34 TROUTBROOK RD — Property Address SANDRA GAY Owner Owner's Name information is required for COTU'IT MA 02635 4/3/07 every page. City/Town 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 within 100 feet. Locate where public water supply enters the building. 4 1 a •'f A3- 3-7 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r ' 1 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 34 TROUTBROOK RD — Property Address SANDRA GAY — Owner Owner's Name information is required for COTUIIT MA 02635 . 4/3/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope 9//S,—urface water Check cellar ❑ Shallow wells =t- Estimated depth to ground water: 36 --- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accesse`d1USGS database-explain: / q You must describe how you established the high ground water elevation: 281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 1 Al 28' 27'-2" 2 CAR N s GARAGE N UP DN PARTIAL FIRST FLOOR PLAN TOWN OFBARNSTABLE LOCATIOR,/A6SZ*.�y� r 7- 9UFE�P� ��_ SEWAGE # ®�_"' it V7UL%kGE ��`A4�i� ST�,KbE E/CV`-+1�ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.. 6UIL 1-/AAI PYIUar-k- '7"21—2V16 SEPTIC TANK CAPACITY D © lx LEACHING FACILITY: (type) AT.1-5R,3 (size)'/Q O.OF BEDROOMS �—­B`UILDER OR OWNER CA V PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well arid 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 1 TOWN OF BARNSTABLE LOCATIONJHT-Ooi QC-oo ICeD 1 /)SEWAGE # VILLAG �` ry 11� _ ASSESSOR'S MAP LOT JAa- 6�C� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY AACHING FACILITY:(type) p , (size) f oo o NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER S f)0J,0 e P�T DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No w G c � o l ro "V j No. ``' FEE �- �. 0. + COMMONWEALT14 ®F MASSACHUS ETTS Board of Health, &W[ , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT � Application for a Permit to Construct(X/RepairO Upgrade( ) Abandon( - UYComplete System ❑Individual Components Location I Owner's Name41 ) V Map/Parcel# —1 p Address Lot# 1A Telephone# Installer's Name ` signer's Name A Address Address Telephone# Telephone# W Type of Building L7' Lot Size u sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 3Ao gpd Calculated design flow Design flow provided gPd Plan: D to 3 Number of sheets / Revision Dat WW14 I- t ^ Title �X Description of Soil(! � ,_�1 civl Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and The undersigned agrees t g p y further agrees to not o place the - em m operation until a Certificate of Compliance been is ed by the Board of Health. Signed Date nrT'�,tieres" 3 /ga 1-77 Town of Barnstable F INE l. ! O Regulatory lato Services Thomas F. Ge ter,Director M Public Health Division Thomas McKean,Director J 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: HAea4 Z`Li Zcp Designer: As5or_i t is s Installer: w WA.-c "'bo C"sC. Address: 1 f A Woecc s cQ C ou ler Address: 11A. 0 Z 5 4-C On Q,LU Ate i,3 Ge 2 was issued a permit to install a (date) (installer) septic system at ' 3 4- r T- eo-r3Qooz F_e A D based on a design drawn by (address) C= P_CiaA A5soc.AreS dated MAzcA 4.) 2w5' (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. t �!OF ° R1CHA Olt (Installer's 1 tore) FROM' ISTEA�® a L (Designer's Signature} (Affix D'dsi nit:s tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED.UNTIL BOTIR THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form � F -� f � t�� .# a 's.1` i+y � `t, a Yam, ^+�R No+!� �a .