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HomeMy WebLinkAbout0158 TROUT BROOK ROAD - Health -158 Trout Brook Road Cotuit - _ _ _ A= 008-- 010 •I I TOWN OF BARNSTABLE LOCATION `NWT" r(JO `� SEWAGE# VILLAGE C�uT ASSESSOR'S MAP&PARCEL d O F Q IO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY UW LEACHING FACILITY:(type) 7rr (size) CA NO.OF BEDROOMS 3 OWNER loses PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 /1.5' I No. � Fee le THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Bigponl *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. �S$ T��y�' Owner's Name,Address and Tel.No. Assessor's Map/Parcel /1 0—ru j^ PAS+ + OtAn ROS9,r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G, G0A P0s1_Z-. F®r- , Type of Building: Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 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? N ture of Repairs or Alterations(Answer when applicable n 5 A I I A H eAV y / 0(� ®t), l ePlG�1 �t'T' �n in Sisal I Aswe/1eit„) 1bPd>c 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 the system in operation until a Certifi- cate of Compliance has been issued by is oaf Health. gned Date 13 Application Approve by Date S , Application Disapproved or the following reasons Permit No. S Date Issued 3 _-'.' i _ 9 may. .. .... .. .._...• , No. / /O `t t 1 _Tee f , ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS--- 01pplication tor-"�i!9tlo5ar *p$tem Cungtruction Permit --... Application for a Permit to Construct Repair Upgrade rade pp _ ( ) p (�1f pg ( .)Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. / O Trd Li �U`0 Owner's Name,Address and Tel.No. Assessor's Map/Parcel CoT CP —C)1Q r-)(A-TT, .A- DQ ArN 20SV' Installer's Name,Address,and Tel.No.' Designer's Name,Address and Tel.No. G. But%pus 7--F04 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow r 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 Nature of Repair or Alterations(Answer when applicable)—L n s7,4 i I /q f�eA V y o p on I eI�(,� - �'tT- And Insi tf A AC,w lb- Soy, r� 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 the system in operation until a Certifi- cateof Compliance has been issu d by this Boardof Health. �q gned .5b Date V" Application Approveky Date 5 3 Application Disapproved for the following reasons Permit No. Date Issued S 3 --------------------------------------- - ; THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance / THIS IS T h h - w O CERTIFY,that the On site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( . )by at S� �0 QUO C.I�U 17 has been constructed ' ac rdance with the provisions of Title 5 and the for Disposal System Construction Permit No.�Y �ated .� �.3 Installer G BUMpu.S - S Ford. Designer_ r i n The issuance of t 's,pi fit�all not be construed as a guarantee that the syst mwa 1 function Adesg6}e DateU Inspector U \\ OVA No.��_ __ � -------------------------Fee �D THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Di!6poar *pg;tem C,*'ongtrurtion Permit Permission is hereby granted to Construct( )Re air(✓)Upgrade( )Aba dLon( ) System located at sk r Wes'System � G�V! / 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 9nust be do(m�pleted within three years of the da< f this pe"'o t. Date:_ 5 �/� / Approved by— COMMONWEALTH OF MASSACHUSETTS A, EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION ASSESSORS MAP NO: 00 PARCEL NO:, 01 O TITLE.S OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A .CERTIFICATION Property Address. . 158.Trout Brook Road Cotuit, MA 02635 Owner's Name: Dean&.Patti Boger ✓ !/ n Owner's Address: Date of Inspection: May 12; 2009 Name of Inspector: (Please Print) Jaines M. Ford, Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT 11 certify that Ihave personally.ins 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', approvedy P. system inspector pursuant.to Section 15.340 of Title 5'(310 CMR 15.000). The system:.. . ✓ Passes Conditionally Passes: IN eds.Further Evaluation by the Local Approving Authority Inspector's Signature: Date:. May 18,-2009 The system inspector shall sub it a copy of is inspection report to the Approving Authority(Board of Health or DEP).within 30 days of:completing this inspection. 