� FEE Board of Health, MA. - APPLICATION FOP, DISPOSAL. SYSTEM CONSTRUCTION PERMIT ° Application for a Permit to Construct(VI'RepairO Upgrade( ) Abandon( 8'6omplete System ❑Individual Components Location 3 R��� I�(�U1� Owner's Name Map/Parcel# a. '1 Q Address Lot# i A Telephone# Installer's Name WIWAII o S (Qa� esigner's Name 1 e V,- S wl l ees Address r r Address MA W b st eK f Telephone# Telephone# 3 ' 1 255Z��Type of Building ���(,�f� rd'�k �-�� �,(,1.���,�T r Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) -33 0 gpd Calculated design flow Design flow provided gpd Plan: /Date .3" -O S� Number of sheets / Revision Date e Title ,�11 & [<�Y)_W (HA Description of Soil(s) �i Q_P_ bL. Soil Evaluator Form No. Name of Soil Evaluator DDate of Evaluation 3 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree s ttoo not.t -place the system in opei on.until a Certificate of Compliance as been iis5sued by the Board of Health. Signed /r%�✓/�/2 /� � Date t^-%i :�l.r.�1.4 �✓ t. .. .r /y//� ST v i ' , r No.1% I � ' FEELA COMMONWEALTH OF MASSACHUSETTS Board of Health, �"� MA. CERTIFICATE OF COMPLIANCE Description of Work: "dividual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired,Upgraded ( ),Abandoned ( ) by:at '3 9- Jhuf k­ C r dki i) has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.�5 a,01 �., dated q/D!� . Approved Design Flow 3 -30 (gpd) Installer i Designer: <;C Inspector: L Date: 3 _ - J The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. ! .0 J� / FEE / L/ Board of Health, tS+?MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissio is her by granPC oConstrue Re�air( ) Upgrade( ) Abandon( ) an individual sewage disposal system at k ti Jr� i / as described in the application for Disposal System Construction Permit No dated, Provided: Construction shall be completed^W//�'thi /three years of the date o this permit. All lo6l co•itions must/be met Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Dat —p ( l ) Board of Health �� TOWN OF BARNSTABLE� �j �� SEWAGE #C LOCATION/�/da4 &LOT O---� ��r-► ��" ,. ASSESSOR'S MAP VI.LAGE 1Y) j3r' n%— INSTALLFR'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 C,a (size) �-- ACHING FACILITY: (type) LE --�' NO.OF BEDROOMS �2 BUILDER OR OWNER COMPLIANCE DATE: pERMITDATE: � COMPL � Separation Distance Between the; Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 1 Well acid Leaching Facility (If any Wells exist Feet private Water Supply on site or within 200 feet of leaching facili tyw Edge of Wetland and Leaching Facility (If any etlands exist Feet within'300 feet of leaching facility) Furnished by �7 l 56- FEE 1 _ �O�ATION SEWAGE PERMIT NO.. Zo7- Zd h1m L r, HFS-T VILLAGE � INSTA LLER'S. NAME & ADDRESS B UILDE R OR OWNER x- cc) KID, DATE PERMIT ISSUED R '~-,DjA'TE ,., COMPLIANCE ISSUED V �Q Nd THE COMMONWEALTH OFMASSACHUSETTS BOAR? OF HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Sewage .Zosal System at: Sea—Lake Corp�. Location-Address Route 6A & Tuppe�r WOP.O.B. 264,Sandwich,Ma. op Route 6A, East SaiWi�h Installer Address 25,500 Other Distribution box Dosing tank 4 4�41 #7;p" Percolation Test Results Performed by-------Alan Jones The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co — The unders* ed f urth rees ot to place the system in operation until a Certificate of Compliance has been s d by e boar of he Date --'.------._—.—_.......................................................... � Date Permit Issued......................Date .................................. ....----_---_'-_'-___--_—_----_--_--'' -------- No........ ---•- Fps.:.. _ .�.......,. THE COMMONWEALTH OF MASSACHUSETTS c, BOARD OF HEALTH Town_.. OF ........IIaxnstahle......:......................................... r - . ppliratiun -fur KliiipoiiatlVorko Tuntrurtiun Pprutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an .Individual Sewage Disposal System at: 'OM" in cowit �w,,,�� ��� ��yy- Location-Address' �p� your Lot Noa j� r� A c �}�^}� p�., -i7G61=-J.K9JSe--`_!