11f the.system is a shared system or has a design flow of I O;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. Notes and Comments ****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 a Title.5.Inspection Form 6/IS/2000 page l f Page 2.of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued] Property Address: 158 Trout Brook Road : Cotuit. MA Owner: Dean&Patti Boger Date of Inspection: _Ma 12, 2009 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: 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 detennined(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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 158 Trout Brook Road Cotuit, MA Owner: Dean&Patti Boizer Date of Inspection: May 12, 2009 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 5.0 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. 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,perfonned at a DEP certified laboratory, for coliforin bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.. A copy of the analysis must be attached to this forma 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 158 Trout Brook Road Cotuit, MA Owner: Dean&Patti Boger. Date of Inspection: May 12 2009. D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 '/2 day flow. Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS,.cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet.of a surface water supply or tributary:to a surface " water supply: _ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 1.00 feet but greater than 50 feet froin 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia " nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria " are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered,a large system the system must serve a facility with a'design flow of 10,000 gpd to 15,000 gpd• You must indicate either."yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking.water supply _ the system is within 200`'feet of a tributary to a surface drinking water supply the system is located in a nitrogen,sensitive area(Interim Wellhead.Protection Area IWPA)or a mapped Zone Il 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. 4 - Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: 158 Trout Brook Road Cotuit, MA Owner: Dean&Patti Boger Date of Inspection: May 12. 2009 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 nonrial 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: Yes No ✓. 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(3)(b)] 5 I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 158 Trout Brook Road Cotuit MA Owner: Dean&Patti Boger Date of Inspection: My 12, 2009 FLOW CONDITIONS RESIDENTIAL 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: 0 Does residence..have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):. No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow.(based on 310 CMR 15.203): apd , Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):. Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5.system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Unavailable Was system pumped as part of the inspection(yes or no): 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: Installed on 7115197-ner as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued), Property Address: 158 Trout Brook Road Cotuit, MA Owner: Dean&Patti Boger Date of Inspection: May 12. 2009 BUILDING SEWER(locate on site plan): Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TAN ✓ , K. ( locate on site plan), ) Depth below grade: 9" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate.of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:. 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6ef Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick . Comments(on pumping reconnnendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invei^t There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass-_polyethylene _other (explain):. Dimensions: Scum thickness: Distance from top of scum to.top of.outlet tee or baffler - Distance from bottom of scum to bottom of`outlet tee or baffle: Date of last pumping. Comments(on pumping recommendations,mlet and outlet tee or baffle condition,structural integrity; liquid levels as related to outlet invert,evidence of leakage,:etc.): . 7 Page 8 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 Trout Brook Road Cotuit, MA Owner: Dean&Patti Boger Date of Inspection: May 12, 2009 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site.plan) Depth below grade: . Material of construction: _concrete _metal _fiberglass _polyethylene._other(explain): Dimensions: Capacity: gallons Design Flow:. gallons/day Aland present.