^_!r'L.r—-•-•------------------ ......... ---'' 3-- -- "r .-_ h�IF eYJt 11.__G6�t�i7 i�l 0h, a. + O,wner M'; Address lt; r, 6At S8rJ3.C1_.....----_••_• ••-_•-_.. Installer Address Q Type of Building Size Lot....25.E_500----------Sq. feet: U Dwelling—No. of Bedrooms------------tM_________________________Expansion Attic (X Garbage Grinder Other—Type of Buildin _ No. of persons............................ Showers Cafeteria Q Other fixtures ....---...Qje. ... ....... ............. --------------- -------------------------------------------------------- ---'-;- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter........-------- Depth................ x Disposal Trench'=No_------------_------- Width-------------------- Total Length-------------------- Total leaching.area--------------------sq. ft. SeepagpRit No....................... Diameter-------------------- Depth below .inlet._... al lea ii g,area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) d/ ' �� �Y 7/ ! 1 W Percolation Test.Results Performed by......AIMZ ........................................... Date----------------------------______--.--- Test Pit;No. 1----------------minutes per inch :Depth of `Pest Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2_................minutes per inch Depth of Test Pit.................... Depth to ground, water...........___-______-- 9 •--._.... ----- �- --- -------- ------ -•----, ---- ---- D ` -- •--•-- -------- -G Description of Sail / ----- - ---------- j---- ----- -- -- �U UW --- -------------- ----------------------------------------------------------------- --- ------------- -------------------------- Nature of Repairs of Alterations—Answer when applicable______________ ____-------------------------------------------------------------------------- ••----•-•----------------•---------- -- -- ---••---------------------------------------------•••-------------••-••------••- --•-- --- ------------------------ Agreement The undersigned agrees to install the aforedescribed "Individual Sewage'Dtspo'sah System iti accordance with the provisions of"Article XI of the State Sanitary Code-/The undersig`n/ed fukher,agrees not to place the system'in `" ! operation until a Certificate of Compliance has been/issued by e.board`of healtli. A - i / .i igned -------------------• -------------------------------- Application'-� ate A roved B PP Y 1 Date Application Disapproved for the following reasons: •------•---------------•-------•-•-••----••-------•-•-------------•-•-•-•------- ,< tt�....... ..........•--------•--•--....__.__...------Date , ^�. } e4� < Permit No............ .................................... Issued......................-.............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ` stir ........O F.. uprrtifiratr of f�umViiana T IS ER T he I tdividual Sewage Di osal 5istem con ucted ( 4�_Or Repaired ( ... ) by `..- - - Install i has been installed in accordance with the,.,provisions of Ar ' e XI of The State Sanitary".Code as described in the application for Disposal Works Construction Permit No,_ -----ll_:*r............... ................. THE ISSUANCE OF THIS CEIMF;C'kTE SHALL. NOT BE CONSTRUE© AS,A GUkR TEE,TWAT.THE SYSTEM-WILL FUJSICTION SATISFACTORY. F DAT16 /// -------•_ `Inspector------- -•----- ---•----- - ---------•--....._-••------- s- THE COMMONWEALTH OF MASSACHUSETTS BOARD. O HEALT 7 �J d� . .... . ... OF......... . ... . 4 7 J _ 0.--•--.1..7-- �..:-. -.- FEE...