(yes or no): Alann level: Alania in working order(yes or no):. Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.):. The D-box was broken down anew one was installed see Permit#2009-125 The cover is 3"below grade PUMP CHAMBER: None (locate on.site plan) Pumps in working order(yes or no): Alarms in working order(yes or:no) Coiimnents(note condition of pump chamber,condition of pumps andL appurtenances,etc.): 8 , Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 Trout Brook Road Cotuit, MA Owner: Dean&Patti Boger Date of Inspection: May 12, 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: T - yPe ✓ leaching pits,number: 1.'-6'x 6''(I000gaI•) 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.): The pit was dr>). The scum line.was a.Ri2roxiniatel 4'u rom the bottom: A H-20 heavyto was installed on it because it is in the driveway, See permit#2009-125. The cover is 6"below grade CESSPOOLS: None (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 or no): Comments (note condition of soil,signs.of hydraulic failure,level of ponding,condition of vegetation,etc,): PRIVY: None, locate on siteplan) ( Materials of construction: Dimensions: Depth of solids: Comments (note condition of.soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 f Page 10 of 11 OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 Trout Brook Road Cotuit, MA Owner: . Dean&.Patti Boger Date.of Inspection: Mav 12, 2009 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. 7 .3 1 A trDnl oZ ' t�ctuc.wA Y 14 cgvy T"o� C 10 i a Page l l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 158 Trout Brook Road Cotuit, MA . Owner: Dean&Patti Boger Date of Inspection: May 12..2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/- feet Please indicate(check)all methods used ter determine the high ground water.elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site.(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of.Health-explain: topographic and water.contours inaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must.describe how you established the:high ground water elevation: Using Barnstable topo.raphic and water contours neaps, the ittaps were showing approximately 50'+1-to ground water at this site. This report has been prepared only for the septic systerti and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future: There have been no warranties or guarantees,either expressed,written or implied, relating to the septic system;the inspection,.this report and/or anyycomponents of the septic system which have not been located and inspected. I .. - - Q) �`"A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAV �SfRuHs Govemor I IOner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A 9Q f CERTIFICATION y ^ Property Address: 158 TROUT BROOK RD COTUIT LOT 8 � o� � Q r Name of Owner CYNTHIA BOURGET B Address of Owner: SAME o�yJj, �10 ,� Date of Inspection: 4/22/99 Name of Inspector:(Please Print)JOHN GRACI �F �� lam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) E @ Company Name: n/a Mailing Address: n/a Telephone Number: n/a ° a Y t, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evalu io By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: �r Date:4/23/99 The System Inspector shall s ibmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.THE LEACH PIT IS 1N THE DRIVEWAY.IT IS H10,AND IT IS NOT RECOMMEND TO BE DRIVEN OVER. revised 9/2198 Page 1 of 11` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 168 TROUT BROOK RD COTUIT LOT 8 Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 INSPECTION SUMMARY: .Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure,conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: } System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nia 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances.If"not determined",explain why not. nla The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nla Sewage backup or breakout or high static water level observed in the distribution box is due to,broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed t distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced , _ obstruction is removed i revised 9/2198 Page 2 of 11' ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 158 TROUT BROOK RD COTUIT LOT 8 Owner: CYNTHIA BOURGET ' Date of Inspection:4/22/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_ (approximation not valid). 3) OTHER nta revised 9/2/98 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 158 TROUT BROOK RD COTUIT LOT 8 Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: - I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.-The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Wa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.' E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply i X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11;; - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 158 TROUT BROOK RD COTUIT LOT 8 , Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X Noneof the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. . X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)1 X The facility owner(and occupants,if different from owner)were provided with information on the proper,maintenance of Subsurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 158 TROUT BROOK RD COTUIT LOT 8 , Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 r FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom a Number of bedrooms(design): 3 Number of bedrooms(actual):2 Total DESIGN flow: Q Number of current residents:A Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):�LQ Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NQ Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL Type of establishment: Wa Design flow: nta gpd(Based on 15.203) . Basis of design flow: n1a Grease trap present:(yes or no):JM Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n(a Last date of occupancy: nLa OTHER: (Describe) n1a Last date of occupancy: n1a GENERAL INFORMATION , PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED IN 97 System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n1a_ gallons ` Reason for pumping: n1a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n1a APPROXIMATE AGE of all components,date installed(if known)and source of information: •NEW PIT WAS INSTALLED ON 7-15-97 BY ABCO Sewage odors detected when arriving at the site:(yes or no) I�LQ t revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 168 TROUT BROOK RD COTUIT LOT 8 , Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 BUILDING SEWER: (Locate on site plan) Depth below grade: T Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: !z Material of construction:X concrete_ metal_'Fiberglass _ Polyethylene _ other(explain) DLa .4 If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: L 8'6'H 6'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: 2L' Scum thickness: r - Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: C w How dimensions were determined: MEASURED M Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EMERY TWO YEARS. GREASE TRAP: - (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) ata Dimensions: nta ' Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:iiLa - Distance from bottom of scum to bottom of outlet tee or baffle I IA ` Date of last pumping: nLA Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert;structural integrity,evidence of leakage, etc.) nta a revised 9/2/98 Page 7 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: 168 TROUT BROOK RD COTUIT LOT 8'• Owner: CYNTHIA BOURGET Date of Inspection:4/22199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLd Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: nLd Capacity: Wit gallons Design flow: nLa gallons/day Alarm present: fllO Alarm level:jiLa- Alarm in working order:Yes_No_: No Date of previous pumping: nLd ti Comments: (condition of inlet tee,condition of alarm and float switches;etc.) Wa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) fILa PUMP CHAMBER: MQ (locate on site plan) ' Pumps in working order:(Yes or No): DLO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 168 TROUT BROOK RD COTUIT LOT 8 Owner: CYNTHIA BOURGET , Date of Inspection:4/22/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: 1]Ld Type: leaching pits,number: 1000 GALLON H10 PIT leaching chambers,number: in& leaching galleries,number: -nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: Wa Name of Technology: .a& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.PIT HAD 2'IN IT AT THE TIME OF THE INSPECTION,HAS NOT HAD MORE T CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert; Wa Depth of solids layer: nLa - Depth of scum layer. nLa Dimensions of cesspool: nLa Materials of construction: n1a Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:Wa Depth of solids: n1a Comments: (note condition of soil,signs,of hydraulic failure,level