�f�! . ... -. } Pe/, ,, n is ereby granted". ,__._-_ _: to Co+ or R' r ( ') Indivi al e age o a] stem at No. !Jw/ sire t r as_shown ori'the application for Disposal Works Construction P t No, f: Dated----,�j�=-1"'7 Board of Health - -- FORM 1255 HOBBS & WARREN. INC.. PUBLISH ERS... _ 1 . y !! 1 i r f - d Al E t I rxrSrf�s _ nab!" N i -rz � i 4 r.,..14 r,_,�a�,..�-�•--=�,�a%^x'.--= .-,�_�.c�.��-_. F rbr,, .� ��.::= vs M.�:�-�z�F�-��.=.�aa�-s re�:-��.- c- _. ��a ____-... ...:._.-�G+ G -- _ a•�•e' -�,.u-�' — .rs- �i:c -_-•. ma's v i J f t Qe t e,o{ O_C. J�% Fc_)� : J -E A, L Al Y� �'�:..�.��!''. �� '�-'#�� '" roe,r►� 4,.� C o r 7 4-0 r or 0P ' ' 1 Al 28' 25'-2" p N DN 5'.-6" R B N r 0 - MASTER a O BATH CLOSET STORAGE-EAVE SPACE I PARTIAL SECOND FLOOR PLAN i SYSTE/Ll PROF/LE NOT TO SCALE NOTE.•DO NOTRUNHEA 1/YEOU/PMEN7'OILER SYSTEM F/N/SHGR4DE 643' _ cINIS11GRQDE GENERAL NOTES :Z 644 OVER TANK FINISHGR405 OVER TRENCHES 1. ALL SYSTEM COMPONENTS SHALL REINSTALLED/N . ACCORDANCEWTNT/TLE5OFTHESTATESAN/TARYCODE ��- SCH40PtIc=S 1 DATEDMARCH>995ANDANYLOCAL RULESAPPL/CABLE i` 62.46' r 6189' 2. ANYCHA/1/GE/N711/SPL4NMUSTBEAPPROYEO ' : i sz2s ti 6f.50, BY7HEBOARD OFMEAL THAND FERRE/R4ASSOC.. ;_` `, ;- 6201• •" 3. WHENCONSTRUCT/ONISCOMPLETED, PRIORTOBACI<F/LL/NG 6f.72:... BSMTFLR `;"' f500 GAL �j EQUALIZERS NOTIFYFERRE/RAASSOC/ATESFOR/NSPECTION 2 s• REINFORCED ? 4. FND. ELE1!MUSTBECME00,0 WMENCOMPLETED 59.5' `4 CONCRETE As D/ST. BOX r? i' -f0 BAFFLE TOBE/NSTALLEDONA 5. 771ESEELEI!MUSTNOTBECHANGE01477HOUTt�• f" ' '_ LEYE THEBOARD OFMEW THAPPRO0,4Z 1 _.�•.�y'z . �s L STABLEBASE ... - 6. BOARD OFHEAL THINSPECT/ONREOD blNENE-VCAIIATED SEPTIC 74NI 59f�j TRENCH LENGTH I 36'-ol TO BE/NSTALLED ONA 1 5'M/N.HEIGHT I LEVEZ STABLEBASE ABOYEAD✓USTED GROUND WA7FR N/F F.L. FRAZIER NOTES.- SOIL AND PERCOLAT/ONDATA N77022'50"E >. ELEW RONSBASED ONMS.L. 150.54 2. FLOOD.zONE C'(NOr1HAZARD) PERC. RATE <5 M/NlN LEGEND 3. TOWN WATER DNS/TE 12' TAIKENBY RICHARD FERREIRA 36. W/TNESSEDBY N/A EX/sr. GROUNDELEv 3 EXISTING DATE MARCH, 2005 F/N/SHGROUNDELEI� 3' 3'o LEACHPIT TESTP/TELE1% 943 58 3 �' �� 47.5' D-BOX ��� A Z-A PLAN 6246' P/PE/NI�ERTELEI� a, 5 o• TESTPITL OC4 RON F SCALE.' "= 20' 4, A - SANDYLOAM 10YR312 r I L 21.1. 1000 GAL 9�9 a B O O SEPTIC TANK Q SEPTIC TANK SANDYLOAM f0YR5� ❑ D/STR/BUT/ONBOX DECK 36• C1 ® SAND 2.5Y" 4'SCH40Pl1C ? I TEST r �v PIT MEDIUM-COARSE SAND ti LOT COVERAGE COBBLES,20 ?'a/uwL PROPERTYL/NES a ti7,111 (LOT 1A -25,500t S.F-) - SETBACKD/STANCE t / EXISTING HSE 34 EXISTING HOUSE- 1307 S.F. -5.1 EXISTING DECK-268 S.F. - 1.1 % C2 3s.r 1 EXISTING SHED-68 S.F. -0.3 % SAND 2.5Y£46 AfMUYSAND TOTAL EXISTING COVERAGE-6.5 % FEWCOBBLES . • --,............... � .. -----�' LOT 9A I 25,500t S.F. w 110' ci� , 31.6' NO GROUNDWATER 70.00 h° 38 .� TROUTBROOK (30.00 WIDE) ROAD n`2os S 60, 50 �23 g .-..-.... - 9 'A LEACHING TRENCHSECT/ON U NOT TO SCALE ROUTE 2 179 S.F. S/D,EXIALI AREA .7f GAL S/SF 132 GALS. SEESYS7L�tlRRRQC7E7LE 93..27 - 319 S.F. BOTTOMAREA .74 GAL S/SF 235 GALS. R-82.58 (� WASHEDsrcwe 07 S.F. TOTAL AREA 367 GAL S. � (1YMN TA OAo t NO. OFBEDROOMS 3 rNATURAL SOIL / D/S, OSAL NO O� �, 6PGRADE SEWAGE DISPOSAL SYSTEM PLAN?' EFFEcneE .� RIC r1 DEP7H ESi' TOTAL DA/L YEFFLUENT 330 GALS. FER IR �p SEI"TIC TANK 1000 GAL. /EXIST/NGl N PREPARED FOR ------------ WASHED S7nWE """'""" - ' -ErfECT/GE WiD/H ,�+ (i[STE����Cu KEl TH GA Y m ��q 8"-' ``��°c, HOUSE J4 TROU TBR00K RDA D LOCUS � 3'-O• 3'-O' t���M� BARNS TABLE _ MASS.N1/",MSR OF TRENCHES 1 q°y — � cEaqGs , SCR a NUMBER OF/NF/L 7RATORS 5 NE' o DESIGNED: SAP DA TE.• MAR. 4, 2004 FERRE/RA ASSOCIA TES 22 - 70 1A 34 �o,� c r��` .� �: DRA KIM- MVB SCALE 1 o = 20' 161A WORCESTER COURT _ �.,,', MAP SEC PCL LOT HSE tS'O " " ° ' CHECKED: GS Df"!V. NAME- CADD FALMDUTH — MASS. 02540 y..