of ponding,condition of vegetation,etc.) ? nLa revised 9/2/913 - Page 9 of 11 - 'f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 168 TROUT BROOK RD COTUIT LOT 8 Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 t SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a I �rofi R k A� 3q DR a7 revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: 168 TROUT BROOK RD COTUIT LOT 8 x Owner: CYNTHIA BOURGET Date of Inspection:4/22/99 NRCS Report name: n!H - a Soil Type: nLa Typical depth to groundwater: nta USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 'Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) µ USGS MAPS AND CHARTS AND VISUAL y revised 9/2/98 Page 11 of 11 TOWN OF BARINSTABLE 1 07"$ LOCATION 15'9Ty'ouT gook 20� SEWAGE # Ft! - 1 VILLAGE �,,T,;r ASSESSOR'S MAP & LOT D INSTALLER'S NAME&PHONE NO. Jai eP4 De Spe-e o S SEPTIC TANK CAPACITY MOO LEACHING FACILITY: (type) Z94d i sto, f i (size) /oa0 NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 3- L XOMPLIANCE DATE: — l S77 12 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 G � I y � r y y 0 � bAm z �w TOWN OF HAKNS'1ABLE LOCATION 45o T (gook /1o,ma( SEWAGE # Tr bin VILLAGE (-oT ASSESSOR'S MAP& LOT O INSTALLER'S NAME&PHONE NO._Ja3 e,y4 D-e- Sloc -'0 5 `SEPTIC TANK CAPACITY /DDO LEACHING FACILITY: (type) Z'1Xd ih s lei (size) /000 NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: ems, COMPLIANCE DATE: — 15 97 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet a :Furnished by G 4 � 00-00 ,r. Fim.s.v.x......... ® t THE COMMONWEALTH OF MASSACHUSETT$ _1 001 BQARD -OF HEALTH TOWN OF BARNSTABLE Apphration for Diopogttl Workg Towitrurtion rumit Appli ca 1a , ma ee f C uctraY msRp � n Individual Sewage Disposal ! 9K e System at: %[` . tq y Loc, \ddress �+. or Lai—�Vo. .... `------------------- = ` ...-•k-1�'�?_le.rr :...ciFCa.' Q. .... 1 ...... Owner Address Installer Address UType of Building Size Lot............................Sq..feet ., Dwelling— No. of Bedrooms------------ ---------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons----------------------.----- Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------•-•-•-------•--......---------------------------. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons�v Length---------------- Width---------------- Diameter--_-_---.-.-_- Depth................ x Disposal Trench— No. .................... Width-------------------- Length...-_--.-_-.-----.- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...........--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---.... ---•------- ...................................................... Date........................................ Test Pit No. L...............minutes per inch Depth of Test Pit-------------------- Depth to ground water...--................-.. fT Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ O Description of Soil.......... .... ------------------------------------------------------------------------------------------=`------------------ U - Nat o Repairs or Alt rations—Answer when applicable.... '� X_ _ �_Z -- ----------- -- - --7 4 ApaVr � � `�C~ . UTheTidersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Com nce has been.,i sued by the board of health. Signed ----- _..... ------_---- t-?.-"9Sf------- Dace Application.Approved By ...... .. -- ----- - - .......... "'� Disapproved for the following reasons: ----------- --------------------------- Application - ..............._......_......------....._---------------------------------------------------......-------------------------- Permit No. ...7- '�� --�`>�,......._ Issued ...............I..."-1.7.."��.------------------- Date A ------------------------- :x MAP 00 No.. ...............1... Q" '� Fes$. ....Q...p THE COMMONWEALTH OF MASSACHUSETTZ�4 BOARD OF HEALTH TOWN OF BARNSTABLE .Appliration for Di-npntial Works C owitrnrtinn ramit Application,is,he made fva Permit Construcct ( ) or Repair n Individual Sewage Disposal System at / 1�a P`OU(ZSJ � V'�� 5. .....................•-----..`.....----..... ............ .......... ........... ........... .................................................:,**Or .--•------•--......-----••• Loc ii-Address or Lo�� o. - � 1� 1\ �., Owner �' Addyr�c^ss 1-^ `^'�...✓ : �_ �a.._..x•'��Jt��1� ........ �]Ll���_ Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther-Type of Building ._------------------ ------ No. of persons---------------------------- Showers ( ) Cafeteria ( ) 04 Other fixtures ----=------------------------- - 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. Seepage Pit No..................... Diameter....-.-.--.--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed by-......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit---.---.--_-.-----_ Depth to ground water...-_------..._.-------. �14 Test Pit No. 2................minutes per inch Depth of Test Pit--..-_-.------.-_ - Depth to ground water........................ CY ......-•--------------------••----.....----•................---•-••-•••-•... ---•-•---------................................................................. D Description of Soil = t'... - ------ x ...` �` - 'a � U •---••.. ) -- -- -- W ----------------------,----------------......------------------------------------------------------------ " x Nat o Re atrs or Alterations—Answer when a licable._-. G�.M.D.._.''.---.-0..1 ��� �t U P PP � .7. i_.J.1 .............�_y. .-.a.._----------- �V7 The ndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com (i,,,4nce has been(is(suued b the board of health. Signed 1. 1.luM- -%- ---------------------------------- ----- --.----..r :...... Dare ApPlication.AP f� � -------- p roved B ~ ------- . ..... Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------------- --------------------------------9------ ...................................................... ... ...........--....----..---.....------......--....----.........---..........---_-.............................---..---_................. -- -- ..�. e. .1............ Permit No. �- ........- t—.--------- Issued ...............-....... I.. qS ---------------- ` Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#tftctt#e of Compliance TH;SVS TO CERTIFY, That the I dividual Sewage Disposal System constructed ( ) or Repaired by - - ------------------_.-....----- Ins a r �. ..at ...__...... - .. has been installed in accordance with the provisions of TITI. 5 of he tate Environmental Code as described in _ the application for Disposal Works Construction Permit No. .. _. -.- dated �. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUEn AS A GUARANTEE THAT"TH SYSTEM WILL FUNCTION SATISFACTORY. DATE---------.. .........7 .....V5... -- 7------------------ -- Inspector ------------- z ---- ------ ........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �j TOWN OF BARNSTABLE � (�� v 30I� " j /� FEE........................ Dwpotitt1 ort i_i Tonotrudion ranfit �.`1<:.P Permission is hereby granted......... - -.�-...-----. ................................r to Construct ( ) or Repair ( ) an Individual Sewage Disposal ystem at No......................................... ; / a� `s'y -rt- - a° ._2�---------------t`�--� �'=J --= `.---- Street ,R.. as shown on the application for Disposal Works Construction Permit N .. �,�`�, ted--_.._-3_ _i7... .......... DATE------. I (.4?... .......... Board of Health FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS '7y �� f 7 � No...--•------------------- Fps............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF.......... 1"la-ZI------------ Apphratiurt -fur 43iivuiittt Works Tomitrurtirin Vanift Application is hereby-made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Loea on- dres or Lo 0 . •- �. --t--P� .p f ..-1 . ....•••------------------ L'f�UC.� _ . .... :••-= � Owner Ad s tall Address Address UType of Building 6/�s � Size Lot____________________________Sq. feet .-� Dwelling No. of Bedrooms...............•_. .......................Expansion Attic ( ) Garbage Grinder ) p, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... w Design Flow................6�7f--___-_______--___-..gallons per person per day. Total daily flow.........Z.-! _------------------- WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------....... Deptll..-..-.--.--._. x Disposal Trench—No--------------------• Width-------------------- Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No..................... Diameter..................... Depth below inlet-------------------- Total leaching area--.---.._.----__--sq. ft. z Other Distribution box ( ) Dosing tUtz�kAl Percolation Test Results Performed by---- . ...�_p.� ------------- Date----- .. ------------ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground wat --_-..--.----.-_-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.-__-_-_:-..._._.... Depth to ground water........................ ----•-- --•---_----- Description of Soil ` >_ `, - -- - - ---- _,a�..._.-. . w VNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the board of health. Signe __ ---- ....................... � ' - ate--------.-•--- Date Application Approved BY. {�� tl .....---•--........................ v.-.�. . 7-7------- Date Application Disapproved for the following reasons------------------ ---------------------------------------------------------------------------•----...........••- -•-----------------------------------------------------------------------------------•--------------•----=---.......----•••----.........•••----•••--•---------------------•--••--•--•-------....--•----- Date PermitNo........................................................ Issued........................................................ Date No -• FEE ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratioo -for Uhipoottl Workii Towdrurtioo Prrutit pplication is hereby made,-for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at LaCa on rep r Lot o :,� ` --l� _ �7' w � C' "A li ' :. fir .... Ad Installer Address UType of Build' Size Lot............................Sq. fe t Dwelling No. of Bedrooms................ .....................EYpansion Attic ( ) Garbage Grinder 1 Other—Type of Building ____ No. ofpersons__________________________ Showers — Cafeteria a' Other fixtures --•---------•------_------- -- Design Flow_-_-_-__________ 4.......:...........gallons per person per day. Total daily flow._.._.._. ._ g� W -------------------- Mons. WSeptic Tank—Liquid capacity -gallons . Length______ ________ Width. __-.._.. .:_.. Diameter-----........... Deptli.. _.._. ...; x Disposal Trench�No ___-___ Width-------------------- Total Length _... Total leaching area------------- -----sq. it. Seepage Pit No _: __ Diameter _ Depth below inlet_:___--_ _____ Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing aPercolation Test Results Performed by.---'. .. Date --1 ` Test Pit No. 1----------------minutes per inch. Depth. of "Pest Pit-------------------- Depth to ground wate _�--------------------- fL Test Pit No. 2.................minutes per incli Depth of Test Pit ,__________ Depth to ground water-.----------- -----_-. . IY, ------------ O Descri tion�of So11; - .�__ � '------ _+ _..... . -- �4 _._._ ,,�, __.___, .... ....................................� ... W -------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ---- U Nature of Repairs or Alterations—Answer when applicable.____________ _____________________________________________________-..-._.___-..__------------- -------------- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been wue,d.by the board of health. Signe ---...•-- ff� Date Application Approved BY--- = { " ......................... `...--�s--- -- f e .,, Application Disapproved for the following.reasons__ ____ _ _........................_______ _________________________________________ ------...Date ...••-•-•••-- ----.._.-•__..--•-----_..--•-•-•-•--------•--------------------•-• --•----------------•---•----------- Date Permit No.........................--•-•--••----------------=--:_.. Issued--------._...---------------=-='= `` Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.. ... ... ? . . ...:.... Cnrrtifiratr of`f�omplialtrr. ,, THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Inst .,rt. : has been installed in accordance with the provisions of _ fqijj�"IrXIIof I'he State Sanitary CodLc as descrube m the application for.Disposal Works Construction Permit No.. .. ............. .. .... ..... dated _____ ._✓�.__ �__,_. .._.._.___._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT-BE CONSTRUED AS A GUARANTEE 7.HAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE { < { InspecYor_..._ r ------------ TH-E, COMMONWEALTH OF MASSACHUSETTS BOARD OW HEALTH k« No. le •--••-•-•-.... FEE--------•--------------- RinVniiai lVarkii ClIongtrurfion Vamit .. Y ed•:--- - --- ---------- = - --- --- Perto Cori tmisc�ion. ts.. 4 t 0 ore R rr nt an. vid age typo. S stem 4 at No. •-- Street . a.,y, as shown on the application for Disposal Works Construction 'it N .___ -___ Dated_____ _____ ___ f __.__ - - . • ---------------••••••-•-- Board of Hea h DATE _.-. ,,. -------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - ��~ - ►` ` TYPICAL SYSTEM PROFILE f A R E A PLAN FINISH GRADE= T T FDN TOP ' NOT 0 SCALE 4 ,._.e...—..—.,.w.��. FINISH ' SCALE : I "= 37 ` `. FINISH GRADE OVER TANK= _ aq I I GRADE EVER Prn VON RESIDENCE 0 l:�'T 1.)t-r" s""�� A c". BAFFLES OR r' s�o O O - - • •�• • • . oTo C ) C. 1 . TEES i .ry" - • + • • e o + e 0 ,. LEGEND . . e • . ' FMR GAL. 4`1 �.� z� =t o + + o • • e e . + 1 REINFORCED _811 UIST. BOX + • 1 1 / 1 • • • • + • d "`-' � '"� �Re 45ED C)N'T' ? �""' CONCRETE TO BE tN51ALLED ON e • + + • • • + e 1 a + C" R NOTE A LEVEL STABLE BASE • + o . • • a 1 1 1 '. v) 1 1 e . e • I • e o + 0 / DIVISION PLAN "E ILLC T" P[AN ��. SEPTIC TANK '' • + • . ! . + + 1 -'h S�<r -4 (JC77 i 9, 19 "t b TO BE INSTALLED ON A • • • I • + + + • 1 LEVEL STABLE BASE , , - ,. r; <- O 2"-1/8' 1/2 "`WASHED PEASTONE AL 1 • • • • • / 1 1 AROUND FREE OF IRONS F -?4'rS t'`-� QV?�f N E RS: � BRICK a .MORTAR COURSES AS � + e • • • e a e G REQUIRED TO BRING COVER TO GRADE i , XJ I its:: ► I AND DUST IN PLACE � .� 24 "C.I. MANHOLE COVER a 1 3A 'PTO I -1/2 "WASHED `. _� LEACHING PIT w; �OCI<�r2 IU��-t< FRAME SEE DETAIL STONE ALL AROUND FREE OF BASE TO BE LEVEL i r.. U) �.,CGT�u)T� NW-6. IRONS, FINES AND DUST IN , .. PLACE ' ' ! 4 /` FOR FIN, GRADE �- T.µ - ,f SEE SYSTEM PROFILE LaT SOIL AND PERCOLATION — tl 4 DATA J 5 ,. _ rr 811 _ — — MI IN. RATE *, � N �- 4 FOR INV. ELEV SEE J°T {rwP40. ` INLE:T a o - SYSTEM PROFILE - -° TAKEN BY ' L D. SPOHR ?.CJx h , ., u'�: LINE _ o6 o a - t G� , , . _ ,v o _ o OPENINGS W/4-1/8" WITNESSED BY. # 0 vo :,�� Prr.�r�.�r -�•; � •-... - W I T N - � ° OUTER DIA. B" I 3/4 DATE : ,"AIr<--,S4-� M10FIL � :.:'ot" ' r,� ¢ . .-..,►.,� �� 1 d d INSIDE DIA p TEST PIT -GND ELEV. �. ?� �c,•;, .awz.k r , .. , �`5 - ° o � 31� .� �, ., / T. _ LOCATION GF P6EZI F?1T i � >-•^:��►��:�'tT-ti`o=�s� - r, " ! .. �, _._.,...::.......:.�. ._..�...,._....__. t3LE �<I*: �.t.AOF-�INCr , , � o , � --- -- ---_ - — _ , , (� F ( '* e 4 �+ }- B `f'8.1l L :,x C�f�t';f 1 L ' ' `..,1 Nyy C + +rvt�+sr«e*. /` T- i T '�.o�..)' !'�P`�V[14 F— t r . `s`> 1 {'�. C e�..I"I .' - •o I 'o •��., C, [� u — _ ` .' o � /� { 7• G O �' t / Ati,J ..s C,)'t' S.1 p O o. _ l )/...11�1 F RO N^, PlZO F�a E Mj ,: Q5 0! tj� , P<OM PA%"r v`� t,FY1(;, 4y^�n Tp p p p �_AINK '' �' ! 71 50C3 — _— . 0 0 0 0 o p o p 0 o �,,1 E U 10 N4 �'�.1'�� H C)L ^.li`r• +-1 r�`•sty; � � 6 `' 6 " D I A C L� a , 4 I: LAY. 100. � ; C_ EDGE r � RCAD - G E E F F E C T I V E D I A. ' � v � �a©T>N HS) TROUT f RCS F D LEACHING PIT - SECTION UPI . � �D� � _.__ � E V HoLf NO SCALE 1 + DESIGN DATA : E LEV3, g2�jo e 92, NOTE DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM NO. OF BEDROOMS Ll`2 _ C SPOSAL - . I cJ' ECT (ON B - B LEACHING PIT NOTES: I EST. T 0 TA L DAILY EFFLUENT � GALS 4� ►=C UNCi,aXIC�t'S► SC.:A.I_E �- 1"= 10' 1 . CONC. TO BE 4000 P.S.1 a 28 DAYS . SEPTIC TANK "" '�� GAL. . °, V._•f �. ._ 2 . REINF W 6 " x 6 ii j°+6 GA. W. W. M. LEACHING AREA I. -� SQ F7/GAL.= -' ' l "SU.FT. 3. 2 `AND 4 SECTIONS ARE AVAILABLE FOR GENERAL NOTES I` GREATER DEPTH REQUIREMENTS ` I . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ' N®TE • ACCORDANCE WITH ART. X I OF THE STATE SANITARY CODE _ -. ---�— EXCAVATE TO ELEV. OR LOWER AS DATED AUG. 15, 1966 a ANY LOCAL RULES APPLICABLE. _w - kE1'� C� REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING 2. ANY CHANGE TO THIS PLAN MUST BE APPR'D. BY THE 01 -' MATERIAL BENEATH PIT, REPLACE EXCAVATED MATERIAL BD OF HEALTH. WITH CLEAN,CLAY FREE GRAVEL, MECHANICALLY COMPACTED 1N PLACE. 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING, , NOTIFY BD, OF HEALTH FOR INSPECTION. w. �. 4. FOUNDATION ELEV, MUST BE CHECKED WHEN COMPLETED, 5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT BOARD r ��' ' OF HEALTH APPROVAL. ! _ .. . LEGEND TOWN O � g '' 6 BOARD OF HEALTH INSPECTION READ, WHEN EXCAVATED. e #irefE.- • 5 0,0` EXIST. GROUND 0 U N D ELEV � E CT 1 I J _ i �I I'.:rw'^n:ED (! W+i�. �T 5' '....C-FT OF I4\.10✓5C S 11� �. . It / r 50.0 FINISH GROUNO ELEV.- UNDERLINED !! 1 .. .v...., .», ... CAL_ . .: , ' 23MrsCf %t aE i) /�O ,,,..HON E�O'34 1F.S.I. .PIT 47 50` PIPE INVERT. ELEV. REv. DaTE T/7, ' ' ' TEST PIT LOCATION SEWAGE DISPOSAL SYSTEM FOR SEPTIC .N sa, . �. _ TANK - EAN BOGER t ❑ DISTRIBUTION BOX I c �-- I mo.�I ,, Ma l_. T T "OUT B ROAD 4 C. I . PIPE .,AI c9� y � .HII._.LCRtST L-.1/ltC or •-r^'q7�^.MC�{I '�_'..-.� '�. r,,> 1?"i Y. ' � SJBDIVISIo^4� -� -1j-J-►+t- ' 4 BIT. FIBER PIPE ' TIGHT JOINTS i; r- C)TU T - T I � ( . l�l A S - -- --- PROPERTY LINE i DESIGNED'. 0 D.SPOHR DATE.A DRAWING N0, DRAWN' SCAL.E'ASSHOWN f` MIN. CODE DISTANCE -.., � .0 •, �` :`' ` CHECKED' C. D. S _ ( i